Investigation number
Occurrence date
6 km NE Coffs Harbour Airport
Report release date
Report status
Investigation type
Occurrence Investigation
Investigation status
Occurrence category
Highest injury level

This report highlights the potential safety benefits of the
Flight Safety Foundation ALAR Tool Kit, especially in regard to the
conduct of non-precision approaches.

Local safety action

The operator has advised that a review of processes has been
carried out and new procedures are in place to ensure that a
similar incident does not occur again. Some of the changes were
reported to have been in the process of being introduced at the
time of the accident.

Reported changes included the following:

  • Appointment of new personnel to key operational roles
  • Creation of a position of Flight Training Manager
  • Creation of a position of Quality Assurance Manager -
  • Review of Flight Manual Supplements
  • Rewriting of the Flight Operations Manual
  • Issue of a standing order to all pilots that a go-around is to
    be conducted anytime on approach below 1,000 ft above ground level,
    if the approach is not stabilised and the sink rate is in excess of
    1,000 fpm
  • Reviewing the use of radio altimeter in non-precision
  • Rewriting of the Check and Training Manual
  • Development of a Quick Action Handbook to cover emergency

At the time of the occurrence, replacement aircraft for the
Sydney-based aeromedical service were on order. Specifications for
the new aircraft included an Enhanced Ground Proximity Warning
System. Those aircraft are now in service.

Airservices Australia is reviewing the Manual of Air Traffic
Services to clarify and remove the ambiguity relating to descent
restrictions for pilots conducting instrument approaches in

Appendix A: Coffs Harbour Runway 21 GPS NPA Approach

Published with permission of Jeppesen Sanderson, Inc. - NOT

Appendix B: Elements of a Stabilised

Note: A suggested definition or policy that might be
considered by operators could be as follows:
"All flights
shall be stabilised by 1,000 feet height above touchdown (HAT) in
instrument meteorological conditions (IMC) and by 500 feet HAT in
visual meteorological conditions (VMC)." An approach is considered
stabilised when all of the following criteria are met:

  1. The aircraft is on the correct flight path
  2. Only small changes in heading and pitch are required to
    maintain that path
  3. The aircraft speed is not more than Vref + 20 knots indicated
    airspeed (KIAS) and not less than Vref
  4. The aircraft is in the proper landing configuration (approach
    configuration for small twins)
  5. Sink rate is maximum 1,000 feet per minute; if an approach
    requires a sink rate greater than 1,000 feet per minute, a special
    briefing is to be performed
  6. Power setting appropriate for configuration and not below the
    minimum power for approach as defined by the aircraft operations
  7. All briefings and checklists have been performed
  8. Specific types of approaches are considered stabilised if they
    also fulfil the following:

    • Instrument landing system (ILS) approaches - must be flown
      within one dot of the glideslope or localiser; a category II or III
      approach must be flown within the expanded localiser band.
    • Visual approaches - wings must be level on final when the
      aircraft reaches 500 feet HAT.
    • Circling approaches - wings must be level on final when
      aircraft reaches 300 feet HAT
  9. Unique approaches such as the 'old' Hong Kong airport, and the
    DCA (Washington, D.C.) river visual approach to Runway 18 require a
    special briefing

Source: Flight Safety Foundation
Approach-and-Landing Accident Reduction Task Force.


Aircraft Details
Departure point
Sydney, NSW
Coffs Harbour, NSW
Serial number
Operation type
Aerial Work
Raytheon Aircraft Company
Departure time
0700 hours EST
Crew Details
Class of Licence
Hours on Type
Hours Total