Pionair E290 at Napier on May 24th 2023, descended below safe height

Last Update: March 5, 2024 / 12:10:16 GMT/Zulu time

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Incident Facts

Date of incident
May 24, 2023

Classification
Report

Airline
Pionair

Departure
Auckland, New Zealand

Destination
Napier, New Zealand

Aircraft Registration
VH-IKJ

Aircraft Type
Embraer ERJ-190-E2

ICAO Type Designator
E290

A Pionair Embraer ERJ-190-300, registration VH-IKJ performing a non-scheduled flight from Auckland to Napier (New Zealand) with 86 passengers and 6 crew, was descending towards Napier when the crew determined their aircraft would be above maximum landing weight upon landing in Napier due to short cuts granted by ATC enroute and additional fuel uplift in Auckland and while conducting the Napier RNP 16 approach decided to enter a hold over waypoint GENDA to burn off fuel. The crew subsequently continued the approach descending through a thin layer of stratus cloud triggering an ice detection alert requiring the crew to work the stall protection ice speed checklist. The crew therefore entered a left hold at 1800 feet (MSA 3300 feet) at waypoint FF16, re-intercepted the final approach path and continued for a safe landing.

On Mar 5th 2024 Australia's Transportation Safety Board (ATSB) released their final report concluding the probable causes of the incident were:

Contributing factors

- After passing the initial approach fix at ELBOW, the aircraft unexpectedly encountered ice, requiring the crew to conduct the appropriate checklists which increased their workload during a critical phase of flight.

- After passing the intermediate approach fix at AROPA, the aircraft was high on the approach and the crew felt time pressure to land the aircraft resulting in the crew conducting an orbit, which was not part of the approach criteria.

- The pilot flying believed the visual approach criteria had been met resulting in the flight crew conducting an orbit below the minimum safe altitude.

The ATSB summarized the relevant part of the approach:

Near waypoint ELBOW, the aircraft flew through a thin layer of stratus cloud resulting in an ice detection system advisory alert. This required the crew to conduct the Stall Protection Ice Speed checklist, and to recomplete the Approach checklist. Passing the intermediate approach fix at AROPA, the crew observed that the aircraft was now high on the approach and increased the descent rate in an attempt to capture the vertical profile from above.

Just prior to reaching the final approach fix at FF16, the captain, who was the pilot flying, engaged altitude hold along with heading mode on the autopilot, and commanded the aircraft to conduct a left orbit over the ocean. This took the aircraft beyond the inbound approach track tolerance for the approach segment and below the minimum safe altitude (see section titled Minimum altitude for flight). The crew completed the Stall Protection Ice Speed checklist and after re-intercepting the final approach track, re-commenced the descent, before continuing the procedure and landing at Napier Airport.

The ATSB analysed:

Prior to the departure from Auckland, the flight was significantly delayed, and the crew were advised that the airport at Napier would close if they did not depart within a short timeframe. This resulted in the crew feeling rushed during their preparations. They advised they continued to feel rushed during the flight and the requirement to enter a holding pattern to burn extra fuel added to this perceived time pressure.

During their approach brief, the crew did not identify icing as a potential threat and therefore were not prepared to complete the Stall Protection Ice Speed checklist when they received the advisory message. A high workload quickly developed inside the cockpit as the first officer had difficulty locating the checklist in the electronic Quick Reference Handbook.

ADS-B data confirmed that the aircraft became high on the vertical approach profile prior to joining the Napier RNP 16 instrument procedure. It also confirmed that the crew did not enter the published holding pattern at AROPA to complete the preparations and instead, continued descending to join the vertical profile. At this time, the pilot monitoring was still completing the checklist and was unable to give full attention to monitoring the aircraft’s flight path.

The pilot flying was using the VNAV autopilot function to descend the aircraft and had expected the autopilot to capture the vertical glide path and begin a constant rate of descent. However, a combination of the aircraft been too high, and underestimating the distance to run due to a misinterpretation of the fly-by waypoint, resulted in the aircraft’s position not being within the autopilot parameters to capture the vertical glide path. The pilot flying attempted to capture the glide path from above using the flight path angle autopilot mode but was unable to successfully do so.

The captain decided that they needed to reduce the workload in the cockpit prior to continuing through the final approach fix. Due to the perceived time pressure and a desire to minimise further delay they decided to do this by conducting an orbit rather than a missed approach which would take significantly longer. They believed the visual approach criteria could be complied with and without further discussion, a left turn was commanded via the autopilot descending to 1,800 ft.

The left turn took the aircraft beyond the lateral tolerance of the intermediate approach segment and below the minimum safe altitude of 3,300 ft.

The flight crew reported that the E190-300 flight characteristics and autopilot system are slightly different to other variants the crew were more experienced with. So, while their experience on the type technically exceeded the ‘inexperience flight crew’ requirements, the combined 89 hours of E190-300 experience likely contributed to the high workload in the cockpit.
Incident Facts

Date of incident
May 24, 2023

Classification
Report

Airline
Pionair

Departure
Auckland, New Zealand

Destination
Napier, New Zealand

Aircraft Registration
VH-IKJ

Aircraft Type
Embraer ERJ-190-E2

ICAO Type Designator
E290

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