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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]
 
 
 
 
General details
Date: 28 July 2011 Investigation status: Completed 
Time: 2005 WST  
Location   (show map):Perth Airport Investigation type: Occurrence Investigation 
State: Western Australia Occurrence type: Airframe overspeed 
Release date: 24 May 2012 Occurrence class: Operational 
Report status: Final Occurrence category: Incident 
 Highest injury level: None 
 
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
 
 
 
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Last update 01 March 2016