Aviation safety investigations & reports

Flight below the minimum permitted altitude involving Boeing 737-376, VH-XMO at Launceston Airport, Tasmania on 17 June 2016

Investigation number:
Status: Completed
Investigation completed

Final Report

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What happened

On 17 June 2016 at about 0055 Eastern Standard Time, a Boeing 737-376, registered VH-XMO and operated by Express Freighters Australia, departed Melbourne Airport, Victoria, on a freight service to Launceston, Tasmania. After arriving overhead Launceston, the flight crew proceeded to conduct an instrument approach for runway 32L. However, due to adverse weather condition, the crew were unable to land and a missed approach was conducted.

On completion of the missed approach, the captain (CA) initiated a left turn to re-position the aircraft for a second approach. A short time later, while responding to a call from the airport groundsman about the weather conditions, the CA handed control of the aircraft to the first officer (FO).

While the captain instructed the FO to maintain the turn, subsequent manoeuvring had not been discussed. The resultant flight path led to the aircraft entering an area with a minimum permitted altitude of 5,800 ft. While the crew had commenced a climb, the aircraft had not reached that minimum altitude and entered the area at about 4,400 ft. In response, air traffic control issued a safety alert for terrain and instructed the crew to climb the aircraft above the minimum safe altitude.

What the ATSB found

The ATSB found that the instrument approach briefing conducted by the flight crew did not ensure that there was a shared understanding of how the aircraft would be manoeuvred on completion of the published missed approach. That resulted in the aircraft being operated in an area below the prescribed minimum safe altitude.

The ATSB also identified that flight path monitoring and safety alerts issued by air traffic control, provided the flight crew with clear and timely minimum altitude requirements and ensured the aircraft was operated well clear of terrain.

What's been done as a result

In response to this occurrence the operator issued a flight standing order that drew flight crew’s attention to the runway 32L instrument approach procedure’s missed approach and the requirements for subsequent manoeuvring. In addition, the approach briefing requirements were amended to include intentions for manoeuvring following the completion of a published missed approach.

The effective management and manipulation of the aircraft, following a missed approach, was included as a discussion item and exercise in the operator’s recurrent simulator training program.

Safety message

This occurrence highlights the value of having a clear, and where appropriate, shared plan. A common understanding between flight crew prevents additional workload associated with clarifying intentions during busy events, such as during and after missed approaches.

Operators and flight crew should consider including appropriate missed approach considerations, such as intended flight path, crew actions, terrain clearance and air traffic control requirements, into their approach briefings, regardless of the existing environmental conditions.

Download final report
[Download  PDF: 581KB]
Alternate: [Download  DOCX: 857KB]

The occurrence

Safety analysis


Safety issues and actions

Sources and submissions

General details
Date: 17 June 2016   Investigation status: Completed  
Time: 0148 EST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Launceston Airport    
State: Tasmania   Occurrence type: Flight below minimum altitude  
Release date: 28 November 2017   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer The Boeing Company  
Aircraft model 737-376  
Aircraft registration VH-XMO  
Serial number 23488  
Operator Express Freighters Australia  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Nil  
Departure point Melbourne, Vic.  
Destination Launceston, Tas.  
Last update 14 November 2018