Investigation number
200504615
Occurrence date
Location
19km NE Melbourne, Aerodrome
Report release date
Report status
Final
Investigation type
Occurrence Investigation
Investigation status
Completed
Aviation occurrence type
Operational non-compliance
Occurrence category
Incident
Highest injury level
None

On 15 September 2005, the crew of a Boeing Company 767-300 (767)
aircraft, registered OE-LAZ, was cleared by air traffic control to
fly the ARBEY TWO Standard Arrival Route (STAR) procedures for an
approach to runway 27 at Melbourne International Airport. As the
aircraft flew the STAR procedure, the controllers observed it
overfly the PAULA airspace fix and continue on the downwind leg
instead of turning right onto the base leg for runway 27, as
required. The controllers provided the crew with radar vectors to
position the aircraft onto the runway 27 localiser, and the
aircraft landed without further incident. When subsequently queried
about the STAR non-compliance, the crew stated that they had been
unsure about how to complete the procedure after overflying
PAULA.

The procedure for the ARBEY TWO STAR for runway 27 specified
that a right turn be made at PAULA to track to the Epping non
directional radio beacon and intercept the localiser of the runway
27 instrument landing system. On 9 September 2005, another of the
operators 767 aircraft was involved in a similar non-compliance
with the ARBEY TWO STAR at Melbourne. On that occasion, the crew
did not follow the published transition onto the STAR from the
APPLE airspace fix to the north-west of Melbourne. On 17 September
2005, and again on 3 November 2005, controllers at Melbourne
observed the operators 767 aircraft overfly the PAULA airspace fix
and continue on the downwind leg instead of turning right and
tracking to Epping as required.

On 16 September 2005, the Australian Transport Safety Bureau
(ATSB) provided the Air Accident Investigation Branch,
Flugunfalluntersuchungsstelle, of the Republic of Austria with
details of the 15 September air safety incident at Melbourne, and
copies of radar plots and air traffic control voice recordings
relating to the occurrence. The ATSB also provided the
Flugunfalluntersuchungsstelle with details of the 9 September, 17
September, and 3 November ARBEY TWO STAR occurrences involving the
operators 767 aircraft.

On 23 December 2005, the Flugunfalluntersuchungsstelle advised
the ATSB that it had held meetings with the operator to discuss the
767 STAR non-compliances at Melbourne. The ATSB has received no
other reports of STAR non-compliances at Melbourne involving the
operators 767 aircraft subsequent to the 3 November 2005
occurrence.

Aircraft Details
Manufacturer
The Boeing Company
Model
767
Registration
OE-LAZ
Operation type
Air Transport High Capacity
Departure point
Singapore
Departure time
22:20
Destination
Melbourne, VIC
Damage
Nil