Nauru Airlines has enhanced pilot training in a range of navigation and approach areas after a serious incident involving a Boeing 737-300 that flew below the minimum descent altitude on a night approach to Kosrae on 12 June 2015.<\/p>\n
Due to several delays, the aircraft (VH-NLK), operating the carrier\u2019s inaugural scheduled service from the Marshall Islands to\u00a0Kosrae<\/a>, reached the island at night in deteriorating weather conditions, says the Australian Transport Safety Bureau (ATSB) in its final report into the incident.<\/p>\n \u201cThe only instrument approach available for use was an offset procedure based on a non-precision navigation aid,\u201d says the ATSB. \u201cThe risk associated with this type of approach was amplified due to the need to use a ‘dive and drive’ style technique instead of a stable approach path, and that it required low level circling maneuvering from the instrument approach to align the aircraft with the runway.\u201d<\/p>\n In addition, there was high ground in the area and the airport\u2019s control tower was unmanned owing to the flight\u2019s late arrival.<\/p>\n On the VH-NLK\u2019s first approach, the crew did not follow checklist procedure, which called for changing the atmospheric pressure.<\/p>\n \u201cLeaving the altimeters\u2019 subscale set to the standard atmospheric pressure setting of 1013hPa, and not setting the subscale to the local barometric pressure of 1007hPa, resulted in the indicated altitude over-reading, such that when the altimeter indicated 500ft, the aircraft\u2019s actual altitude was about 320ft above the mean sea level,\u201d says ATSB.<\/p>\n During the approach, there were three enhanced ground proximity warning systems (EPGWS) \u2018too low terrain\u2019 warnings in the cockpit. The crew, thinking the issue was due to \u2018map shift\u2019 caused by an inaccurate flight management system information, disengaged all three alerts.<\/p>\n The flight crew then lost visual contact with the runway and initiated a missed approach.<\/p>\n \u201cThe captain was experiencing fatigue and the flight crew had an increased workload and stress due to the inaugural regular public transport flight into\u00a0Kosrae<\/a>\u00a0at night in rapidly deteriorating weather. As a result, the crew\u2019s decision making and task execution on the missed approach were affected, and the aircraft state, airspeed, and attitude were not effectively monitored by either crew member.\u201d<\/p>\n Following the missed approach the crew climbed to 4,000ft. The crew identified that the altimeters were set to the wrong barometric pressure, and corrected this. Following this, the aircraft landed at\u00a0Kosrae<\/a>.<\/p>\n The pilot had 16,000hrs of experience, and the first office 3,300hrs. Overall, there were seven crew and 69 passengers on the aircraft. Passengers included Nauru\u2019s president, its aviation minister, and the chairman of Nauru Airlines. The pilot had gotten little sleep before the flight owing to his mother\u2019s serious illness, but felt obligated to fly owing to the presence of dignitaries aboard the jet.<\/p>\n \u201cThis occurrence highlights the importance of flight crews declaring any instances of acute fatigue and stress-inducing circumstances that may have an impact on their flying performance,\u201d says the ATSB.<\/p>\n \u201cOperators also need to remind flight crew of the importance of their decisions with regards to their fitness to fly. For flight crews, the importance of completing approach checklists and monitoring the approach at safety critical times is emphasized. For operators, the occurrence highlights the importance of incorporating dual-engine go-arounds into simulator training sessions.\u201d<\/p>\n