Aviation safety investigations & reports

Flight below the minimum safe altitude involving Fairchild SA227, VH-OZV 9 km east of Melbourne Airport, Victoria on 18 January 2021

Investigation number:
AO-2021-003
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

Download Final Report
[Download  PDF: 558KB]
 

What happened

On 18 January 2021, at 2029 Eastern Daylight‑saving Time, a Sharp Airlines Fairchild SA227 aircraft, registered VH-OZV, departed Launceston Airport, Tasmania for a scheduled freight flight to Melbourne Airport, Victoria with one pilot on board.

At 2133, the aircraft was being positioned to commence a night-time Instrument Landing System approach to runway 27 at Melbourne. While joining the approach, a turn was not commenced until after the aircraft crossed the localiser track.

After crossing the localiser track and while descending along the approach glideslope, the aircraft descended clear of cloud and the pilot sighted the runway. At that time, the aircraft was positioned slightly less than full-scale on the course deviation indicator (CDI) to the right of, and tracking away from, the localiser track. From this position, the pilot elected to continue the approach visually. However, exacerbated by a prevailing southerly wind, the aircraft continued tracking away from the localiser and, shortly after, proceeded beyond the full scale of the CDI, requiring that a missed approach be initiated. Despite that, the pilot assessed that the visual approach could be continued.

The aircraft continued to deviate from the localiser track and at 2135, reached a maximum lateral deviation of 0.55 nautical miles. The pilot then turned the aircraft further to track toward the localiser while continuing to descend. At about the same time, the Melbourne Tower air traffic controller noticed the deviation and contacted the pilot.

At 2136, at about 980 ft above mean sea level (about 583 ft above ground level), the aircraft was re‑established within full-scale CDI deflection and landed shortly after.

What the ATSB found

The ATSB found that during approach to the airport in darkness, the aircraft was not maintained within the required navigational tolerance. While that should have resulted in the conduct of a missed approach, the approach was continued with the aircraft manoeuvring significantly below the minimum safe altitude.

Safety message

Handling of approaches is one of the ATSB’s SafetyWatch priorities. Adherence to operational procedures ensures consistency of pilot action and aircraft operation during the approach and landing phases of flight. This, along with careful monitoring of aircraft and approach parameters, provides assurance that an instrument approach can be safely completed.

Most importantly, if the criteria for safe continuation of an approach are not met, the pilot should conduct a missed approach to negate the risk of colliding with obstacles or terrain.

Download Final Report
[Download  PDF: 558KB]
 
 
 

The investigation

General details
Date: 18 January 2021   Investigation status: Completed  
Time: 21:34 EDT   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): 9 km east of Melbourne Airport, Victoria   Investigation phase: Final report: Dissemination  
State: Victoria   Occurrence type: Flight below minimum altitude  
Release date: 25 June 2021   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Fairchild Industries Inc  
Aircraft model SA227-AC  
Aircraft registration VH-OZV  
Serial number AC-610B  
Operator Sharp Aviation Pty Ltd  
Type of operation Air Transport Low Capacity  
Sector Turboprop  
Damage to aircraft Nil  
Departure point Launceston, Tasmania  
Destination Melbourne, Victoria  
Last update 25 June 2021