Aviation safety investigations & reports

TAWS alert involving ATR-GIE Avions de Transport Regional ATR72-212A, VH-FVR on approach to Moranbah Airport, Queensland on 15 May 2013

Investigation number:
AO-2013-085
Status: Completed
Investigation completed

Summary

Download final report
[Download  PDF: 3.25MB]
 

What happened

On 15 May 2013, an ATR-GIE Avions de Transport Regional ATR72-212A (ATR72), registered VH‑FVR and operated by Virgin Australia Regional Airlines Pty Ltd (VARA), was conducting an instrument flight rules flight from Brisbane Airport to Moranbah Airport, Queensland. During the visual approach to Moranbah, the aircraft descended to a height of 440 ft above ground level as the pilot manoeuvred to avoid cloud. As the pilot levelled the aircraft, a number of terrain awareness warning system (TAWS) ground proximity warning system alerts activated. The aircraft was climbed and the circuit was continued, with the activation of another TAWS alert prior to the aircraft landing.

What the ATSB found

The ATSB found that the captain’s rapid decision to descend limited the opportunity to discuss alternative approach options, descent limits and go around options should visibility reduce to below that required for visual flight.

The ATSB also identified significant under reporting by VARA of ATR72 TAWS-related occurrences to the ATSB.

What's been done as a result

VARA advised the ATSB of a number of safety actions following this occurrence. This includes the incorporation of the ATR fleet into the company’s cyclic recurrent check programme, the provision of safety promotion briefings to all company pilots, and the production of safety publications that alert crew to the defences that standard operating procedures and threat and error management provide.

In addition, VARA directed its flight crew to submit occurrence reports for all ground proximity warning system (TAWS) occurrences and implemented a review process to ensure that all relevant reports are passed to the ATSB. A review of the ATSB database in the period since these initiatives and the production of this investigation report showed that VARA’s reporting of TAWS occurrences was now consistent with other similar operator/operation reporting rates.

Safety message

This occurrence highlights the importance to flight crew of good communication and the inherent risk of spontaneous decision making. In addition, the advantages of following procedural information contained in operational documentation and aeronautical publications, such as the Aeronautical Information Publication Australia, is evident.

Download final report
[Download  PDF: 3.25MB]
 
 
 

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Safety Issue

Go to AO-2013-085-SI-03 -

Virgin Australia Regional Airlines Pty Ltd TAWS under reporting

There was a significant underreporting by Virgin Australia Regional Airlines Pty Ltd ATR72 terrain awareness warning system-related occurrences.

Safety issue details
Issue number: AO-2013-085-SI-03
Who it affects: Virgin Australia Regional Airlines flight crew
Status: Adequately addressed
General details
Date: 15 May 2013   Investigation status: Completed  
Time: 0800 EST   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): near Moranbah Airport    
State: Queensland   Occurrence type: E/GPWS warning  
Release date: 12 March 2015   Occurrence class: Operational  
Report status: Final   Occurrence category: Incident  
  Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer ATR-Gie Avions de Transport Régional  
Aircraft model ATR72-212A  
Aircraft registration VH-FVR  
Serial number 1058  
Type of operation Air Transport High Capacity  
Sector Turboprop  
Damage to aircraft Nil  
Departure point Brisbane, Qld  
Destination Moranbah, Qld  
Last update 14 November 2018