Qantas has updated its training manuals for visual approaches after an Australian Transport Safety Bureau (ATSB) investigation found a pilot flew an Airbus A330-200 carrying 211 passengers and 11 crew too low on approach to Melbourne Airport.
The March 8 2013 incident involved Qantas A330-200 VH-EBV flying from Sydney to Melbourne and on descent into Tullamarine Airport in daylight hours in the early evening.
After being cleared for approach, the captain, who was the pilot flying, set an altitude target of 1,000ft in the autopilot and selected the landing gear down.
However, as the aircraft descended through about 1,800ft the first officer advised the captain that “they were low”, the ATSB report said.
“The captain reduced the rate of descent by selecting auto-flight vertical speed mode but a short time later the enhanced ground proximity warning system (EGPWS) provided ‘TERRAIN’ alerts followed by ‘PULL UP’ warnings,” the ATSB report said.
“The crew carried out an EGPWS recovery manoeuvre and subsequently landed via an instrument approach.”
At the time of the EGPWS alert, the aircraft had descended to 1,400ft, which in that area was 600ft above ground level, with 9nm to run to touchdown, the ATSB said, noting that this was 100ft below the control area lower limit and 1,900ft below a normal three degree descent profile.
The report noted the flight crew were on the fifth day of a five-day duty roster pattern and had flown from Perth to Sydney earlier in the day.
Moreover, the ATSB report said the captain, who had 21,907 hours’ experience including 2,272 hours on the A330, recalled having an interrupted sleep, waking at about 0500 with a throat irritation that worsened as the day progressed.
The captain also had no appetite for food and did not have breakfast and lunch, consuming only tea, coffee and soup during the day.
While the captain reported being tired prior to commencing work, he “self-assessed being fit for duty”.
“The ATSB found that during the visual approach the captain’s performance capability was probably reduced due to the combined effects of disrupted and restricted sleep, a limited recent food intake and a cold/virus,” the ATSB report said.
“The captain assessed the aircraft’s flightpath using glideslope indications that were not valid. This resulted in an incorrect assessment that the aircraft was above the nominal descent profile.”
In response to the incident, the ATSB said Qantas had made some changes to its instruction for visual approaches.
“Qantas updated their training material for visual approaches and enhanced similar material in their captain/first officer conversion/promotion training books,” the ATSB said.
“In addition, targeted questions were developed that required check pilot sign-off for proficiency. Finally, visual approaches were included as a discussion subject during flightcrew route checks for the period 2013-2015.”