Jetgo E135 at Melbourne on Oct 27th 2017, descended below safe height on approach

Last Update: December 19, 2018 / 15:14:21 GMT/Zulu time

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Incident Facts

Date of incident
Oct 27, 2017

Classification
Report

Airline
Jetgo

Flight number
JG-44

Departure
Dubbo, Australia

Destination
Melbourne Essendon, Australia

Aircraft Registration
VH-ZJG

Aircraft Type
Embraer ERJ-135

ICAO Type Designator
E135

A Jetgo Embraer ERJ-135, registration VH-ZJG performing flight JG-44 from Dubbo,NS to Melbourne Essendon,VI (Australia) with 25 passengers and 3 crew, was descending towards Essendon Airport, both flight crew were on their first flight into Essendon and had prepared for an ILS approach to runway 26, when ATC advised runway 26 was not available due to traffic configuration at nearby Melbourne International Airport. The captain considered to request ILS runway 26 nonetheless but was aware that ATC would put them into a hold until coordination was done and thus agreed with the suggested visual approach to Essendon's runway 35. ATC vectored the aircraft for the visual approach to runway 35, instructed the flight to descend to 2100 feet, the first officer, pilot flying, selected 2100 feet into the flight control panel, while the captain, pilot monitoring, was on the lookout to establish visual contact with the runway. ATC queried whether they were visual with the runway just when the captain had lost visual contact with the runway, the first officer joined in the effort to establish visual contact. While the first officer also looked out of the cockpit windows the aircraft descended through 2100 feet. Soon after the captain saw the aircraft descending through 1600 feet, called out Altitude, the first officer stopped the descent at 1500 feet and climbed back to 2100 feet. ATC in the meantime had received an according alert and was instructing the aircraft to climb back to 2100 feet then queried whether the crew wanted to continue the approach. The crew decided to position for another approach and landed safely on second approach.

The ATSB released their final report concluding the probable causes of the incident were:

- During radar vectoring to runway 35 at Essendon, the aircraft descended through the radar lowest safe altitude (2,100 ft). The extent to which there was a problem with the functioning of the aircraft’s automatic flight control system could not be determined.

- Due to the captain (pilot monitoring) having difficulty sighting the runway, as well as perceived pressure to complete the flight, the first officer (pilot flying) focussed his attention outside the aircraft at a critical time during the descent.

- The flight crew did not detect that the aircraft had descended through the assigned level (2,100 ft) until the aircraft reached 1,600 ft.

The ATSB analysed:

During radar vectoring to runway 35 at Essendon Airport, the aircraft descended below the radar minimum safe altitude of 2,100 ft. The flight crew reported that the autopilot was engaged and the altitude of 2,100 ft was preselected at the time of the occurrence. A subsequent engineering inspection found no fault with the AFCS. Because no flight data was able to be obtained, the ATSB was unable to confirm what the AFCS mode(s) and settings were at the time of the occurrence, or the reason why the aircraft descended below the preselected altitude.

Regardless of the reason for the aircraft descending through the prescribed altitude, flight crew have a vital role in monitoring the aircraft’s flight path, particularly during descent. In this case, the first officer (pilot flying) relied upon automation to capture the assigned altitude and diverted his attention outside of the aircraft to assist the captain (pilot monitoring) in sighting the runway. As a result, neither pilot was monitoring the aircraft’s flight instruments or descent path as it approached and subsequently descended through the assigned level, which was also the minimum safe altitude.

The flight had been significantly delayed from its scheduled time of operation. The flight crew were aware of the reduced time margin for their scheduled return flight to depart Essendon prior to the 2300 curfew. In addition, neither pilot had operated at night into Essendon Airport, and the captain’s requested option of conducting an ILS approach to runway 26 had been declined by ATC due to traffic. The captain’s subsequent difficulty in identifying runway 35 at night, the delayed arrival of the aircraft at Essendon and the proximity of the curfew time probably contributed to the first officer (pilot flying) focussing his attention outside the aircraft at a critical time of flight.

Both flight crew had the previous days off duty and had a reasonable amount of sleep the night before. Although both flight crew had been awake for 15−16 hours at the time of the occurrence, there was insufficient evidence to conclude that they were operating at a level of fatigue known to influence performance at the time of the occurrence. Nevertheless, they would probably have been operating at an elevated risk of fatigue during the subsequent two flights.
Incident Facts

Date of incident
Oct 27, 2017

Classification
Report

Airline
Jetgo

Flight number
JG-44

Departure
Dubbo, Australia

Destination
Melbourne Essendon, Australia

Aircraft Registration
VH-ZJG

Aircraft Type
Embraer ERJ-135

ICAO Type Designator
E135

This article is published under license from Avherald.com. © of text by Avherald.com.
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