Aviation safety investigations & reports

Operational non-compliance - Embraer ERJ 190, VH-ZPA, overhead Essendon Airport, 30 July 2011

Investigation number:
AO-2011-091
Status: Completed
Investigation completed

Summary

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On 30 July 2011, a Virgin Australia Airlines, Embraer-Empresa Brasileira de Aeronáutica ERJ 190-100 IGW aircraft, registered VH-ZPA, was being operated on a scheduled passenger service from Sydney, New South Wales to Melbourne, Victoria.

The crew were assigned the LIZZI FIVE VICTOR standard arrival route for a visual approach to runway 34 at Melbourne by air traffic control, with a requirement to cross waypoint SHEED (overhead Essendon Airport) at or above 2,500 ft.

When about 3 NM before SHEED, the First Officer (FO) disconnected the autopilot as he believed he had visually identified SHEED (Essendon Airport) and passed overhead. Immediately after, the aircraft descended through 2,500 ft. The descent was continued with the aircraft actually crossing overhead SHEED at about 1,800 ft. Neither crew identified the error until receiving altitude alerts.

The operator conducted an investigation into the incident and identified that the crew's situation awareness had reduced, resulting in the aircraft being flown 700 ft below the required altitude restriction at SHEED.

This incident emphasises the impact reduced situation awareness can have, and the importance of monitoring not only the aircraft's state, but also the actions of other crew members.

Download Final Report
[Download  PDF: 3.63MB]
 
 
Alternate: [Download  DOC: 9.81MB]
 
General details
Date: 30 July 2011   Investigation status: Completed  
Time: 1537 EST    
Location   (show map): overhead Essendon Airport   Investigation type: Occurrence Investigation  
State: Victoria   Occurrence type: Operational non-compliance  
Release date: 24 May 2012   Occurrence class: Airspace  
Report status: Final   Occurrence category: Incident  
  Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Embraer-Empresa Brasileira De Aeronautica  
Aircraft model ERJ 190  
Aircraft registration VH-ZPA  
Serial number 19000148  
Operator Virgin Australia  
Type of operation Air Transport High Capacity  
Damage to aircraft Nil  
Departure point Sydney, NSW  
Destination Melbourne, Vic.  
Last update 14 November 2018