ATSB TRANSPORT SAFETY REPORT

Aviation Occurrence Investigation –AO-2007-055

Final

Procedures-related event
Melbourne Airport, Vic.
4 November 2007
HS-TJW
Boeing Company 777-2D7
 ATSB TRANSPORT SAFETY REPORT
Aviation Occurrence Investigation – AO-2007-055
Final

Procedures-related event
Melbourne Airport, Vic.
4 November 2007
HS-TJW
Boeing Company 777-2D7

Released in accordance with section 25 of the Transport Safety Investigation Act 2003

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Published by: Australian Transport Safety Bureau
Postal address: PO Box 967, Civic Square ACT 2608
Office location: 62 Northbourne Avenue, Canberra City, Australian Capital Territory
Telephone: 1800 020 616; from overseas + 61 2 6257 4150
Accident and incident notification: 1800 011 034 (24 hours)
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E-mail: [email protected]
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© Commonwealth of Australia 2009.

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ISBN and formal report title: see ‘Document retrieval information’ on page v.

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CONTENTS

THE AUSTRALIAN TRANSPORT SAFETY BUREAU ................................. vi

FACTUAL INFORMATION ................................................................................ 1

Sequence of events............................................................................................ 1
Personnel information ....................................................................................... 5
Flight Crew ........................................................................................... 5
Air traffic controllers ............................................................................ 6
Aircraft systems ................................................................................................ 6
Automatic flight control system ........................................................... 6
Enhanced ground proximity warning system ....................................... 7
Meteorological information .............................................................................. 7
Aerodrome forecasts............................................................................. 7
Actual weather information .................................................................. 8
Provision of weather information to the flight crew............................. 8
Aids to navigation ............................................................................................. 8
Ground-based navigation aids .............................................................. 8
Unavailability of the runway 16ILS ..................................................... 9
Communications ............................................................................................... 9
Aerodrome information .................................................................................... 9
Recorded information ....................................................................................... 9
Airline operations manuals ............................................................................... 9
Flight Operations Manual ................................................................... 10
Flight Crew Training Manual 777 ...................................................... 11

ANALYSIS ............................................................................................................ 13
Operator actions .............................................................................................. 13
Crew actions ................................................................................................... 13
Mode control panel operation ......................................................................... 13
Weather aspects .............................................................................................. 14
Company procedures ...................................................................................... 14
System defences .............................................................................................. 14

FINDINGS............................................................................................................. 17
Contributing safety factors .............................................................................. 17
Other safety factors ......................................................................................... 17

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SAFETY ACTIONS ............................................................................................. 19
Aircraft operator.............................................................................................. 19
Continuous Descent Final Approach training .................................... 19

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DOCUMENT RETRIEVAL INFORMATION
Report No. Publication date No. of pages ISBN
AO-2007-005 29 June 2009 27 978-1-921602-79-5

Publication title
Procedures-related event – Melbourne Airport, Vic. - 4 November 2007 - HS-TJW, Boeing
Company 777-2D7

Prepared by Reference No.

Australian Transport Safety Bureau INFRA-08556
PO Box 967, Civic Square ACT 2608 Australia
www.atsb.gov.au
Acknowledgements
Figure 1. Courtesy of Lido
Figure 3. Courtesy of the Boeing Company

Abstract
On 4 November 2007, a Boeing Company 777-2D7 (777) aircraft, registered HS-TJW, was being
operated on a scheduled passenger service from Bangkok, Thailand to Melbourne, Vic. with 17
crew and 277 passengers on board. During the conduct of a non-directional beacon (NDB) non-
precision approach to runway 16 at Melbourne, the crew descended the aircraft below a segment
minimum safe altitude. Soon after, the crew received two enhanced ground proximity warning
system cautions. At that time, the crew became visual with the ground below and the Melbourne
aerodrome controller observed the aircraft ‘unusually low for an aircraft’. The crew levelled the
aircraft and made a visual approach and landed, on runway 16.
The investigation found that the aircraft had descended below a critical altitude whilst carrying
out an NDB approach and that the crew did not monitor the aircraft’s progress correctly during
the NDB approach.
The aircraft operator had known about the difficulties in flying approaches without constant angle
approach paths and was in the process of training flight crews on procedures specific to NDB
approaches when the incident occurred. In October 2007, the operator introduced a training
program to instruct pilots on a new method to conduct those approaches. At the time of the
incident, the pilots of the 777 had not undergone that training.

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THE AUSTRALIAN TRANSPORT SAFETY BUREAU
The Australian Transport Safety Bureau (ATSB) is an operationally independent
multi-modal bureau within the Australian Government Department of
Infrastructure, Transport, Regional Development and Local Government. ATSB
investigations are independent of regulatory, operator or other external
organisations.
The ATSB is responsible for investigating accidents and other transport safety
matters involving civil aviation, marine and rail operations in Australia that fall
within Commonwealth jurisdiction, as well as participating in overseas
investigations involving Australian registered aircraft and ships. A primary concern
is the safety of commercial transport, with particular regard to fare-paying
passenger operations.
The ATSB performs its functions in accordance with the provisions of the
Transport Safety Investigation Act 2003 and Regulations and, where applicable,
relevant international agreements.
Purpose of safety investigations
The object of a safety investigation is to enhance safety. To reduce safety-related
risk, ATSB investigations determine and communicate the safety factors related to
the transport safety matter being investigated.
It is not the object of an investigation to determine blame or liability. However, an
investigation report must include factual material of sufficient weight to support the
analysis and findings. At all times the ATSB endeavours to balance the use of
material that could imply adverse comment with the need to properly explain what
happened, and why, in a fair and unbiased manner.
Developing safety action
Central to the ATSB’s investigation of transport safety matters is the early
identification of safety issues in the transport environment. The ATSB prefers to
encourage the relevant organisation(s) to proactively initiate safety action rather
than release formal recommendations. However, depending on the level of risk
associated with a safety issue and the extent of corrective action undertaken by the
relevant organisation, a recommendation may be issued either during or at the end
of an investigation.
The ATSB has decided that when safety recommendations are issued, they will
focus on clearly describing the safety issue of concern, rather than providing
instructions or opinions on the method of corrective action. As with equivalent
overseas organisations, the ATSB has no power to implement its recommendations.
It is a matter for the body to which an ATSB recommendation is directed (for
example the relevant regulator in consultation with industry) to assess the costs and
benefits of any particular means of addressing a safety issue.
About ATSB investigation reports: How investigation reports are organised and
definitions of terms used in ATSB reports, such as safety factor, contributing safety
factor and safety issue, are provided on the ATSB web site www.atsb.gov.au.

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FACTUAL INFORMATION

Sequence of events
On 4 November 2007, a Boeing Company 777-2D7 (777) aircraft, registered HS-
TJW, was being operated on a scheduled passenger service from Bangkok,
Thailand to Melbourne, Vic. with 17 crew and 277 passengers on board. At
1309 Eastern Daylight-saving Time1, during a non-directional beacon (NDB) non
precision approach2 to runway 16 at Melbourne, the aircraft descended below a
segment minimum safe altitude. Soon after, the crew received two enhanced ground
proximity warning system (EGPWS)3 cautions. At that time, the crew became
visual with the ground below and the air traffic control (ATC) aerodrome controller
(ADC) observed the aircraft ‘unusually low for an aircraft’. The crew levelled the
aircraft and made a visual approach to land on runway 16.

The flight crew consisted of the pilot in command (PIC), a copilot and a relief pilot.
The copilot was the pilot flying (PF) for the descent, approach and landing at
Melbourne. The PIC was the pilot monitoring (PM).The relief pilot was not
occupying a control seat, and was in the observer seat behind the PIC and the
copilot. The crew had received a notice to airmen (NOTAM) prior to departure
from Bangkok stating that the instrument landing system (ILS)4 for runway 16 at
Melbourne was not available.

The copilot reported that, about 10 minutes prior to top of descent, he conducted an
approach briefing, which included a briefing for the NDB approach to runway 16.
The pilots used instrument approach charts produced by Lido5 (Figure 1), which
they had displayed on their respective control columns for reference during the
approach. The crew also reported that the approach briefing stated the intention to
conduct a constant angle approach path using the vertical navigation mode of the
aircraft’s automatic flight control system (AFCS).

The provider of the flight management computer (FMC) database stated that the
NDB runway 16 approach was loaded in the database. However, the pilots could
not locate the approach in the database.

1 The 24-hour clock was used in this report to describe the local time of day, Eastern Daylight-
saving Time, as particular events occurred. Eastern Daylight-saving Time was Coordinated
Universal Time (UTC) + 11 hours.

2 The non-directional beacon (NDB) was a ground-based navigation aid. An NDB instrument
approach provided lateral guidance to a point where a circling approach, a straight-in approach or
a missed approach could be made. In this occurrence, it also provided vertical guidance via a
number of altitudes and distances that provided terrain protection and also the desired 3° slope
guidance.

3 EGPWS provided immediate alerts, and look-ahead obstacle and terrain alerts for potentially
hazardous flight conditions involving imminent impact with the obstacles and the ground.

4 Instrument landing system (ILS) referred to a ground-based navigation aid, which was able to
align an aircraft both vertically and horizontally with a particular runway.

5 Lido supplied approach charts and FMC data base information as part of the Lido Route manual.

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The copilot reported that he entered the final approach fix waypoint at 6 DME6
(11 km) with an altitude constraint of 2,100 ft above mean sea level (AMSL) into
the FMCs. Other segment minimum safe altitude constraints associated with the
NDB approach were not entered into the FMCs. The only other waypoint that was
entered was the runway 16 threshold height of 432 ft AMSL.

Figure 1: Melbourne Runway 16 NDB approach chart

6 Distance measuring equipment (DME) was a ground based aid that provided distance information
in nautical miles. The aircraft was equipped with two DME receivers that displayed the distance
from a DME facility. The Melbourne DME was located about 900 m south-east of the runway
16 threshold.

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The following events were obtained from air traffic control (ATC) radar, flight
crew interviews, automatic voice recording and data from the aircraft’s flight data
recorder:
1232:05 ATC cleared the crew to conduct the ARBEY FOUR ARRIVAL,
standard arrival route (STAR) to runway 16.
1241:52 The aircraft commenced descent from flight level (FL) 3707. That was
done in LNAV and VNAV8 with the autopilot engaged.
1259:20 The crew selected Flight Level Change Mode (FLCH), which took the
aircraft out of VNAV, at an altitude of 10,230 ft.
1303:55 When the aircraft was approximately 20 NM (37 km) from the airport at
9,037 ft, the approach controller instructed the crew to ‘descend to
4,000, cleared for runway 16 NDB approach’. (That was also a clearance
to descend in accordance with the instrument approach procedure to the
minimum descent altitude.)
The copilot selected FLCH to continue descent to 4,000 ft with the
autopilot engaged. The crew then configured the aircraft for the initial
approach with the selection of flaps 5.
1304:25 The crew of another aircraft transmitted to ATC that they were at
Avalon Airport ‘….. and the cloud base is about 1,700 ft’. Avalon
Airport was located on the west coast of Port Phillip Bay and about 20
NM (37 km) from Melbourne Airport.
Approximately 1 NM (2 km) before the Bolinda NDB, the crew selected
1,190 ft on the Mode Control Panel (MCP). That altitude was 50 ft
above the published minimum descent altitude for the approach9.
1306:31 The aircraft overflew the Bolinda NDB while maintaining 4,000 ft. The
copilot reported that at that time, descent should have been initiated, but
he was unsure whether ATC had issued a clearance for the crew to
conduct the NDB approach. Remaining at 4,000 ft, the copilot sought
confirmation from the PIC that they were cleared for the approach.

The operator later reported that the crew was confused by the descent
clearance, as the air traffic controller transmitted ‘cleared[10] for runway
16 NDB approach’, instead of the standard phrase ‘cleared for NDB
approach runway 16’.
1307:23 Descent was initiated at 9.9 DME (20 km) from Melbourne and the
published descent point was at 11.5 DME (24 km). The copilot reported
that, as the aircraft was above the constant approach path, and with the
minimum descent altitude plus 50ft (1,190 ft) in the Altitude Window of

7 Flight level was a surface of constant atmospheric pressure related to a datum of 1013.25 hPa,
expressed in hundreds of feet; flight level 370 equated to 37,000 ft AMSL.

8 LNAV and VNAV referred to Lateral Navigation Tracking information derived from the FMC
and Vertical Navigation Path derived from the FMC.

9 The operators’ procedures required the crew set the minimum descent altitude plus 50 ft.

10 Authorised to proceed under the conditions specified.

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 the MCP, he selected FLCH on the MCP and initiated descent, instead
of using VNAV path as briefed. The copilot explained that he did this to
enable the aircraft to regain the constant angle approach path of 3°. At
that time, the AFDS modes were FLCH for descent, LNAV for lateral
navigation and the autopilot was engaged. The crew then commenced
configuring the aircraft for landing by extending the landing gear and
selecting flaps 20.
1308:21 The landing reference speed of 142 kts was set on the MCP.

The FDR indicated that the average rate of descent from 4,000 ft was
1,500 ft/min, with a maximum of 1,808 ft/min when the aircraft was at
8.5 DME (16 km). The aircraft descended below the 2,100 ft segment
minimum altitude step at 6.8 DME (12 km).
1309:08 The aircraft was approximately 6.25 DME (7 km) and descending
through 1,544 ft, which was 556 ft below the 2,100 ft segment minimum
safe altitude.

The aircraft descended below the clouds and, almost simultaneously, the
EGPWS aural terrain alert, ‘CAUTION TERRAIN’, sounded for
4 seconds and the terrain display and the terrain caution message
appeared on the navigation displays on the forward instrument panel for
15 seconds.

The PIC and the relief pilot reported that they were both attempting to
visually locate the runway. The copilot (PF) reported that his monitoring
of the instruments was diverted to looking outside the aircraft in an
attempt to locate the runway.
1309:18 A second EPGWS aural terrain alert ‘TOO LOW TERRAIN’ sounded
for 4 seconds.
1309:20 The copilot disengaged the autopilot and initiated a pitch-up manoeuvre.
The lowest altitude recorded during the manoeuvre was 1,247 ft, which
was 513 ft above ground level (AGL).
At about that time, the ADC in the air traffic control tower saw lights
below the cloud base that appeared to be unusually low for an aircraft.
1309:30 After confirming the aircraft position on the air situation display, the
ADC transmitted ‘…low altitude alert check your altitude immediately’
to the crew. The copilot reported that, after that transmission, he saw the
runway and the PAPI11. The PIC replied to the ADC ‘…okay have the
runway in sight now’.
The copilot continued to fly the aircraft manually and climbed the aircraft to about
1,400 ft. The aircraft was held at that altitude until intercepting the PAPI 3°
indication, which was then maintained until landing. The approach was stabilised
by 500 ft above the runway.

11 The precision approach path indicator (PAPI) was a ground-based light system that provided
visual approach slope guidance to a crew during an approach.

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The derived approach profile that was flown by the crew, the published constant
angle descent path, the segment minimum limiting steps and the terrain profile, are
depicted at Figure 2.

Figure 2: Approach profile (in red) derived from recorded flight data,
published constant angle descent path (in blue), segment
minimum altitude limiting steps (in grey) and terrain profile (in
brown).

Personnel information

Flight Crew
The PIC held an Airline Transport Pilot Licence, was type rated on the 777 aircraft,
held a current medical certificate, and had 23,707 hours total flight experience. The
PIC’s flight time included 9,149 hours on the 777 aircraft. He reported that he had
last flown into Melbourne 15 days prior to the incident.
The copilot held an Airline Transport Pilot Licence, was type rated on the
777 aircraft, held a current medical certificate, and had 6,282 hours total flight
experience, with 4,389 hours on the 777 aircraft. The copilot reported that he had
last flown into Melbourne in the month prior to the incident.
The relief copilot held a Commercial Pilot Licence, was type rated on the 777
aircraft, held a current medical certificate, and had 1,914 hours total flight
experience, with 1,320 hours on the 777 aircraft. The relief copilot reported that he
had last flown into Melbourne about 2 months prior to the incident.
Neither the PIC nor copilot had conducted an NDB approach in the aircraft or
simulator in the last 18 months.

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Air traffic controllers
Airservices Australia reported that all air traffic controllers involved in the control
of the aircraft as it approached Melbourne Airport were licensed, rated and current
for the relevant controller positions.

Aircraft systems

Automatic flight control system

The 777 automatic flight control system consisted of the autopilot flight director
system (AFDS) and the auto-throttle system. Both the AFDS and the auto-throttle
were controlled using the mode control panel (MCP) and the two flight
management computers (FMCs). The crew used the MCP to select and activate
AFDS modes, and to select altitudes, speeds and climb/descent profiles (Figure 3).

Figure 3: Mode control panel

Crew selection of the lateral navigation (LNAV) mode and/or vertical navigation
(VNAV) mode resulted in the FMCs calculating the optimum lateral and/or vertical
navigation flightpath. That flightpath was calculated using information obtained
from the FMC databases, flight plan information entered by the crew, and other
aircraft systems information. When conducting an approach using both the LNAV
and VNAV modes, whether that information was taken from the FMC database or
entered into the FMC by the pilots, that approach is known as a VNAV/LNAV
approach.
Alternatively, the aircraft’s vertical flight path could also be controlled by other
AFDS modes. Those other vertical modes did not interface with the FMCs and
relied solely on MCP selections by the crew. As a result, any speed restrictions and
altitude constraints entered by the crew into the FMCs did not alter the aircraft’s
flight path in those other modes.
The other AFDS vertical modes included:
• flight level change (FLCH) mode, which varied the aircraft’s pitch attitude to
maintain the speed selected on the MCP, with engine thrust being held at a pre-
determined value
• vertical speed (V/S) mode, which varied the aircraft’s pitch attitude to maintain
the vertical speed selected on the MCP
• flight path angle (FPA) mode, which controlled the aircraft’s flight path during a
descent by varying the aircraft’s pitch attitude to maintain the angle selected on
the MCP.
While descending in any one of those modes with the autopilot engaged, the
altitude hold mode would automatically level the aircraft at the altitude selected on

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the MCP. Altitude hold mode could also be selected at any altitude by pushing the
altitude hold switch on the MCP and the aircraft would maintain the altitude
existing when the switch was pushed.

Enhanced ground proximity warning system

The aircraft was fitted with an EGPWS, also known as a terrain awareness and
warning system (TAWS). Compared with the conventional ground proximity
warning system, EGPWS was capable of providing an increased warning time to
pilots about potential terrain conflicts by incorporating two additional functions: a
forward-looking terrain avoidance function, and a premature descent alert function.
The EGPWS also enhanced pilot situational awareness by providing coloured
terrain information on the navigation displays on the forward instrument panels.
The forward-looking terrain avoidance function used data from the aircraft’s global
positioning system receiver to compare the aircraft’s position and flightpath with a
terrain database; to compute if there were any potential conflicts with the terrain.
The premature descent alert function compared the aircraft’s position and flightpath
with an aerodrome database to determine if the aircraft was hazardously below the
normal approach path for the nearest runway.
The EGPWS coloured terrain display provided the pilots with a graphical
presentation of terrain information. The continuous terrain display also provided
various visual indications of imminent contact with the ground, including aural
warnings of excessive rates of descent and excessive closure rate to terrain.

Meteorological information

Aerodrome forecasts
The Bureau of Meteorology (BoM) issued a terminal aerodrome forecast (TAF) for
Melbourne Airport at 2138 on 3 November 2007, with a local time validity period
from 2300 on 3 November to 2300 on 4 November. The forecast was issued about
7 hours prior to the aircraft’s departure from Bangkok, and the validity
encompassed the aircraft’s planned arrival time at Melbourne. From 1100, the
forecast wind was from 170° T at 23 kts, gusting to 35 kts; visibility 9 km; rain; and
cloud, broken12 with a cloud base of 1,000 ft above the aerodrome level (AAL).
The BoM issued an amended TAF for Melbourne at 0341, with a validity period
that extended beyond the aircraft’s planned arrival time at Melbourne. The main
difference was that from 1100, the cloud was forecast to be scattered at 1,000 ft and
broken at 3,000 ft. A further amended TAF was issued at 0930, with the main
difference being that the cloud was forecast to be scattered at 1,000 ft and broken at
1,400 ft during the period of the aircraft’s arrival.

12 Cloud amount is described using the following abbreviations Sky Clear- no cloud; Few - 1 to 2
oktas; Scattered - 3to 4 oktas; Broken - 5 to 7 oktas; Overcast - 8 oktas. Cloud amounts are
reported in oktas. An okta is a unit of sky area equal to one-eighth of total sky visible to the
celestial horizon.

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Actual weather information
The Melbourne special aerodrome weather report (SPECI)13, issued at 1230,
indicated: the wind was from 150° T at 25 kts, gusting to 32 kts; visibility was 9
km; and rain showers with three oktas of cloud at 1,300 ft and six oktas of cloud at
1,600 ft AAL.
The Melbourne trend type forecast (TTF)14 that was appended to the 1230 SPECI,
indicated that at the aircraft’s estimated time of arrival (ETA), the visibility would
be 3,000 m in rain, with broken cloud at 800 ft AAL for periods of 30 minutes or
more, but less than 1 hour.
The Melbourne SPECI that was issued at 1300, indicated: the wind was from 150°
T at 21 kts, gusting to 26 kts; visibility was 9 km; rain showers and with one okta
of cloud at 1,100 ft AAL and seven oktas of cloud at 1,500 ft AAL. The TTF that
was appended to the 1300 SPECI did not vary from the 1230 TTF.

Provision of weather information to the flight crew

At 1256:40, ATC broadcast to pilots of aircraft on frequency that the Melbourne
Airport automatic terminal information service (ATIS) had changed, with the
current ATIS being identified as ‘X-RAY’. That broadcast occurred while the
aircraft was descending through FL 130, about 48 NM (89 km) to the north-west of
the airport.
Those changes to the ATIS included the wind being 140° M at 15 to 30 kts, and the
cloud being scattered at 1,200 ft AAL and broken at 1,800 ft AAL, and the QNH
being 1010 hPa15. At 1300:05, the crew contacted ATC on a different radio
frequency and reported that they had received ATIS ‘X-RAY’. The correct QNH
had been set by the crew.
At 1307:54, ATC cleared the crew to land on runway 16. During that transmission,
the controller advised the crew that the wind was 140° at 25 kts.

Aids to navigation

Ground-based navigation aids

There were two instrument approach procedures published for runway 16; an ILS
precision approach procedure and a runway-aligned NDB non-precision approach
procedure, which utilised the Bolinda and Rockdale NDBs and the Melbourne

13 SPECI is a report of actual weather conditions at a particular aerodrome at a specified time, when
conditions have changed beyond specified limits, or when ‘special’ conditions occur at the time of
a routine report.

14 TTF consists of the latest aerodrome weather report followed by a concise statement indicating
significant changes, expressed as a trend, expected in the 3-hour period commencing at the time of
the report.

15 QNH was the barometric pressure setting that enabled an altimeter to indicate altitude; that was,
the height above mean sea level.

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DME (see Figure 1). Of all the approach types, the ILS was the most accurate and
preferred method of aligning an aircraft with the runway.

Unavailability of the runway 16ILS

In September 2007, work commenced on the Melbourne runway 16 ILS to permit
the installation of new equipment. That work was part of a navigation aid
replacement program that Airservices Australia had announced to the aviation
industry in October 2005.
A Notice to Airmen (NOTAM) was issued by the Australian NOTAM Office on
4 October 2007 to inform appropriate personnel of the planned unavailability of the
runway 16 ILS. The NOTAM advised that the ILS would be unavailable from
0900 local time on 8 October to 1700 on 22 November 2007.

Communications
The transmissions between the air traffic controllers and the crew during the
aircraft’s descent and approach to Melbourne Airport were recorded by ground-
based automatic voice-recording equipment. The quality of those recorded
transmissions was good.

Aerodrome information
Melbourne Airport was located about 20 km north-west of the Melbourne central
business district at an elevation of 434 ft. The airport had two runways: runway
16/34, aligned 160/340° M, which was 3,657 m long and 60 m wide; and runway
09/27, aligned 083/263° M, which was 2,286 m long and 45 m wide.
Runway 16 was equipped with a PAPI that was calibrated for a 3° visual glidepath
angle. The touchdown elevation of runway 16 was 432 ft and the runway sloped
down to 330 ft at the departure end.

Recorded information
The operator forwarded the aircraft’s digital flight data recorder (FDR) to the
Australian Transport Safety Bureau (ATSB) and the data was downloaded. The
operator also forwarded the data from the quick access recorder (QAR) to the
ATSB. Data from the cockpit voice recorder (CVR) for the incident flight had been
over-written, and therefore was not available to the investigation.

Airline operations manuals

The operator provided the flight crew with a number of manuals that gave guidance
to flight crew on how to carry out their duties and to operate the 777 aircraft.
Those manuals included a Flight Operations Manual (FOM), Flight Crew Training
Manual FCT 777 (TM) and a 777 Flight Crew Operations Manual (FCOM).

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Flight Operations Manual
The FOM set out mandatory requirements that the airline expected its pilots to
abide by and included:
3.1.8.1.3 Briefing
A number of areas were to be covered in relation to a descent briefing. Those areas
included weather, navigation aids, clearance limits, type and method of approach,
altitudes, decision altitude or minimum descent altitude, constant angle non-
precision approach (CANPA), dimming of runway and approach lights, lookout
and notices to airmen.
3.1.8.2 Letdown
In regard to the letdown, the FOM stated that:
Before commencing a letdown the PIC shall carefully cover various aspects
with regard to letdown.’

Those aspects included terrain clearance, altitude limit, visual letdown and
approach.
3.1.8.2.3 Procedure
The procedure for application during the letdown required that:
The PM shall carefully monitor the letdown and check that the relevant points
and altitudes mentioned during the briefing are adhered to.

Some other requirements were specified with respect to rate of descent and speed.
3.1.8.3 Approach
That section described a number of requirements in relation to ATC clearances,
terrain clearance, and weather requirements.
3.1.8.3.3 Procedure
That section dealt with the duties and requirements during the approach, and
included that:
Both pilots shall monitor the instruments approach and it is especially a very
important duty of PNF (PM) to automatically inform the PF of abnormal
deviations from the approach procedure, altitude, rate of descent, speed and
timing, and to progressively follow the under briefing in ...

Stabilised approach includes-

While maintaining an acceptable rate of descent, and not exceeding 1000ft
per minute.

All instrument approaches and straight-in visual approaches shall be planned

to be stabilized at 1000ft AGL, otherwise a go-around shall be made.

3.1.8.5.3 Go-around on approach without glidepath reference

There are a number of situations where a go-around may be required whilst
on approach. In this instance the relevant criteria was being:
Not stabilized at 1000ft AGL

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3.2.2.4.11 GPWS Activation
In regard to the activation of the GPWS, the FOM stated that:
With the surroundings clearly visible in daylight, the pullup requirement may
be disregarded, but action must be taken to exit from the warning envelope.

Flight Crew Training Manual 777

The FCT 777 TM provided information and recommendations on manoeuvres and
techniques. It was intended to provide information in support of the other manuals
that were supplied by the airline.
The section on Non-ILS Instrument Approaches stated:
Over the past several decades there have been a number of CFIT [controlled
flight into terrain] and unstabilized approach incidents and accidents
associated with Non-precision (non-ILS) approaches and landings. Many of
these could have been prevented by the use of continuous Descent Final
Approach (CDFA) methods. Traditional methods of flying non-ILS
approaches involve setting a vertical speed on final approach, levelling off at
step down altitudes (if applicable) and at MDA (H), followed by a transition
to a visual final approach segment and landing. These traditional methods
involve changing the flight path at low altitudes and are not similar to
methods for flying ILS approaches. Further, these traditional methods often
require of the crew a higher level of skill, judgement and training than the
typical ILS approach.

The airline had known about the difficulties in flying approaches without constant
angle approach paths. In October 2007, it introduced a training program to instruct
pilots on a new method to conduct those approaches. At the time of the incident the
pilots of the 777 had not undergone that training.

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ANALYSIS

Operator actions
The operator had recognised the difficulties associated with flying non-constant
angle approach paths and had commenced a training program to improve the
situation. Unfortunately, the pilots who were involved in this event had yet to
complete the training. Had they completed the training, it is possible that this event
would not have occurred.

Crew actions
The crew conducted a detailed briefing that included all of the appropriate
information that was required to carry out the approach and landing. As the
instrument landing system (ILS) approach to runway 16 was not available, and the
crew were unable to locate the non-directional beacon (NDB) runway 16 approach
in the aircraft’s flight management computer (FMC), they manually entered a
number of coordinates into the FMC that had a similar profile to the NDB runway
16 approach. The investigation was unable to determine whether the NDB runway
16 approach was loaded into the aircraft’s FMC. The approach was conducted in
accordance with the briefing, until the copilot sought confirmation that they were
cleared for the approach. The resultant delay in descent put the aircraft above the
FMC-computed flightpath. As a consequence, the vertical navigation (VNAV)
mode was not available to the crew until they positioned the aircraft closer to the
FMC-computed flightpath (where VNAV could once again be selected).

Mode control panel operation

To achieve the required flightpath, there were a number of modes available to the
crew. In this incident, the crew chose the flight level change (FLCH) mode for the
approach part of the descent. When using this mode, it was very important that the
crew were aware that the aircraft would descend without restriction to the altitude
set by the pilot in the altitude window of the mode control panel (MCP). In this
occurrence, the aircraft was at 4,000 ft when the MCP altitude was set to 1,190 ft.
Consequently, the aircraft descended through the height restriction of 2,100 ft at 5.5
DME (11 km), and would have levelled off at 1,190 ft at 5.5 DME (11 km), if the
autopilot had not been disengaged and a pitch-up manoeuvre performed by the pilot
flying (PF).
To ensure the minimum altitude restrictions on the approach were met, the copilot
should have set 2,100 ft in the MCP. The aircraft would then have descended to and
levelled off at that altitude. At 5.5 DME (11 km), the pilot should then have reset
the MCP to 1,190 ft, and the aircraft would have then descended to that altitude.
Had the pilots been more aware of the operation of the MCP, they would probably
have used a number of steps in the procedure to ensure that the protections afforded
by the altitude restrictions were maintained.

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Weather aspects
Due to the weather conditions being different to the pilots’ expectations, the pilot
monitoring’s (PM’s)16 attention was outside the cockpit as he attempted to gain
visual reference with the airport/ground. The flight crew did not realise that the
weather report from the other aircraft was made from Avalon Airport, not
Melbourne Airport. Had the pilot in command (PIC) been monitoring the aircraft’s
flightpath in accordance with the flight operations manual, it is likely that he would
have recognised that the aircraft was deviating from its intended flightpath and
brought the situation to the attention of the pilot flying (PF).17

Company procedures
The operator’s Operations Manuals outlined stabilised approach criteria. At 1,000 ft
above ground level, the aircraft was still in cloud with a descent rate in excess of
1,000 feet per minute, which did not comply with the stabilised approach criteria. In
that situation, the flight crew were required to carry out a missed approach and
position the aircraft for another approach and landing. It is most likely that the PM
was distracted as a result of his attempt to establish visual reference, and was
unaware that the aircraft was operating outside the operator’s stabilised approach
criteria.

System defences
A VNAV/lateral navigation (LNAV) approach, used in conjunction with the
autopilot, afforded the most protection whilst carrying out an instrument approach.
Once the approach is entered into the FMC, and the details are checked for
correctness against the applicable approach chart, there are no further MCP inputs
necessary and the pilot’s workload during the approach is significantly reduced
when compared with a non-precision approach. The pilot’s primary duty is then to
monitor the aircraft’s flightpath and configure the aircraft for landing. In other
modes, such as FLCH (as was used in this case), the pilots were required to manage
the aircraft’s flightpath and to make changes as required to comply with the
approach chart requirements. In this case, it would have meant making several
inputs to the MCP altitude to comply with the altitude restrictions, and to the MCP
speed to configure the aircraft for landing. This would have increased the crew’s
workload during the approach, and affected their ability to adequately monitor the
aircraft’s flightpath.
As the pilots had not conducted an NDB approach in over 18 months, their
workload may also have increased because of a lack of familiarity with this type of
approach flown in the selected MCP modes.
As the PM became visual with the ground, the aircraft’s enhanced ground proximity
warning system (EGPWS) terrain caution sounded. That caution signal alerted the
pilots to the aircraft’s close proximity to the ground, but as they were already visual
with the ground, this served as an advisory alert. Similarly, the warning provided by

16 The pilot in command.

17 The copilot.

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the aerodrome controller that the aircraft was low, assisted in improving the pilots’
situational awareness. Under the circumstances, either warning would have been
sufficient to alert the pilots of the proximity to terrain in sufficient time for them to
react and respond to ensure a safe outcome.

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FINDINGS
From the evidence available, the following findings are made with respect to the
procedures-related event involving Boeing Company 777-2D7 (777) aircraft,
registered HS-TJW, that occurred near Melbourne Airport, Vic. and should not be
read as apportioning blame or liability to any particular organisation or individual.

Contributing safety factors

• The copilot was unsure of the descent clearance, which delayed further descent.
This placed the aircraft above the flight management computer (FMC)-
computed flightpath.
• The crew did not maintain awareness of the aircraft’s profile during the
approach.
• The crew did not fly a 3° constant angle descent.
• The operator’s Continuous Descent Final Approach training had not been
provided to the crew. [Safety issue]
• The crew did not conduct a ‘go-around’ as was required by the operator’s
procedures when the aircraft was 1,000ft above terrain with a high rate of
descent.

Other safety factors

• The pilots had not conducted a non-directional beacon (NDB) approach in an
aircraft or simulator for 18 months.

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SAFETY ACTIONS
The safety issues identified during this investigation are listed in the Findings and
Safety Actions sections of this report. The Australian Transport Safety Bureau
(ATSB) expects that all safety issues identified by the investigation should be
addressed by the relevant organisation(s). In addressing those issues, the ATSB
prefers to encourage relevant organisation(s) to proactively initiate safety action,
rather than to issue formal safety recommendations or safety advisory notices.
All of the responsible organisations for the safety issues identified during this
investigation were given a draft report and invited to provide submissions. As part
of that process, each organisation was asked to communicate what safety actions, if
any, they had carried out or were planning to carry out in relation to each safety
issue relevant to their organisation.

Aircraft operator

Continuous Descent Final Approach training

Safety Issue
The operator’s Continuous Descent Final Approach training had not been provided
to the crew.

Action taken by the operator

The aircraft operator advised the ATSB that it has put in place a Continuous
Descent Final Approach (CDFA) method training package. This package trains
pilots so that they are able to achieve a stabilised approach to a landing once
suitable visual reference to the runway environment has been established.
In response to its own investigation, the operator also advised that the following
actions were undertaken or are being undertaken:
• developing positive actions by the pilot flying in confirming approach
clearances
• emphasising to crew the requirement to call out altitude steps during non-
precision approaches
• providing all crew with automation complacency and degraded management
training
• developing, at an organisational level, relevant defences against items that might
be found in notices to airman and that might affect a flight .
• emphasising to all crew to carry out a go-around in case of an unstabilised
approach in accordance with company procedures.

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APPENDIX A: SOURCES AND SUBMISSIONS

Sources of Information
The main sources of information were:
• the flight crew of HS-TJW
• the aircraft operator
• Airservices Australia
• the Bureau of Meteorology.

Submissions
Under Part 4, Division 2 (Investigation Reports), Section 26 of the Transport Safety
Investigation Act 2003, the Executive Director may provide a draft report, on a
confidential basis, to any person whom the Executive Director considers
appropriate. Section 26 (1) (a) of the Act allows a person receiving a draft report to
make submissions to the Executive Director about the draft report.
A draft of this report was provided to the Civil Aviation Safety Authority, the flight
crew, the operator, the aircraft manufacturer, the Thailand Department of Civil
Aviation and Airservices Australia.
Submissions were received from the operator and the aircraft manufacturer. The
submissions were reviewed and, where considered appropriate, the text of the report
was amended accordingly.

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