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Summary

Summary

Updated: 18 October 2016

Completion of this investigation has been delayed by other competing high priority aviation safety investigations and tasks. A draft investigation report is being written and is anticipated for release to directly involved parties (DIP) for comment in January 2017. Feedback from those parties over the 14-day DIP period on the factual accuracy of the draft report will be considered for inclusion in the final report.

 

 

 

Updated: 5 November 2015

On the evening of 14 May 2015 an Airbus A319, call sign Snowbird 2 (SND2) departed Perth, Western Australia for Melbourne, Victoria. The aircraft was registered as VH-VCJ and operated by Skytraders Pty Ltd.

Approaching Melbourne and before commencing descent, air traffic control (ATC) cleared the aircraft for a Wendy 1A standard arrival procedure and to expect an instrument landing system (ILS)[1] approach to runway 16 for landing (Figure 1). The Melbourne Automatic Terminal Information Service (ATIS)[2] reported conditions at Melbourne including:

  • scattered cloud at 200 ft and broken cloud at 500 ft[3]
  • visibility 10 km reducing to 6 km in rain
  • wind from 230 ° at 10 kt
  • temperature 11 °C
  • barometric pressure 1034 hPa.

Low visibility procedures were in force at Melbourne Airport. Runway 16 was the arrivals runway and the runway condition was wet. The ATIS information was designated as information Romeo.

At about 0120 Eastern Standard Time[4] on 15 May, SND2 commenced descent into Melbourne.

Figure 1: The Wendy 1A standard arrival procedure to Melbourne runway 16 ILS approach

Figure 1: The Wendy 1A standard arrival procedure to Melbourne runway 16 ILS approach

Source: Airservices Australia

The flight crew of SND2 called Melbourne Departures (MLB DEP) via radio at 0128 and advised that the aircraft was on descent to a cleared altitude of 9,000 ft, and that they had received ATIS information Romeo.

The following sequence of events was recorded by ATC:

  • At 01:34:25, as SND2 approached position KIKEX, MLB DEP cleared the aircraft to descend to 3,000 ft and for the ILS approach to runway 16. At that time, the aircraft was passing 5,900 ft.
  • Approaching position NEFER at 01:35:30 and passing about 4,700 ft, SND2 commenced the left hand turned towards BOL NDB (the Bolinda non-directional beacon[5]).
  • The aircraft completed the turn at about 01:36:20, as it was passing through about 3,700 ft. At that time the aircraft’s rate of descent began to reduce.
  • At 01:37:09, the aircraft descended through the cleared altitude of 3,000 ft, while continuing to track towards BOL.
  • At 01:37:17, the ATC minimum safe altitude warning (MSAW) alert activated on the controller’s console. ATC data identified that the aircraft was descending through 2,300 ft at that time.
  • At the same moment, the flight crew of SND2 called via radio that they were going around. This was acknowledged by ATC and the aircraft was cleared to climb to 4,000 ft.
  • The aircraft’s lowest altitude was recorded by ATC as 2,200 ft.
  • As the aircraft began to climb ATC provided SND2 with a low altitude safety warning, triggered by the ATC MSAW alert.
  • As the aircraft approached 4,000 ft the flight crew requested 5,000 ft. ATC approved the request.
  • A clearance level adherence monitoring alert activated at the controller’s console as the aircraft passed through 5,200 ft. The aircraft levelled at about 5,300 ft. ATC enquired with the flight crew of SND2 as to whether operations were normal.
  • The flight crew returned the aircraft to 5,000 ft and requested vectors to intercept the ILS for runway 16.
  • SND2 landed on runway 16 at 01:50:20.

The investigation is continuing and will review:

  • ATC data
  • aircraft flight data recorder information
  • company and flight crew procedures
  • the human factors aspects of the occurrence.

It is anticipated that the draft investigation report will be released to directly involved parties (DIP) in February 2016 for comment on the factual accuracy of the draft. Any DIP comments over the DIP period will be considered for inclusion in the final report, which is expected to be issued to the public no later than April 2016.

 

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The information contained in this web update is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this web update. As such, no analysis or findings are included in this update.

 

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  1. A standard ground aid to landing, comprising two directional radio transmitters: the localizer, which provides direction in the horizontal plane; and the glideslope, for vertical plane direction, usually at an inclination of 3°. Distance measuring equipment or marker beacons along the approach provide distance information.
  2. An automated pre-recorded transmission indicating the prevailing weather conditions at the aerodrome and other relevant operational information for arriving and departing aircraft.
  3. Cloud cover is normally reported using expressions that denote the extent of the cover. The expression scattered indicates that cloud was covering between a quarter and a half of the sky and broken indicates that more than half to almost all the sky was covered.
  4. Eastern Standard Time (EST) was Coordinated Universal Time (UTC) + 10 hours.
  5. A non-directional (radio) beacon (NDB) is a radio transmitter at a known location, used as a navigational aid. The signal transmitted does not include inherent directional information.
 
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