Dig into the detail in the ATSB preliminary report into the June 30 unsafe approach by a Tiger Airways A320 to Avalon Airport released today and you will discover why that incident pushed CASA’s hand when it came to suspending its AOC less than 24 hours later.

After abandoning a landing on the north to south runway because the tail wind exceeded the permitted limit, the captain of  ‘Go Cat 6207’ from Sydney was cleared to pull a tear drop shaped turn south of the airport, first making a left turn then a right turn to line up to the approach from the south, back across the stretch of water where Corio Bay merges into Geelong’s outer harbor on maritime charts.

The bottom of the ‘tear drop’ turn shown below occurred over the middle of the Bellarine Peninsula, and its patchwork of housing estates and rural spreads.

The 180 seat jet breaks off its first landing attempt at 11.02 pm, and climbs steeply away from the runway, and begins the first turn.  The jet reaches 3,000 feet in altitude and the captain confirms to air traffic control that he will maintain that altitude until established on the final approach, but almost immediately says he is leaving (descending from) that altitude to complete the turn back to the runway.

The first officer had at that stage started and possibly completed entering the runway data for the new approach into the Multifunction Control Display Unit or MCDU, but the report doesn’t clear up that point.

At 11.05 pm and 15 seconds the captain tells the first officer to ignore the MCDU as he will track visually to the runway.

At 11.05 pm and 22 seconds the captain calls 1600 feet altitude to his first officer, as the intended altitude.  This is 400 feet below the safe minimum altitude for that part of the manoeuvre, an altitude of 2000 feet which should have been contained in the MCDU which the first officer has been instructed to ignore.

At 11.05 pm and 29 seconds there is a ‘discussion concerning the position of the aircraft relative to the runway’. The first officer confirms at that point that he has seen the runway.

At 11.05 pm and 37 seconds the aircraft is reported as ‘level’ at 1600 feet. (The terminology of this report leaves much to be desired in terms of clarity, for example, does it mean wings level and at 1600 feet, or at just adhering to a level of 1600 feet.)

At 11.05 pm and 54 seconds air traffic control says :

“Go Cat 6207 are you happy with the terrain there, you are showing 1600.”

The captain replies “Yeh. Go Cat, affirm, we are visual”

Immediately afterwards the captain says ‘Runway in sight’.

The flight then subsequently lands.

This is the first ATSB report in a very long time which quotes directly from the conversations on a cockpit voice recorder although the ‘discussion’ about where the jet was in relation to the runway referred to earlier has obviously been sanitised.

The ATSB says in its summary of this incident that the pilot descended below the safe minimum altitude and left the assigned altitude without clearance.

The map provided of the flight track shows that it broke the safe minimum altitude while it was over or close to  Leopold, a community of around 7000 people. The captain involved was also in command of the Tiger flight that broke the legal safe minimum altitude while on approach to Melbourne Airport on June 7.

Less than 24 hours after the Avalon incident, shortly before 11 pm on Friday, July 1, CASA had reviewed what was known about its conduct and  had suspended Tiger’s AOC or licence to fly. It was described by CASA spokesman, Peter Gibson, as the ‘last straw’ for the regulator, which had for months been trying to focus the attention of Tiger’s management on their legal obligations to satisfy the safety rules.

A further 24 hours after that AOC suspension was announced,  the then CEO of Tiger Airways Holdings, and now CEO of the Australian domestic division, Tony Davis, was giving interviews claiming that CASA was wrong and Tiger’s operations and the flights in question were perfectly safe.

This report makes it clear that if Davis really believed that he is completely unfit to head the airline, and that until it can demonstrate conformity with the requirements of Australian air safety regulations, Tiger is too dangerous to be allowed back into service.

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