B733, vicinity Kosrae Micronesia, 2015

B733, vicinity Kosrae Micronesia, 2015

Summary

On 12 June 2015, a Boeing 737-300 crew forgot to set QNH before commencing a night non-precision approach to Kosrae which was then flown using an over-reading altimeter. EGPWS Alerts occurred due to this mis-setting but were initially assessed as false. The third of these occurred when the eventual go-around was initially misflown and descent to within 200 feet of the sea occurred before climbing. The Investigation noted failure to action the approach checklist, the absence of ATC support and the step-down profile promulgated for the NDB/DME procedure flown as well as the potential effect of fatigue on the Captain.

Description

On 12 June 2015, a Nauru Airlines Boeing 737-300 (VH-NLK) being operated on a scheduled international passenger flight from the Marshall Islands to Kosrae and making a non-precision offset approach to runway 05 at destination in night IMC received successive EGPWS terrain proximity alerts. These were initially assessed as false but a go around was eventually commenced due to lack of the visual reference required to commence circling but insufficient thrust was applied and descent to within 200 feet of the sea occurred accompanied by a further EGPWS terrain proximity alert. A climb was then established, the aircraft stabilised and the subsequent approach and landing were uneventful.

Investigation

An Investigation was carried out by the Australian Transport Safety Bureau (ATSB). Data relevant to the Investigation was obtained from the aircraft QAR and the NVM contained in the EGPWS.

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