Aviation safety investigations & reports

Flight below minimum safe altitude, Piper PA-31 Mojave, VH-XGW, near Bankstown Airport, New South Wales, on 22 March 2021

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


Download Final report
[Download  PDF: 1.38MB]

What happened

In the early afternoon of 22 March 2021, a Piper PA‑31P‑350 Mojave aircraft, registered VH-XGW, departed Dubbo Airport, New South Wales (NSW), for a flight conducted under the instrument flight rules to Bankstown Airport, NSW, with one pilot and a crew member on board.

On arrival at Bankstown, the pilot commenced a GPS instrument approach for runway 11C. While the initial part of the approach proceeded normally, the aircraft was observed by the Bankstown tower controller to track 0.5 NM (0.9 km) to the south of the required track and this was advised to the pilot. After the aircraft passed the final approach fix, due to continued deviation, the tower controller instructed the pilot to discontinue the approach.

The pilot initially acknowledged that instruction but then requested, and was approved by the controller, to continue the approach visually as the aircraft had descended clear of cloud. The pilot then conducted extensive manoeuvring, including two orbits, at low altitude that were not in accordance with the approach requirements, before landing the aircraft safely on runway 11C.

What the ATSB found

The ATSB identified that, while conducting an instrument approach into Bankstown Airport in instrument meteorological conditions, the pilot did not conduct a missed approach when the aircraft exceeded the tracking tolerance limits. That resulted in the aircraft operating significantly below the minimum allowable altitude.

Additionally, having descended visually below the minimum descent altitude and commenced manoeuvring to position the aircraft for a landing at Bankstown Airport, the pilot did not conduct a missed approach when the aircraft exited the circling area and the required visual reference with the runway was lost.

Safety message

Managing 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, ensures instrument approaches are conducted safely.

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: 1.38MB]

The investigation


The Australian Transport Safety Bureau (ATSB) is investigating a flight below minimum altitude involving a Piper PA-31P-350, VH-XGW, on 22 March 2021.

While the aircraft was conducting an instrument approach to Bankstown Aerodrome runway 11C, the aircraft was observed to be tracking south of and parallel to the published instrument approach. ATC notified the aircraft of the tracking error and issued a terrain alert with an instruction that the aircraft conduct the published missed approach. The aircraft responded with a request for a visual approach. On receiving confirmation that the aircraft was visual, ATC issued a visual circling approach. The aircraft was then observed to conduct two low level orbits. ATC issued a second terrain alert. The aircraft subsequently joined the Bankstown circuit and landed on runway 11C.

As part of the investigation, ATSB investigators will examine ATC 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: 22 March 2021   Investigation status: Completed  
Time: 1448 EDT   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): 6 km west of Bankstown Airport   Investigation phase: Final report: Dissemination  
State: New South Wales   Occurrence type: Flight below minimum altitude  
Release date: 06 December 2021   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Piper Aircraft Corp  
Aircraft model PA-31P-350 Mojave  
Aircraft registration VH-XGW  
Serial number 31P-8414001  
Operator Airmed Australia Pty Ltd  
Type of operation Aerial Work  
Sector Piston  
Damage to aircraft Nil  
Departure point Dubbo Airport, New South Wales  
Destination Bankstown Airport, New South Wales  
Last update 09 December 2021