Safety Action
Local Safety Action
The airline has issued a fleet notice to B767 crews, reminding pilots to be more vigilant when flying into Sydney, and alerting them to the inadequacy of holding information.
BASI Safety Action
As a result of this occurrence, the Bureau of Air Safety Investigation is currently investigating a perceived safety deficiency.
The deficiency relates to the depiction of holding patterns on en-route charts, the appropriateness of the use of non-standard holding patterns, and associated radiotelephony phraseology.
Any safety output issued as a result of this analysis will be published in the Bureau's Quarterly Safety Deficiency Report.
Summary
Air traffic control had issued the crew of a foreign Boeing 767 (B767) with an instruction to hold at Bindook. Although the published holding procedure required a left pattern, the crew turned the aircraft for a right pattern. The right turn subsequently placed the aircraft into conflict with a Boeing 747, which was being radar vectored to the south of Bindook. Separation was reduced to approximately 700 ft vertically, and 4 NM laterally. The required separation standard was 1,000 ft, or 5 NM.
An investigation revealed that the crew did not locate the holding pattern on the Jeppesen terminal chart. The depiction of the holding pattern was difficult to distinguish from other markings on the chart and the pattern was not displayed on the appropriate Standard Arrival Route (STAR) chart. In addition, the holding pattern was not loaded in the aircraft's flight management computer database. The Captain of the B767 reported that in the USA, where a holding pattern is not displayed, or in the absence of other information, a "default" right hand pattern is to be flown. There is no such procedure in Australia. As a result, the Captain elected to fly a right hand pattern without checking with air traffic control for holding pattern information.
Occurrence summary
| Investigation number | 199803921 |
|---|---|
| Occurrence date | 21/09/1998 |
| Location | 9 km S Bindook |
| State | New South Wales |
| Report release date | 17/08/1999 |
| Report status | Final |
| Investigation type | Occurrence Investigation |
| Investigation status | Completed |
| Mode of transport | Aviation |
| Aviation occurrence category | Loss of separation |
| Occurrence class | Incident |
| Highest injury level | None |
Aircraft details
| Manufacturer | The Boeing Company |
|---|---|
| Model | 767 |
| Registration | N601EV |
| Sector | Jet |
| Operation type | Air Transport High Capacity |
| Departure point | Taipei, TAIWAN |
| Destination | Sydney, NSW |
| Damage | Nil |
Aircraft details
| Manufacturer | The Boeing Company |
|---|---|
| Model | 747 |
| Registration | 9M-MPD |
| Sector | Jet |
| Operation type | Air Transport High Capacity |
| Departure point | Melbourne, VIC |
| Destination | Sydney, NSW |
| Damage | Nil |