Aviation safety investigations & reports

Procedural non-compliance - Embraer 120, VH-TWZ, Perth Airport,WA, 28 July 2011

Investigation number:
Status: Completed
Investigation completed


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On 28 July 2011, the crew of an Embraer EMB-120 ER Brasilia, registered VH-TWZ, were conducting an instrument approach at Perth, Western Australia in frontal weather conditions that included significant thunderstorm activity. At a time of high workload, the crew's situation awareness was compromised, resulting in the aircraft flight path being above the desired descent profile. An appropriate decision was made to discontinue the approach, but during the go-around the crew did not conform to the published missed approach procedure.

As a result of the incident, the operator advised the ATSB that it had taken the following safety actions:

  • simulator retraining was conducted for the flight crew with specific focus on instrument flying skills and go around procedures
  • a proficiency assessment was made after the retraining
  • random monitoring of crews' ongoing performance from the jump seat during normal line operations was conducted
  • incorporated aspects of the incident into recurrent simulator training for all EMB-120 ER crews
  • a procedure to define removal from line, retraining and return to line has been developed for inclusion in the next edition of the Training and Checking Manual

This incident highlights the need for flight crews to be fully prepared for the go-around when it is required. As a go-around is not a regular occurrence, its preparation requires a complete knowledge of standard calls, sequence of actions, task sharing and cross-checking.


Download Final Report
[Download  PDF: 3.63MB]
Alternate: [Download  DOC: 9.81MB]
General details
Date: 28 July 2011   Investigation status: Completed  
Time: 2005 WST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): Perth Airport    
State: Western Australia   Occurrence type: Airframe overspeed  
Release date: 24 May 2012   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Embraer-Empresa Brasileira De Aeronautica  
Aircraft model EMB-120  
Aircraft registration VH-TWZ  
Serial number 120.266  
Operator Network Aviation  
Type of operation Charter  
Damage to aircraft Nil  
Departure point Meekatharra, WA  
Destination Perth, WA  
Last update 14 November 2018