Lessons to be learnt: Although probably too late for TSB review purposes, it is worth doing a comparison with a recently completed TSB investigation vs a bureau ongoing investigation, which appear to have some very similar causational elements...unstablised approach, SOPs, IFR to VFR visual segments etc...
This is the summary for ATsB investigation
AO-2013-085
On 15 May 2013, an ATR-GIE Avions de Transport Régional, ATR72‑212A aircraft, registered VH-FVR and operated by Virgin Australia Regional Airlines, was conducting a scheduled passenger service from Brisbane to Moranbah, Queensland.
At about 0715 Eastern Standard Time1 the flight crew commenced a descent from flight level (FL)2 180 and conducted a visual approach3 to runway 16 at Moranbah Airport (Figure 1).
During the approach to the downwind position of the circuit, the crew observed a band of low scattered cloud4 and fog along the flight path. The crew reported that the cloud base appeared to be about 1,500 ft above ground level (AGL), which was their planned downwind altitude for the circuit.
As the aircraft approached 1,500 ft AGL the captain, who was the pilot flying, elected to continue descending the aircraft to remain clear of the cloud. The captain reported that, as the cloud appeared to be ‘sloped’ and he had visual reference with the ground, the aircraft could be flown visually under the cloud on the downwind leg.
It became apparent during the descent that the cloud was more extensive than expected and, in order to remain visual, the captain increased the aircraft’s rate of descent to about 1,900 ft/min until levelling below the cloud at a recorded altitude of about 450 ft AGL.
Recorded data identified that, during the descent, the aircraft’s terrain alert warning system (TAWS) activated a number of terrain proximity and aircraft configuration alerts to the crew (Figure 1). The crew reported that, as they were visual, the alerts were acknowledged and flight continued below the cloud base. They also reported that the height of the cloud base was difficult to judge due to the combination of the scattered cloud and the underlying fog.
Once past the low band of cloud, the aircraft was climbed to about 950 ft AGL before the captain turned the aircraft onto the base leg of the circuit. While on base, two TAWS 'Don’t Sink' alerts, which were based on a number of parameters including the degree of altitude loss and radio altitude, were annunciated to the crew. These alerts were acknowledged by the crew and, as the aircraft’s performance appeared normal, the approach was continued and the aircraft landed on runway 16.
The investigation is continuing and will include a review of the:
•operator’s standard operating procedures and pilot training relating to the conduct of approaches
•operation and performance of the TAWS
•operator’s management of TAWS alerts.
It is anticipated that the investigation report will be released to the public no later than April 2014.
{Note:This incident was also covered by Planetalking What were they thinking on this Virgin flight? }
And this is the Findings & Safety Action statements for TSB Final report for
AIR A12P0034
Findings
Findings as to causes and contributing factors
1.Although the hazardous runway condition had been identified by the company's safety management system, the delay in action to mark the runway allowed this condition to persist.
2.Up-to-date weather and runway condition information was not provided to the crew, nor was it requested by the crew.
3.The pilot continued the approach below the visibility limits specified in the company's standard operating procedures.
4.Deteriorating weather, as well as the lack of approach aids and runway markings, hampered the pilot's ability to establish the aircraft onto a stable final approach prior to crossing the threshold.
5.The company's standard operating procedures for stabilized approaches were not followed, and an unstabilized approach was allowed to continue.
6.The pilot was unable to position the aircraft over the centre of the runway as it settled to land, and the left main landing gear entered the deeper snow at the runway edge, causing the aircraft to veer into the snow bank.
Findings as to risk
1.If a company's risk mitigation strategy is not implemented in a timely manner, hazards are allowed to persist, increasing the risk of an accident.
2.If company standard operating procedures do not include criteria and procedures for stabilized approaches, or they are not followed, there is an increased risk of landing accidents.
3.Operating on a snow-covered runway that does not have markings or devices to allow a pilot to easily identify the runway surface increases the risk of runway excursions.
4.If the identified risks and mitigation strategies are not communicated to the people exposed to the risks, it is possible they will deem the risk as acceptable to management and continue operations.
Safety action
Safety action taken
Transport Canada
Transport Canada indicated that further prescriptive regulations may not be the appropriate way forward, but rather that the issue of rejected approaches may be better addressed through guidance material on pilot decision making and crew resource management.
This issue will be addressed in the development of the contemporary crew resource management (CRM) and pilot decision making (PDM) training standards for 702, 703, 704, and 705 operations. These standards will include the threat and error management (TEM) model.
The regulatory development of CRM and PDM is part of the 2013/2014 priorities.
This report concludes the Transportation Safety Board's investigation into this occurrence. The Board authorized the release of this report on 18 December 2013. It was officially released on 07 Februrary 2014.
It will be interesting to see if we get the same standard of informative, clear & concise reporting with similar (but somewhat repetitive) safety messages when the bureau report comes out...
