Express Freighters B733 at Launceston on Jun 17th 2016, during go around flew below minimum safe altitude
Last Update: November 28, 2017 / 17:10:31 GMT/Zulu time
Incident Facts
Date of incident
Jun 17, 2016
Classification
Incident
Airline
Express Freighters
Departure
Melbourne, Australia
Destination
Launceston, Australia
Aircraft Registration
VH-XMO
Aircraft Type
Boeing 737-300
ICAO Type Designator
B733
The aircraft refueled in Melbourne, departed again about 100 minutes after landing, entered a hold at Launceston for about 70 minutes, then commenced a safe landing in Launceston.
Australia's TSB reported on Jun 20th 2016, that the aircraft diverted off published heading while performing the published missed approach procedure for the ILS runway 32 approach and flew below the lowest safe altitude. The occurrence was rated an incident and is being investigated.
On Nov 28th 2017 the ATSB released their final report concluding the probable causes of the incident were:
Contributing factors
- The instrument approach briefing conducted by the flight crew did not ensure there was a shared understanding of how the aircraft would be manoeuvred following completion of the published missed approach.
- The absence of an established, and shared, manoeuvring plan, resulted in the aircraft being operated in an area below the prescribed minimum safe altitude.
- On completion of the missed approach, the flight crew did not obtain an onwards airways clearance prior to further manoeuvring. That negated the terrain clearance assurance that would otherwise have been provided and increased the risk of conflict with other aircraft.
Other findings
- The flight path monitoring and safety alerts issued by air traffic control, provided the flight crew with clear and timely minimum altitude requirements and ensured the aircraft was operated well clear of terrain.
The ATSB reported the aircraft had been on a final ILS approach to Launceston's runway 32L when a decision height (750 feet MSL, 202 feet AGL) the crew could not see the runway and initiated a go around. The aircraft levelled off at the missed approach altitude of 3200 feet MSL, however, about 20 seconds after levelling off at 3200 feet the captain rotated the heading bug for a left turn to a south westerly heading with the intention to position the aircraft over the aerodrome for another approach. The ATSB wrote: "The FO reported being surprised by the turn and immediately thought that they should climb the aircraft."
When the crew reported with ATC again advising they had gone around ATC queried whether they were following the missed approach procedure which the crew affirmed stating they were turning back to Launceston. The captain reacted to a radio call from Launceston ground, handed control to the first officer instructing to keep the turn going, then discussed the weather scenario with the ground. The first officer noticed the radio altimeter became active and advised the captain they should climb the aircraft. On a heading of 140 degrees the aircraft was climbing through 3900 feet MSL when ATC advised they were nearing the boundary of the 3200 feet MSA sector and would either need to stay within the sector or climb to 5800 feet MSL. The aircraft entered the 5800 feet MSL sector at 4400 feet MSL on a steady heading of 110 degrees. ATC issued a safety alert for terrain and instructed the crew to climb to 5800 feet MSL immediately, in response the crew advised they were climbing to 6000 feet. The aircraft subsequently was about to enter a 6300 feet MSA sector, ATC instructed to immediately climb to 6300 feet MSL. The crew advised they would return to Melbourne, a short time later ATC re-issued the instruction to immediately climb to 6300 feet as the aircraft had still not reached 6300 feet MSL. The aircraft was subsequently cleared to climb to cruise level and returned to Melbourne.
The ATSB analysed:
Flight below the minimum sector altitude (MSA) occurred following a missed approach that was conducted due to poor weather conditions. While the flight crew assessed that the safety of the aircraft was never in doubt, there was confusion as to how the aircraft was to be manoeuvred on completion of the missed approach.
This analysis will examine the aircraft’s flight path following the missed approach, and factors that contributed to the flight below MSA.
Prior to commencing descent, the crew conducted a normal approach briefing. The prevailing weather conditions at Launceston airport were such that the flight crew were required to conduct an instrument landing system (ILS) approach. The weather conditions also meant that it was reasonably foreseeable that they would need to conduct a missed approach. While an instrument approach briefing was conducted prior to descent, and covered the standard components including the missed approach segment, there was no discussion of how the aircraft would be subsequently manoeuvred.
A missed approach following an ILS approach is not common as the associated low weather minima usually permits the landing to be completed. As such, planning how the aircraft is to be manoeuvred in the event of a missed approach may not always be considered in detail.
Additionally, tracking and altitude requirements following a missed approach are often provided by air traffic control (ATC), particularly in the case of larger commercial aircraft such as VH-XMO. Additionally, with the exception of situations such as simulator training, missed approaches are often unexpected. Consequently, the safe conduct of a go-around and subsequent manoeuvring relies on a shared appreciation to avoid the need to clarify intentions during an already busy period. Irrespective of the weather conditions, a thorough go-around briefing, that gives consideration to factors such as initial and subsequent flight paths, crew actions and co-ordination, terrain clearance and ATC requirements, offers an effective means of ensuring that a common appreciation exists.
Although air traffic control (ATC) services were available en route and during descent, Launceston Tower was closed when the aircraft arrived. Consequently, the normally tower-controlled Class D airspace below 1,500 ft became non-controlled Class G airspace. This meant that, in the event of a missed approach, the aircraft would re-enter Launceston Class C and D controlled airspace at 1,500 ft and an ATC clearance would be required prior to manoeuvring beyond the published missed approach.
The approach and missed approach flight paths were aligned to enable the aircraft to descend and climb clear of terrain. The missed approach path positioned the aircraft within a sector that had an MSA of 3,200 ft. Any manoeuvring outside of that sector required the crew to climb the aircraft to the relevant sector MSA prior to entry. In this case, the left turn was towards a sector that had an MSA of 5,800 ft. Alternatively, climbing straight ahead on the missed approach track to 5,800 ft would have enabled the crew to manoeuvre the aircraft as required within 10 NM (19 km) of the airport.
On completion of the missed approach, the captain commenced a left turn with the intention of positioning the aircraft for a second approach. While a continuous left turn may have maintained the aircraft within the 3,200 ft sector, this manoeuvre had not been discussed during the approach briefing. As a result, when the CA handed control of the aircraft to the FO, the left turn was stopped on a south-easterly heading.
The south-easterly flight path resulted in the aircraft tracking towards a sector with a MSA of 5,800 ft while at an altitude of 3,200 ft. Although the crew had commenced a climb, the aircraft had only achieved an altitude of 4,400 ft when it entered the 5,800 ft sector. As a result, ATC issued a safety alert for terrain proximity. ATC also issued instructions for an immediate climb to 5,800 ft and later, to 6,300 ft.
Although the aircraft was never in immediate danger of colliding with terrain, it was operated over an area and at an altitude less than that prescribed for safe flight. Had the required clearance been obtained prior to manoeuvring, ATC would have provided the crew with appropriate tracking and altitude requirements. Additionally, without the flight path monitoring and timely altitude alerts provided by ATC, the risk of collision with terrain may have increased.
Had the approach briefing included a discussion about subsequent manoeuvring, both crew members would have had a shared understanding of the expected flight path. Such a discussion would have provided the crew with an opportunity to discuss alternative tracking, minimum safe altitude requirements, and the need to obtain a clearance.
Metars:
YMLT 161700Z AUTO 33012KT 0450 // OVC002 12/11 Q1008
YMLT 161630Z AUTO 34012KT 1300 -SHRA OVC002 11/11 Q1009
YMLT 161600Z AUTO 34012KT 2500 // OVC002 11/11 Q1009
YMLT 161530Z AUTO 34012KT 0300 // OVC002 11/11 Q1009
YMLT 161516Z AUTO 34012KT 6000 -SHRA OVC002 11/11 Q1009
YMLT 161513Z AUTO 34012KT 9000 -SHRA OVC002 11/11 Q1009
YMLT 161500Z AUTO 34011KT 6000 -SHRA OVC002 11/11 Q1009
YMLT 161430Z AUTO 34011KT 0600 -SHRA OVC001 11/11 Q1010 RESHRA
YMLT 161400Z AUTO 34013KT 5000 -RA OVC001 11/10 Q1010 RERA
YMLT 161330Z AUTO 34013KT 1900 RA OVC001 11/10 Q1010
YMLT 161300Z AUTO 34013KT 6000 -RA OVC001 10/10 Q1011
YMLT 161230Z AUTO 33011KT 2500 -SHRA OVC003 OVC007 10/10 Q1011
YMLT 161200Z AUTO 33008KT 4900 // OVC009 10/09 Q1011
Aircraft Registration Data
Incident Facts
Date of incident
Jun 17, 2016
Classification
Incident
Airline
Express Freighters
Departure
Melbourne, Australia
Destination
Launceston, Australia
Aircraft Registration
VH-XMO
Aircraft Type
Boeing 737-300
ICAO Type Designator
B733
This article is published under license from Avherald.com. © of text by Avherald.com.
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