Procedures related event - Melbourne Airport, Victoria, on 4 November 2007, HS-TJW, Boeing 777-2D7

AO-2007-055

Preliminary

Preliminary report released 21 January 2008

On 4 November 2007, a Boeing Company 777-2D7 aircraft, registered HS-TJW, was being operated on a scheduled passenger service from Bangkok, Thailand, to Melbourne, Vic, with 17 crew and 277 passengers on board. During a non-directional beacon (NDB) non-precision approach to runway 16 at Melbourne Airport, the aircraft descended below the segment minimum safe altitude at 6.8 distance measuring equipment (DME, a measure in nautical miles). Soon after, the crew received two enhanced ground proximity warning system (EGPWS) cautions. The crew then levelled the aircraft and conducted a visual approach and landing on runway 16.

Summary

On 4 November 2007, a Boeing Company 777-2D7 (777) aircraft, registered HS-TJW, was being operated on a scheduled passenger service from Bangkok, Thailand to Melbourne, Vic. with 17 crew and 277 passengers on board. During the conduct of a non-directional beacon (NDB) non-precision approach to runway 16 at Melbourne, the crew descended the aircraft below a segment minimum safe altitude. Soon after, the crew received two enhanced ground proximity warning system cautions. At that time, the crew became visual with the ground below and the Melbourne aerodrome controller observed the aircraft 'unusually low for an aircraft'. The crew levelled the aircraft and made a visual approach and landed, on runway 16.

The investigation found that the aircraft had descended below a critical altitude whilst carrying out an NDB approach and that the crew did not monitor the aircraft's progress correctly during the NDB approach.

The aircraft operator had known about the difficulties in flying approaches without constant angle approach paths and was in the process of training flight crews on procedures specific to NDB approaches when the incident occurred. In October 2007, the operator introduced a training program to instruct pilots on a new method to conduct those approaches. At the time of the incident, the pilots of the 777 had not undergone that training.

Occurrence summary

Investigation number AO-2007-055
Occurrence date 04/11/2007
Location Melbourne Aerodrome
State Victoria
Report release date 29/06/2009
Report status Final
Investigation level Systemic
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category E/GPWS warning
Occurrence class Serious Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 777
Registration HS-TJW
Serial number 34591
Sector Jet
Operation type Air Transport High Capacity
Departure point Bangkok, Thailand
Destination Melbourne, Victoria
Damage Nil