Aviation safety investigations & reports

Weather-related operational event involving Boeing 717, VH NXO, Perth Airport, WA on 1 June 2012

Investigation number:
AO-2012-073
Status: Completed
Investigation completed

Final Report

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What happened

At 0027 Western Standard Time on 1 June 2012, a Boeing 717 aircraft, registered VH-NXO and operated by Cobham Airline Services, was conducting an instrument approach to land on runway 03 at Perth Airport after a flight from Paraburdoo, Western Australia.

The approach was being conducted in instrument meteorological conditions. When the aircraft was at the decision altitude, the crew initiated a missed approach procedure as they had not obtained visual reference with the runway. Almost immediately, the crew obtained visual reference with the runway, discontinued the missed approach procedure and landed.

What the ATSB found

The onset of fog at Perth Airport at the estimated time of arrival was not forecast until after the aircraft had passed the point in the flight when it had insufficient fuel remaining to divert to a suitable alternate aerodrome. Before that point, there had been no requirement for the aircraft to carry fuel to continue to a suitable alternate.

Under the circumstances, the flight crew considered that the better option was to discontinue the missed approach procedure and land, in spite of the aircraft being in an unstable condition due to the initiation of the missed approach.

Safety message

This occurrence highlights that during a flight, the forecast weather at the destination may change and the advisability of obtaining the most up-to-date weather forecasts. However, pilots should be alert to the fact that the actual weather can differ significantly from forecasts.

The occurrence also highlights the risk of an unstable approach from not following a missed approach through to its conclusion. Unstable approaches are a frequent factor in approach and landing accidents, including controlled flight into terrain. The Flight Safety Foundation has developed an Approach and Landing Accident Reduction Tool Kit aimed at reducing the risk of approach and landing accidents. The toolkit can be found at Flight Safety Foundation website.

 

Download Final report
[Download  PDF: 1.37MB]
 
 
Alternate: [Download  DOCX: 512KB]
 

The occurrence

Context

Safety analysis

Findings

Sources and submissions

Photo

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General details
Date: 01 June 2012   Investigation status: Completed  
Time: 0025 WST   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): Perth Airport    
State: Western Australia   Occurrence type: Missed approach  
Release date: 12 October 2015   Occurrence class: Operational  
Report status: Final   Occurrence category: Incident  
  Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer The Boeing Company  
Aircraft model 717  
Aircraft registration VH-NXO  
Serial number 55096  
Operator National Jet Systems  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Nil  
Departure point Paraburdoo, WA  
Destination Perth, WA  
Last update 14 November 2018