Sick, tired, hungry, Qantas captain flew too low over Melbourne

A Qantas A330-200 captain, who flew a plane at a dangerously low altitude while on descent into Melbourne Airport on March 8 last year, was feeling sick, tired and hadn’t had enough sleep and food.

According to the final report released by the Australian Transport Safety Bureau (ATSB) on Thursday, the captain’s performance capability was “reduced due to the combined effects of disrupted and restricted sleep, a limited recent food intake and a cold/virus.”

The captain reported having a slightly sore throat and experiencing further cold symptoms.

“In addition, the captain indicated not feeling like eating, and he did not eat breakfast or lunch that day”.

“A cup of coffee and tea were reported consumed on the trip from Perth to Sydney and a half-cup of soup on the flight from Sydney to Melbourne. The captain reported feeling tired prior to commencing duty on 8 March but self-assessed being fit for duty”.

The aircraft from Sydney with 211 passengers and 11 crew on board flew 100 ft below the control area lower limit and 1,900 ft below a normal 3° descent profile, with ground proximity sensors warning the pilots that the airplane was only 600 ft (183 meters) above the ground with still 17 km to run to touchdown.

As the aircraft was descending on a “visual approach” as opposed to an instrument guided landing through about 1,800 ft the first officer advised the captain that they were low to the ground.

“The captain assessed the aircraft’s flight path using glide slope indications that were not valid. This resulted in an incorrect assessment that the aircraft was above the nominal descent profile,” found the investigators.

The captain quickly reduced the rate of descent by selecting auto-flight vertical speed mode but soon received emergency warning alerts ‘TERRAIN’, followed by ‘PULL UP’.

The crew carried out a procedural recovery manoeuvre and subsequently landed safely via an instrument approach.

The ATSB concluded that the ineffective altitude target and the ineffective monitoring of the plane’s flight path resulted in “a significant deviation below the nominal descent profile”.

The ATSB also identified that limited guidance was provided by Qantas on the conduct of a visual approach and the associated briefing required to ensure flight crew had a shared understanding of the intended approach.

In response to the incident, Qantas updated their training material for visual approaches and enhanced similar material in their captain/first officer conversion/promotion training books. In addition, targeted questions were developed that required check pilot sign off for proficiency.

Finally, visual approaches were included as a discussion subject during flight crew route checks for the period 2013–2015.