Batik B738 at Canberra on Jun 14th 2024, descended below minimum safe altitude
Last Update: September 4, 2024 / 09:32:50 GMT/Zulu time
Incident Facts
Date of incident
Jun 14, 2024
Classification
Incident
Airline
Batik Air
Flight number
ID-6015
Departure
Denpasar, Indonesia
Destination
Canberra, Australia
Aircraft Registration
PK-LDK
Aircraft Type
Boeing 737-800
ICAO Type Designator
B738
Australia's ATSB rated the occurrence a serious incident and opened an investigation stating:
The ATSB is investigating a flight below minimum altitude involving a Boeing 737-800, registered PK-LDK, about 19 km south of Canberra Airport, Australian Capital Territory, on 14 June 2024. The aircraft was operated by Batik Air as flight ID 6015, scheduled from Denpasar, Indonesia to Canberra.
During an instrument landing system approach into Canberra, the crew elected to hold at the waypoint MOMBI. During the holding, the aircraft was operated below the minimum holding altitude.
On Sep 4th 2024 the ATSB released their preliminary report summarizing the sequence of events:
On the evening of 13 June 2024, a Batik Air Boeing 737-800, registered PK-LDK, departed Denpasar International Airport, Indonesia for the inaugural passenger transport flight of a new service to Canberra, Australian Capital Territory. The captain was acting as pilot flying, and the first officer was acting as pilot monitoring. A second captain was also on board, acting as a relief crewmember, occupying the flight deck jump seat located behind the flight crew during the arrival and approach.
As the aircraft climbed to the cruising level of flight level 350 the crew input forecast winds, which included strong tailwinds, into the aircraft’s flight management computer. The crew noted that the estimated time of arrival into Canberra was prior to 0600 local time on 14 June, when Canberra Tower and Approach air traffic control began providing services for the day (see the section titled Canberra Tower and Approach). The crew elected to continue to Canberra without any en route delays and prepared for an arrival without those air traffic control services, using the Canberra Airport common traffic advisory frequency (CTAF).
As the aircraft descended towards Canberra in darkness, the flight was cleared by air traffic control (ATC) to track via the waypoint AVBEG direct to Canberra Airport and to descend to FL120. During the descent, the flight crew prepared to conduct the AVBEG 5A standard arrival route (STAR) but did not make a request to track via the STAR to the Melbourne Centre air traffic controller managing the airspace.
At 0541 local time, as the aircraft approached AVBEG, ATC cleared the crew to leave controlled airspace descending. The aircraft crossed AVBEG while descending below FL205 and commenced tracking via the AVBEG 5A STAR. The Melbourne Centre air traffic controller identified that the Batik flight was deviating from the cleared track (direct to Canberra) and noted that the aircraft was descending toward a restricted area.
The controller did not query the flight crew’s deviation, but asked the crew if they were going to remain clear of the restricted area. The crew advised the controller that they were tracking via the AVBEG 5A STAR (see the section titled AVBEG 5A standard arrival route and restricted areas). The controller acknowledged the tracking advice and instructed the crew to maintain 10,000 ft above mean sea level (AMSL) to remain above the restricted area. After receiving this instruction, the flight crew became uncertain as to whether the aircraft would be operating within, or outside of, controlled airspace during the STAR and approach.
The crew levelled the aircraft at 10,000 ft AMSL with the autopilot engaged and the aircraft passed over the restricted airspace. As was required by ATC procedures, the controller waited until the aircraft was observed to be more than 2.5 NM past the restricted area before instructing the crew to continue the descent to leave controlled airspace. The crew responded by advising that they would descend and continue tracking via the STAR. At about this time, the crew noted that the aircraft was about 1,300 ft above the desired descent profile for the arrival.
At 0551, the crew requested ATC clearance to conduct the instrument landing system (ILS) approach to runway 35 at Canberra. The controller responded by advising that the Canberra control tower was closed and that CTAF procedures applied for that airspace. At 0551:38, the aircraft descended below 8,500 ft AMSL, outside controlled airspace (class G).
As the aircraft was higher than the desired flightpath, the captain decided to conduct a holding pattern at the approach waypoint of MOMBI to reduce altitude and the first officer requested ATC clearance to hold at MOMBI. The controller responded by providing traffic information for the MOMBI holding pattern. The crew then again requested clearance for the ILS approach and the controller responded by advising that clearance was not required and that the crew must broadcast their intentions on the Canberra CTAF.
At 0553:10, the aircraft passed the arrival waypoint MENZI (Figure 2) while descending below 6,720 ft AMSL and soon after made another request to hold at MOMBI. The controller provided traffic information for the hold and requested that the crew make a right-hand orbit to remain clear of the restricted airspace, now to the west of the aircraft.
As the aircraft approached MOMBI, the captain entered 5,400 ft AMSL (the approach’s minimum safe altitude before intercepting the ILS glideslope) into the autopilot mode control panel (MCP) and at 0554:15, the aircraft descended below the minimum holding altitude of 5,600 ft AMSL (see the section titled Instrument landing system approach) before levelling at 5,400 ft AMSL.
The captain then used the heading select function to make a right turn to a heading of 170°3 and the aircraft commenced turning prior to crossing MOMBI. At 0554:30, the aircraft passed MOMBI at a speed of 172 kt (2 kt above the maximum speed for the 5,600 ft AMSL minimum holding altitude).
The captain then asked the first officer to enter a holding pattern into the aircraft’s flight management system (FMS) at MOMBI. As the aircraft had already passed MOMBI, the waypoint had dropped off the FMS track and the first officer was required to manually re-enter the waypoint into the FMS planned track. As the turn continued, the speed reduced below 170 kt, the captain selected 4,700 ft AMSL (the crew’s intended MOMBI crossing altitude) on the autopilot MCP and the aircraft commenced descending to that altitude. During this time, the Melbourne Centre controller did not identify that the aircraft was operating below the minimum holding altitude of 5,600 ft AMSL.
The aircraft turned to a heading of 170° and continued descending until levelling at 4,700 ft AMSL at 0555:59. As the aircraft tracked south, the incoming Canberra Approach air traffic controller prepared to take control of the Approach airspace (see the section titled Canberra airspace) and commenced a handover with the Melbourne Centre controller.
The aircraft continued south and at 0556:25, proceeded beyond the 14 distance measuring equipment (DME) limit for the 5,600 ft AMSL minimum holding altitude. At or before that DME limit, an inbound turn back to MOMBI needed to be commenced, or the minimum holding altitude increased to 6,000 ft AMSL. By that time, the first officer had completed re-entering MOMBI into the FMS and the captain then used the lateral navigation autopilot mode to commence a right turn toward the waypoint.
As the aircraft was turning back toward MOMBI, at 0556:58, the incoming Canberra Approach controller completed their handover with the Melbourne Centre controller and took over the airspace and the Melbourne Centre radio frequency that the aircraft was using (this frequency then became a Canberra Approach frequency).
At the same time, the Canberra Tower air traffic controller preparing to commence the tower service observed that the aircraft was operating below the minimum holding altitude and made multiple unsuccessful attempts to contact the crew on the Canberra CTAF frequency. As the Canberra Tower controller did not have a direct means of communication with the Melbourne Centre controller, the Tower controller contacted a Melbourne Approach controller to relay their concerns to the Melbourne Centre controller.
The aircraft continued turning toward MOMBI (Figure 3) and as it crossed over the eastern slopes of Mount Campbell at 0557:46, the recorded radio height reduced to a minimum of 924 ft above ground level. At 0558:21, the aircraft rejoined the ILS approach.
The Melbourne Approach controller contacted the Melbourne Centre controller to relay the Tower controller’s concerns about the aircraft’s altitude and the Melbourne Centre controller responded by advising that the airspace was now being controlled by Canberra Approach.
At about the same time, the Canberra Approach controller also identified that the aircraft was operating below the minimum altitude. The controller contacted the crew to provide a safety alert and asked the crew if they were ‘visual’. The crew responded advising that they were ‘visual with the runway’ and continued the approach. The aircraft landed at 0602 without further incident.
The ATSB reported the captain was an instructor pilot (ATPL, 10508 hours total, 7,772 on type) by the airline, the first officer (CPL, 6,843 hours total, 6,688 hours on type), and the relief captain in the observer's seat (ATPL, 11,295 hours total, 11,108 hours on type) and added: "From 1998 to 2010, the captain was a pilot in the Indonesian military and, in that role, had conducted operations in uncontrolled airspace. In 2010, the captain commenced employment with Batik Air’s parent company Lion Air and moved to Batik Air in 2013. From 2010, the captain had not undertaken any flights within uncontrolled airspace. The first officer and relief captain reported having no experience operating in uncontrolled airspace. All crewmembers had previously operated flights to Australian destinations."
The ATSB reported the airline implemented a number of safety actions already:
Following the occurrence, Batik Air implemented several safety actions:
- The Canberra Airport flight crew briefing document was revised to include more detailed information on Canberra air traffic control hours, common traffic advisory frequency (CTAF) procedures, holding requirements and guidance for adherence to lowest safe altitude requirements.
- Internal flight crew notices were also issued to highlight the importance of a comprehensive approach briefing, adherence to air traffic control instructions and altitude awareness. These notices also provided information on CTAF and traffic information by aircraft (TIBA) procedures and highlighted the additional risks and absent protections when operating in non-controlled airspace. Details of this incident were also disseminated to all flight crew and Batik Air conducted a special flight crew briefing with event details and lessons.
- Batik Air also adjusted the flight schedule for the Denpasar to Canberra flight (ID6015) to ensure that arrivals occur during Canberra Tower and Approach air traffic control operating hours.
Incident Facts
Date of incident
Jun 14, 2024
Classification
Incident
Airline
Batik Air
Flight number
ID-6015
Departure
Denpasar, Indonesia
Destination
Canberra, Australia
Aircraft Registration
PK-LDK
Aircraft Type
Boeing 737-800
ICAO Type Designator
B738
This article is published under license from Avherald.com. © of text by Avherald.com.
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