Lockhart River

The accident was the consequence of a controlled flight into terrain.
The following contributing factors were identified:
• While the pilot was operating in the vicinity of Lockhart River Airport, there were areas of cloud and rain that significantly reduced visibility and increased the risk of controlled flight into terrain.
In particular, the aircraft probably entered areas of significantly reduced visibility during the second approach.
• After an area navigation (RNAV) global satellite system (GNSS) approach to runway 30 and missed approach, the pilot immediately conducted another approach to the same runway that was on a similar gradient to the recommended descent profile but displaced about 1,000 ft below that profile. While continuing on this descent profile, the aircraft descended below a segment minimum safe altitude and the minimum descent altitude, then kept descending until the collision with terrain about 6 km before the runway threshold.
• Although the exact reasons for the aircraft being significantly below the recommended descent profile and the continued descent below the minimum descent altitude could not be determined, it was evident that the pilot did not effectively monitor the aircraft’s altitude and descent rate for an extended period.
• When passing the final approach fix (FAF), the aircraft’s lateral position was at about full-scale deflection on the course deviation indicator (CDI), and it then exceeded full-scale deflection for
an extended period. In accordance with the operator’s stabilized approach procedures, a missed approach should have been conducted if the aircraft exceeded half full-scale deflection at the FAF, however a missed approach was not conducted.
• The pilot was probably experiencing a very high workload during periods of the second approach. In addition to the normal high workload associated with a single pilot hand flying an approach in instrument meteorological conditions, the pilot’s workload was elevated due to conducting an immediate entry into the second approach, conducting the approach in a different manner to their normal method, the need to correct lateral tracking deviations throughout the approach, and higher than appropriate speeds in the final approach segment.
• The aircraft was not fitted with a terrain avoidance and warning system (TAWS). Such a system would have provided visual and aural alerts to the pilot of the approaching terrain for an extended period, reducing the risk of controlled flight into terrain.
• Although the aircraft was fitted with a GPS/navigational system suitable for an area navigation (RNAV) global satellite system (GNSS) approach and other non-precision approaches, it was not fitted with a system that provided vertical guidance information, which would have explicitly indicated that the aircraft was well below the recommended descent profile. Although the operator had specified a flight profile for a straight-in approaches and stabilized approach criteria in its operations manual, and encouraged the use of stabilized approaches, there were limitations with the design of these procedures. In addition, there were limitations with other risk controls for minimizing the risk of controlled flight into terrain (CFIT), including no procedures or guidance for the use of the terrain awareness function on the aircraft’s GNS 430W GPS/navigational units and limited monitoring of the conduct of line operations.

Other factors that increased risk:
• Although an applicable height of 1,000 ft for stabilized approach criteria in instrument meteorological conditions has been widely recommended by organizations such as the International Civil Aviation Organization for over 20 years, the Civil Aviation Safety Authority had not provided formal guidance information to Australian operators regarding the content of stabilized approach criteria. (Safety issue)
• The Australian requirements for installing a terrain avoidance and warning system (TAWS) were less than those of other comparable countries for some types of small aeroplanes conducting air transport operations, and the requirements were not consistent with International Civil Aviation Organization (ICAO) standards and recommended practices. More specifically, although there was a TAWS requirement in Australia for turbine-engine aeroplanes carrying 10 or more passengers under the instrument flight rules:
- There was no requirement for piston-engine aeroplanes to be fitted with a TAWS, even though this was an ICAO standard for such aeroplanes authorized to carry 10 or more passengers, and this standard had been adopted as a requirement in many comparable countries.
- There was no requirement for turbine-engine aeroplanes authorized to carry 6–9 passengers to be fitted with a TAWS, even though this had been an ICAO recommended practice since 2007, and this recommended practice had been adopted as a requirement in many comparable countries. (Safety Issue)

Other findings:
• The forecast weather at Lockhart River for the time of the aircraft’s arrival required the pilot to plan for 60 minutes holding or diversion to an alternate aerodrome. The aircraft had sufficient fuel for that purpose; and the aircraft had sufficient fuel to conduct the flight from Cairns to Lockhart River and return, with additional fuel for holding on both sectors if required.
• There was no evidence of any organizational or commercial pressure to conduct the flight to Lockhart River or to complete the flight once to commenced.
• Based on the available evidence, it is very unlikely that the pilot was incapacitated or impaired during the flight.
• There was no evidence of any aircraft system or mechanical anomalies that would have directly influenced the accident. However, as a consequence of extensive aircraft damage, it was not possible to be conclusive about the aircraft’s serviceability.
• The aircraft was fitted with Garmin GNS 430W GPS/navigational units that could be configured to provide visual (but not aural) terrain alerts. However, it could not be determined whether the
terrain awareness function was selected on during the accident flight.

Contributing factors relating to occurrence events and individual actions:
- The crew commenced the Lockhart River Runway 12 RNAV (GNSS) approach, even though the crew were aware that the copilot did not have the appropriate endorsement and had limited experience to conduct this type of instrument approach.
- The descent speeds, approach speeds and rate of descent were greater than those specified for the aircraft in the Transair Operations Manual. The speeds and rate of descent also exceeded those appropriate for establishing a stabilised approach.
- During the approach, the aircraft descended below the segment minimum safe altitude for the aircraft's position on the approach.
- The aircraft's high rate of descent, and the descent below the segment minimum safe altitude, were not detected and/or corrected by the crew before the aircraft collided with terrain.
- The accident was almost certainly the result of controlled flight into terrain.

Contributing factors relating to local conditions:
- The crew probably experienced a very high workload during the approach.
- The crew probably lost situational awareness about the aircraft's position along the approach.
- The pilot in command had a previous history of conducting RNAV (GNSS) approaches with crew without appropriate endorsements, and operating the aircraft at speeds higher than those specified in the Transair Operations Manual.
- The Lockhart River Runway 12 RNAV (GNSS) approach probably created higher pilot workload and reduced position situational awareness for the crew compared with most other instrument approaches. This was due to the lack of distance referencing to the missed approach point throughout the approach, and the longer than optimum final approach segment with three altitude limiting steps.
- The copilot had no formal training and limited experience to act effectively as a crew member during a Lockhart River Runway 12 RNAV (GNSS) approach.

Contributing factors relating to Transair processes:
- Transair's flight crew training program had significant limitations, such as superficial or incomplete ground-based instruction during endorsement training, no formal training for new pilots in the operational use of GPS, no structured training on minimising the risk of controlled flight into terrain, and no structured training in crew resource management and operating effectively in a multi-crew environment. (Safety Issue)
- Transair's processes for supervising the standard of flight operations at the Cairns base had significant limitations, such as not using an independent approved check pilot to review operations, reliance on passive measures to detect problems, and no defined processes for selecting and monitoring the performance of the base manager. (Safety Issue)
- Transair's standard operating procedures for conducting instrument approaches had significant limitations, such as not providing clear guidance on approach speeds, not providing guidance for when to select aircraft configuration changes during an approach, no clear criteria for a stabilised approach, and no standardised phraseology for challenging safety-critical decisions and actions by other crew members. (Safety Issue)
- Transair had not installed a terrain awareness and warning system, such as an enhanced ground proximity warning system, in VH-TFU.
- Transair's organisational structure, and the limited responsibilities given to non-management personnel, resulted in high work demands on the chief pilot. It also resulted in a lack of independent evaluation of training and checking, and created disincentives and restricted opportunities within Transair to report safety concerns with management decision making. (Safety Issue)
- Transair did not have a structured process for proactively managing safety related risks associated with its flight operations. (Safety Issue)
- Transair's chief pilot did not demonstrate a high level of commitment to safety. (Safety Issue)

Contributing factors relating to the Civil Aviation Safety Authority processes:
- CASA did not provide sufficient guidance to its inspectors to enable them to effectively and consistently evaluate several key aspects of operator management systems. These aspects included evaluating organisational structure and staff resources, evaluating the suitability of key personnel, evaluating organisational change, and evaluating risk management processes. (Safety Issue)
- CASA did not require operators to conduct structured and/or comprehensive risk assessments, or conduct such assessments itself, when evaluating applications for the initial issue or subsequent variation of an Air Operator's Certificate. (Safety Issue)

Other factors relating to local conditions:
- There was a significant potential for crew resource management problems within the crew in high workload situations, given that there was a high trans-cockpit authority gradient and neither pilot had previously demonstrated a high level of crew resource management skills.
- The pilots' endorsements, clearance to line operations, and route checks did not meet all the relevant regulatory and operations manual requirements to conduct RPT flights on the Metro aircraft.
- Some cockpit displays and annunciators relevant to conducting an instrument approach were in a sub-optimal position in VH-TFU for useability or attracting the attention of both pilots.

Other factors relating to instruments approaches:
- Based on the available evidence, the Lockhart River Runway 12 RNAV (GNSS) approach design resulted in mode 2A ground proximity warning system alerts and warnings when flown on the recommended profile or at the segment minimum safe altitudes. (Safety Issue)
- The Australian convention for waypoint names in RNAV (GNSS) approaches did not maximise the ability to discriminate between waypoint names on the aircraft global positioning system display and/or on the approach chart. (Safety Issue)
- There were several design aspects of the Jeppesen RNAV (GNSS) approach charts that could lead to pilot confusion or reduction in situational awareness. These included limited reference regarding the 'distance to run' to the missed approach point, mismatches in the vertical alignment of the plan-view and profile-view on charts such as that for the Lockhart River runway 12 approach, use of the same font size and type for waypoint names and 'NM' [nautical miles], and not depicting the offset in degrees between the final approach track and the runway centreline. (Safety Issue)
- Jeppesen instrument approach charts depicted coloured contours on the plan-view of approach charts based on the maximum height of terrain relative to the airfield only, rather than also considering terrain that increases the final approach or missed approach procedure gradient to be steeper than the optimum. Jeppesen instrument approach charts did not depict the terrain profile on the profile-view although the segment minimum safe altitudes were depicted. (Safety Issue)
- Airservices Australia's instrument approach charts did not depict the terrain contours on the plan-view. They also did not depict the terrain profile on the profile-view, although the segment minimum safe altitudes were depicted. (Safety Issue)

Other factors relating to Transair processes:
- Transair's flight crew proficiency checking program had significant limitations, such as the frequency of proficiency checks and the lack of appropriate approvals of many of the pilots conducting proficiency checks. (Safety Issue)
- The Transair Operations Manual was distributed to company pilots in a difficult to use electronic format, resulting in pilots minimising use of the manual. (Safety Issue) Other factors relating to regulatory requirements and guidance
- Although CASA released a discussion paper in 2000, and further development had occurred since then, there was no regulatory requirement for initial or recurrent crew resource management training for RPT operators. (Safety Issue)
- There was no regulatory requirement for flight crew undergoing a type rating on a multi-crew aircraft to be trained in procedures for crew incapacitation and crew coordination, including allocation of pilot tasks, crew cooperation and use of checklists. This was required by ICAO Annex 1 to which Australia had notified a difference. (Safety Issue)
- The regulatory requirements concerning crew qualifications during the conduct of instrument approaches in a multi-crew RPT operation was potentially ambiguous as to whether all crew members were required to be qualified to conduct the type of approach being carried out. (Safety Issue)
- CASA's guidance material provided to operators about the structure and content of an operations manual was not as comprehensive as that provided by ICAO in areas such as multi-crew procedures and stabilised approach criteria. (Safety Issue)
- Although CASA released a discussion paper in 2000, and further development and publicity had occurred since then, there was no regulatory requirement for RPT operators to have a safety management system. (Safety Issue)
- There was no regulatory requirement for instrument approach charts to include coloured contours to depict terrain. This was required by a standard in ICAO Annex 4 in certain situations. Australia had not notified a difference to the standard. (Safety Issue)
- There was no regulatory requirement for multi-crew RPT aircraft to be fitted with a serviceable autopilot. (Safety Issue)

Other factors relating to Civil Aviation Safety Authority processes:
- CASA's oversight of Transair, in relation to the approval of Air Operator's Certificate variations and the conduct of surveillance, was sometimes inconsistent with CASA's policies, procedures and guidelines.
- CASA did not have a systematic process for determining the relative risk levels of airline operators. (Safety Issue)
- CASA's process for evaluating an operations manual did not consider the useability of the manual, particularly manuals in electronic format. (Safety Issue)
- CASA's process for accepting an instrument approach did not involve a systematic risk assessment of pilot workload and other potential hazards, including activation of a ground proximity warning system. (Safety Issue) Other key findings An 'other key finding' is defined as any finding, other than that associated with safety factors, considered important to include in an investigation report. Such findings may resolve ambiguity or controversy, describe possible scenarios or safety factors when firm safety factor findings were not able to be made, or note events or conditions which 'saved the day' or played an important role in reducing the risk associated with an occurrence.
- It was very likely that both crew members were using RNAV (GNSS) approach charts produced by Jeppesen.
- The cockpit voice recorder did not function as intended due to an internal fault that had developed sometime before the accident flight and that was not discovered or diagnosed by flight crew or maintenance personnel.
- There was no evidence to indicate that the GPWS did not function as designed.
- There would have been insufficient time for the crew to effectively respond to the GPWS alert and warnings that were probably annunciated during the final 5 seconds prior to impact with terrain.

Tyre burst on landing.