Aviation safety investigations & reports

Unstable approach involving de Havilland Canada Dash 8, VH-XFZ, Laverton Aerodrome, WA, 17 May 2012

Investigation number:
AO-2012-070
Status: Completed
Investigation completed

Summary

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What happened

On 17 May 2012, the flight crew of a de Havilland Canada Dash 8 aircraft, registered VH-XFZ and operated by Skippers Aviation Pty Ltd, was conducting a circling approach to runway 07 at Laverton Aerodrome, Western Australia. In conditions of low cloud, the crew positioned the aircraft on a close base leg to maintain visual reference with the runway threshold. This led to a steep final approach and a high rate of descent that triggered alerts from the aircraft’s Enhanced Ground Proximity Warning System (EGPWS) and exceeded the operator’s stable approach criteria. The crew heard some alerts from the EGPWS and knew they had a high rate of descent but at the time did not identify an unstable approach. The crew continued the approach and landed.

What the ATSB found

The ATSB found that at the time of the occurrence the flight crew did not have an adequate understanding of operational aspects of the aircraft’s EGPWS and the operator’s standard operating procedures in regard to mandatory go-arounds. Crew fixation on the runway environment at a time of higher than normal cognitive workload and an inadequate monitoring of the aircraft’s rate of descent resulted in the continuation of an unstable approach, contrary to the operator’s procedures. The ATSB also determined that the operator’s minimum height for achieving the criteria for a stable approach was lower than recommended by the International Civil Aviation Organization.

What has been done as a result

In response to this occurrence, the operator implemented a number of safety actions to refine their stabilised approach criteria and formulate a method of incorporating realistic EGPWS warning events in the Dash 8 simulator training program. The intent was to enhance crews’ ability to recognise and respond correctly and rapidly to EGPWS alerts.

Safety message

The ATSB continues to stress the risks associated with the handling of an approach to land. The Flight Safety Foundation cites a lack of go-arounds from unstable approaches as the number one risk factor in approach and landing accidents and the primary cause of runway excursions. This occurrence highlights the importance of crews adhering to standard operating procedures and correctly responding to cockpit warnings.

Download Final Report
[Download  PDF: 1.16MB]
 
 
Alternate: [Download  DOCX: 580KB]
 
General details
Date: 17 May 2012   Investigation status: Completed  
Time: 0752 WST    
Location   (show map): Laverton Aerodrome   Investigation type: Occurrence Investigation  
State: Western Australia   Occurrence type: Unstable approach  
Release date: 05 December 2013   Occurrence class: Operational  
Report status: Final   Occurrence category: Incident  
  Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer de Havilland Canada  
Aircraft model DHC-8  
Aircraft registration VH-XFZ  
Serial number 365  
Type of operation Charter  
Sector Turboprop  
Damage to aircraft Nil  
Departure point Perth, WA  
Destination Laverton, WA  
Last update 14 November 2018