REX SF34 at Williamtown on Nov 8th 2012, crew misidentifies aerodrome

Last Update: March 13, 2015 / 20:29:51 GMT/Zulu time

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Photo of REX Regional Express VH-TRX, SAAB 340 — REX Regional Express VH-TRX, SAAB 340 (Photo credit: Ev Brown / Flickr / License: CC by)

Incident Facts

Date of incident
Nov 8, 2012

Classification
Report

Airline
REX Regional Express

Flight number
ZL-382

Departure
Sydney, Australia

Destination
Williamtown, Australia

Aircraft Registration
VH-TRX

Aircraft Type
SAAB 340

ICAO Type Designator
SF34

A REX Regional Express Saab 340B, registration VH-TRX performing flight ZL-382 from Sydney,NS to Williamtown,NS (Australia) with 2 passengers and 3 crew, was descending towards Williamtown about 20 minutes before last light at 19:28L when Williamtown Approach cleared the flight for a visual approach to runway 12 via a right downwind and to contact Williamtown Tower, the aircraft was about 10nm from wthe aerodrome. A minute later the crew contacted tower while the approach controller continued to monitor the progress of the flight and noticed the aircraft was turning left unexpectedly.

In the meantime the captain had identified buildings and lights as associated with the aerodrome and provided the first officer with tracking information. The captain later confirmed that he had misidentified buildings and lights of a coal loading and storage facility 6nm southwest of the aerodrome as the aerodrome.

The first officer was not confident seeing the runway and queried but when the captain explained they were doing a wide base turn did not insist considering that the captain's experience at Williamtown was greater than his.

At 19:31L the approach controller, while still observing the aircraft, became concerned and prompted the tower controller to query the crew. Tower queried whether the crew was still visual, the crew replied they had lost contact with the runway and were doing a right hand turn.

The first officer, becoming increasingly uneasy about the aircraft's position, handed control of the aircraft to the captain and subsequently noticed that the distance to the aerodrome on the DME was larger than expected.

The controllers realised the crew had lost situational awareness, the tower offered to increase intensity of the runway lights, at the suggestion of the approach controller the tower controller added they were 6nm southwest of the aerodrome tracking east.

The ATSB reported: "When told they were not at the airport, the captain immediately requested radar vectors8 to resolve the uncertainty. As the tower controller was not qualified to provide radar vectors, a heading of left 020° was suggested. At about the same time, the crew turned onto a southerly heading and descended to 680 ft. While the aircraft was tracking south, heading toward the boundary of controlled airspace, the approach controller advised the tower controller to instruct the crew of TRX to initiate a climb and pass traffic advice to the crew about another aircraft 5 NM (9 km) ahead and outside controlled airspace. The tower controller advised the crew to climb, but did not issue a safety alert or a clearance as that would have necessitated a coordinated handover to the approach controller and a radio frequency change. Instead, the controllers elected to keep TRX on the tower frequency and under tower control as visual meteorological conditions11 existed and both controllers could see the aircraft."

The ATSB continued: "Information from the flight data recorder showed that the aircraft climbed to about 900 ft. The captain reported that engine power was increased but they did not commence a go-around or reconfigure the aircraft. The approach controller reported suggesting that the tower controller advise the crew to turn north in order to locate the airport. The captain complied and adopted a northerly heading before requesting further guidance as they could still not see the runway. The tower controller turned the runway lighting to stage 6 (full brightness) and continued to provide position information until satisfied that the crew had sighted runway 12. At about 1935, after further guidance, the captain identified the runway and approach lights and positioned the aircraft for a landing on runway 12. The aircraft landed at about 1937, 14 minutes before last light. After landing, the crew advised the aerodrome controller that they were unfamiliar with locating the airport ‘at night’."

The ATSB released their final report concluding the probable cause of the incident was:

In the low light conditions and using the visual cues available, the captain incorrectly identified a coal loading and storage facility as the airport environment and manoeuvred the aircraft for an approach to that location.

The ATSB analysed: "The phenomenon of pilots attempting to approach areas that have similar features to the destination airport environment or runway has occurred previously and is generally due to the features strongly resembling the airport environment or runway. Pilot’s rely on these visual cues to confirm their understanding of their position and, unless they are alerted by air traffic control (ATC) or another crewmember, they often persist with the approach, believing they are aligned with the runway."

The ATSB further analysed: "The FO displayed sound crew resource management skills in seeking to hand control to the captain when he became uncertain of the aircraft’s position. However, the FO reported that, while he sighted the coal facility after handing over control, by not articulating their uncertainty about the aircraft’s position, an opportunity was missed to alert the captain to the misidentification of the airport environment and associated navigational error. Earlier understanding by the crew of the aircraft’s actual position would likely have precluded the descent to 680 ft. When the captain requested radar vectors to runway 12, the tower controller provided a suggested heading of 020°. However, it was only following further suggested headings and advice on the position of the airport reference the aircraft that the crew visually acquired the runway. A missed approach and a climb to a circuit height of 1,500 ft after being alerted by ATC of the apparent navigational error would have afforded the crew a better chance of visually acquiring the runway sooner."

The ATSB analysed that both controllers were familir with the approach pattern to be flown. When the aircraft descended through 1300 feet about 8nm southwest of the aerodrome tracking to the west the controllers decided to query the crew but keep them on tower frequency in order to not increase their workload and to limit distractions. The ATSB concluded analysis of ATC performance: "When the crew advised that they were having difficulty sighting the runway, the tower controller informed them of their location reference the airport and advised them to climb. The preface of that transmission with the phrase ‘safety alert – low altitude warning’, and an instruction to climb to the 10 NM (19 km) minimum safe altitude of 2,100 ft, may have more promptly enhanced the crew’s situation awareness and alerted them to the potential risk of being at low level in that area."

With respect to the environment the ATSB wrote: "The flight was completed in daylight and although visibility was reported to have been good, the crew reported that lighting conditions were darker than usual at that time of the evening due to cloud cover in the western sky. Although the tower controller increased the intensity of the airport approach lighting in an attempt to assist the crew identify the runway, the aircraft’s low altitude probably meant that the runway and approach lighting was not as readily apparent to them. Additionally, Williamtown did not, and was not required to have an aerodrome beacon to provide additional visual guidance in conditions of poor light and at night."