Once again, the ATSB raises more questions than it answers. But you have to wonder that if it takes 18 months to issue a relatively straight forward report - how long does it take for a complex one.
The ATSB are pretty good at using units of measurement that confuse rather than illuminate. For instance, nearly all the altitude reports are done against time, but the glideslope is defined by distance. A diligent report would have used distance so that the report was transparent someone reviewing it could plot it against the chart. The ATSB have denied us this ability.
The ATSB are also a bit prone to using emotive language / distortion. I'm not sure that the delay to go-around was quite as it was represented. And of course there is no transcript of radio calls which once again denies independent review. Another favorite ATSB trick. Other international agencies not only publish the relevant transcript, but also publish any corrections - including those requested by the participants after they were given the opportunity to review it. Another thing the ATSB doesn't seem to do.
The aeroplane was too low. There is no getting around that and the captain did admit that, but a point missed by Sunfish and glossed over by the ATSB is that they were cleared for visual approach. The controllers comments of confirming that the aircraft was low by visual identification confirms that the conditions were visual. Others will correct me if I'm wrong, but I'm pretty sure the command "cleared for visual approach" waives the approach altitude requirements and allows the pilot to descend at his / her discretion to make the landing. On that basis the pilot was guilty of poor airmanship, but not of breaching the approach procedure. It is entirely likely at the time of the instruction to go around, the aircraft was back on glideslope. According to the pilots description (confirmed by the ATSB report) he an initiated recovery before the ATC alert.
The ATSB listing of the sequence of events is not fully clear, but I would question whether the aircraft was as far below the glideslope as suggested. The report lists the minimum altitude that the aircraft reached, but is not clear where this was relative to the glideslope. It was inside the 6.5nm point at its lowest, so the comparison of 984 ft to 1950 ft is not valid. If the ATSB used distance from the aid rather than time, we could have a go at working it out. The MDA inside 6.5 mile is 760 ft, so the aircraft was ABOVE the published minima. Once again, the pilot was guilty of poor airmanship, but not necessarily in breach of the procedure.
It will require some work to try and reconstruct, but I suspect that the most serious breach may have been while the aircraft was flying the 11 DME arc and under ATC direction (ie before it was cleared for approach). I suspect that this is the only part where the aircraft breached the LSALT. It was above MDA when it was at 984 ft which is where the attention is focused (and its easier to say it was the pilots fault exclusively).
The big question - which has already been raised - is why we don't have ILS on all runways. The crew was from Thailand. They may not be used to operating in third world countries like Australia that do not have the funds to invest in basic safety infrastructure. Has anyone noticed that the YWE VOR is still U/S? Together with the procedure having been removed from CWS - exactly where does one train for VOR approaches in Melbourne at the moment?
The other question I have is whether the controller should be expected to pick up a diversion from glideslope before it becomes such a large incident? Should the pilot expect a warning before being "waved off"the approach? This is a genuine question for the ATC among us and not a barbed comment.