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What happened

On 12 February 2012, the flight crew of a Boeing 737 aircraft, registered VH-TJS and operated by Qantas Airways Limited, was conducting a scheduled passenger service from Sydney, New South Wales to Canberra, Australian Capital Territory. Due to scheduled maintenance the instrument landing system at Canberra was not available and the crew prepared for an alternate instrument approach that provided for lateral but not vertical flight path information. The flight was at night with rain showers and scattered cloud in the Canberra area.

Shortly after becoming established on the final approach course with the aircraft’s automatic flight system engaged, the flight crew descended below the minimum safe altitude for that stage of the approach. The crew identified the deviation and levelled the aircraft until the correct descent profile was intercepted, then continued the approach and landed. No enhanced ground proximity warning system alerts were generated, as the alerting thresholds were not exceeded.

What the ATSB found

The ATSB found that at the time of the occurrence the automatic flight system was in the level change mode rather than the vertical navigation mode specified by the operator for such approaches. While in that mode the flight crew had selected an altitude lower than the applicable minimum safe altitude, with the effect that unless the crew intervened, the aircraft would descend to that lower altitude. The flight crew then allowed the aircraft to continue descending in the level change automatic flight mode through the segment minimum safe altitude, reflecting a temporary loss of situation awareness.

Safety message

During those phases of flight when terrain clearance is unavoidably reduced, such as during departure and approach, situation awareness is particularly crucial. Any loss of vertical situation awareness increases the risk of controlled flight into terrain. This occurrence highlights the importance of crews effectively monitoring their aircraft’s flight profile to ensure that descent is not continued through an intermediate step-down altitude when conducting a non-precision approach.

Download Final Report
[ Download PDF: 1.6MB]
 
 
 
 
General details
Date: 12 February 2012 Investigation status: Completed 
Time: 2200 ESuT Investigation type: Occurrence Investigation 
Location   (show map):21 km south of Canberra Airport Occurrence type:Operational non-compliance 
State: Australian Capital Territory Occurrence class: Airspace 
Release date: 05 July 2013 Occurrence category: Incident 
Report status: Final Highest injury level: None 
 
Aircraft details
Aircraft manufacturer: The Boeing Company 
Aircraft model: 737 
Aircraft registration: VH-TJS 
Serial number: 24444 
Operator: Qantas 
Type of operation: Air Transport High Capacity 
Damage to aircraft: Nil 
Departure point:Sydney, NSW
Destination:Canberra, ACT
 
 
 
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Last update 25 March 2014