Aviation safety investigations & reports

Descent below minimum safe altitude involving Boeing 737-476, VH-TJS, 21 km south of Canberra Airport, ACT, 12 February 2012

Investigation number:
AO-2012-040
Status: Completed
Investigation completed

Summary

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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    
Location   (show map): 21 km south of Canberra Airport   Investigation type: Occurrence Investigation  
State: Australian Capital Territory   Occurrence type: Operational non-compliance  
Release date: 05 July 2013   Occurrence class: Airspace  
Report status: Final   Occurrence category: Incident  
  Highest injury level: None  

Aircraft details

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  
Last update 14 November 2018