Aviation safety investigations & reports

Flight below the minimum safe altitude involving Beechcraft Baron 95-B55, VH-CBG 5 km north-east of Parafield Airport, South Australia, on 13 May 2021

Investigation number:
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase


Download Final report
[Download  PDF: 992KB]

What happened

On the evening of 13 May 2021, a Hartwig Air Beechcraft Baron 95-B55 aircraft, registered VH‑CBG, departed Ceduna Airport, South Australia (SA), for a charter flight under the instrument flight rules (IFR) to Parafield Airport, SA, with the pilot and one passenger on‑board. During the flight, the autopilot system did not function as the pilot expected.

At 1851, the aircraft was cleared for a night visual approach and descended towards Parafield Airport. At the time, the pilot’s focus was on the autopilot, resulting in the pilot losing sight of the runway and inadvertently overflying the airport towards an area of rising terrain at an altitude well below the minimum safe altitude. The pilot maintained this altitude and continued the approach while looking for the runway. Despite the night conditions, there was enough light for the airport tower controller to see the aircraft and the hill‑line to the east, so its terrain clearance did not raise concerns.

At 1855, the aircraft re-entered the Parafield control area and was cleared for a visual approach to the runway, landing shortly thereafter.

What the ATSB found

The ATSB found that during the night visual approach under the IFR, the pilot lost situational awareness, probably as a result of distraction due to a perceived autopilot system issue. The approach was then continued at an altitude below the minimum safe altitude, removing obstacle clearance assurance.

What has been done as a result

The operator’s pilot training program has been updated to include a threat and error management course.

Airservices Australia advised that Parafield Airport tower controllers will be provided with a briefing paper about the incident and incorporate any learning opportunities and safety messaging from the ATSB investigation. The briefing will include information on the circling area, descent below the minimum safe altitude during visual approaches, go-arounds, and the ‘safety alert’ procedure. This procedure is intended to warn pilots that their aircraft is in unsafe proximity to terrain, obstruction, active restricted/prohibited areas, or other aircraft.

Safety message

Handling of approaches is one of the ATSB’s SafetyWatch priorities. Due to the reduced visibility at night, a night approach requires even greater pilot awareness. Unless there is a problem affecting flight safety, pilots should remain focussed on monitoring aircraft and approach parameters, which provides assurance that an approach can be safely completed. If a visual approach cannot be completed, pilots must inform air traffic control so assistance can be provided.

If the criteria for the safe continuation of an approach are not met, for example losing sight of the runway, pilots must initiate a go-around and attain a safe altitude to reduce the risk of colliding with obstacles or terrain.


Download Final report
[Download  PDF: 992KB]

The investigation


The Australian Transport Safety Bureau (ATSB) is investigating a flight below minimum safe altitude involving a Beechcraft Baron 95-B55, VH-CBG, on 13 May 2021.

While conducting a visual approach at night under the instrument flight rules to runway 21 Right at Parafield Airport, the aircraft was manoeuvred outside of the circling area while below the minimum safe altitude. The pilot lost visual contact with the runway, and after regaining visual contact, manoeuvred the aircraft to re-join the circuit for runway 21 Right.

As part of the investigation, ATSB investigators will examine air traffic control recordings and interview crew.

A final report will be released at the conclusion of the investigation.

Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate safety action can be taken.

General details
Date: 13 May 2021   Investigation status: Completed  
Time: 1854 CST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): 5 km north-east of Parafield Airport   Investigation phase: Final report: Dissemination  
State: South Australia   Occurrence type: Flight below minimum altitude  
Release date: 22 October 2021   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Beech Aircraft Corp  
Aircraft model 95-B55  
Aircraft registration VH-CBG  
Serial number TC-1698  
Type of operation Charter  
Sector Piston  
Damage to aircraft Nil  
Departure point Ceduna, South Australia  
Destination Parafield, South Australia  
Last update 22 October 2021