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Crew fatigue behind low-flying plane

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A Qantas plane flew lower than it should have near Canberra last year because its tired co-pilot entered the wrong data into a flight computer, a report has found.The Australian Transport Safety Bureau (ATSB) said the early-morning flight from Perth to Canberra was never in danger from the error.But it said the airline and the chart publisher had made some changes since the incident on July 24, 2004, to ensure it did not happen again.The ATSB investigation found the co-pilot entered incorrect information into the flight management computer (FMC), prompting a message from the plane's warning system.The ATSB said the co-pilot was affected by fatigue at the time, partly as a result of an air-conditioning fault aboard the Boeing 737 that led to uncomfortably hot conditions in the cockpit.An automatic caution terrain alert was activated about 0545 (AEST) when the plane was at 5,850 feet south of Canberra.The minimum sector altitude permitted in the area was 7,400 feet due to the mountainous terrain."The aircraft was fitted with an enhanced ground proximity warning system, which detected the aircraft's proximity to the terrain and provided the crew with a caution terrain message to which the crew responded by climbing the aircraft to 6,500 feet," the report said.ATSB deputy director Alan Stray said the plane was already turning away from the terrain when the message was generated."So they were well clear, they were turning away from it, no one was in danger," he said."That's one of the reasons we have determined this was not a serious incident, it was an incident because there were a number of issues involved, but it was not classified as a serious incident."The crew on board the flight had earlier been advised that due to staff shortages, air traffic controllers were not monitoring radar equipment at Canberra.The ATSB said several factors contributed to the incident and it was not simply the result of incorrect data entry.The ATSB said Qantas had amended its procedures, requiring a higher altitude for aircraft holding to the south of Canberra, while the chart publisher was also making changes to make holding pattern limits clearer, to reduce the likelihood of misinterpretation.

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