Loss of situational awareness during night approach near Parafield

No fatalities • 5 km north-east of Parafield Airport, South Australia

A pilot's distraction by a perceived autopilot issue led to a loss of situational awareness and an approach below minimum safe altitude near Parafield.

What happened

During a night approach under instrument flight rules, the aircraft followed an abnormal track characterized by incorrect positioning on the downwind leg and high inbound airspeed. As the approach progressed, the pilot became distracted by what was perceived to be a malfunction within the autopilot system. This distraction led to a significant loss of situational awareness, preventing the pilot from accurately monitoring the aircraft's position and altitude.

As a result of this loss of awareness, the aircraft was maneuvered outside of the designated circling area and the Parafield control area. The aircraft's altitude dropped significantly below the minimum sector altitude. After turning onto a leg the pilot believed to be the base leg, the runway could not be visually identified. Despite the lack of visual contact, the approach was continued while searching for the runway. Relying on familiarity with the airport and the perceived visibility, the pilot chose to maintain altitude rather than climbing to a safer level.

The investigation

Investigators analyzed the aircraft's tracking data and the pilot's statements to reconstruct the flight path. The investigation focused on the stages of situational awareness: the ability to obtain information, understand the environment, and predict future developments. The findings indicated that the pilot's ability to perform these functions was compromised by the perceived issue with the autopilot.

Findings

  • The pilot experienced a loss of situational awareness during the night visual approach.
  • A perceived issue with the autopilot system acted as a primary distraction.
  • The approach was continued at an altitude below the minimum safe altitude, which removed the assurance of obstacle clearance and increased the risk of terrain collision.

Probable cause

The pilot's loss of situational awareness, likely caused by distraction from a perceived autopilot malfunction, led to the aircraft being operated below the minimum safe altitude during a night approach.

Frequently asked questions

What happened in the 2021-05-13 Beech Aircraft Corp 95-B55 accident near 5 km north-east of Parafield Airport, South Australia?

A pilot's distraction by a perceived autopilot issue led to a loss of situational awareness and an approach below minimum safe altitude near Parafield.

Were there any fatalities in the 2021-05-13 Beech Aircraft Corp 95-B55 accident?

No fatalities were recorded in this accident.

What aircraft was involved and where did it happen?

The accident on 2021-05-13 involved a Beech Aircraft Corp 95-B55, registration VH-CBG, at 5 km north-east of Parafield Airport, South Australia.

What was the probable cause of the accident?

The pilot's loss of situational awareness, likely caused by distraction from a perceived autopilot malfunction, led to the aircraft being operated below the minimum safe altitude during a night approach.

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