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An aircraft operator has changed its operating procedures following a go-around during an attempted landing at Melbourne in July 2007. The aircraft manufacturer has also revised some of its procedures for the aircraft type.

A passenger aircraft had attempted to land at Melbourne airport in fog, but abandoned the landing due to low visibility. During the go-around, the aircraft descended to within 38 feet of the ground before climbing.

An Australian Transport Safety Bureau (ATSB) investigation report, released today, found that the go-around did not work as intended due to a combination of:
•    problems in positioning the thrust levers for the aircraft's engines
•    failure of the aircraft's flight computers to switch to go-around status and
•    the way tasks were sequenced in the operator's go-around procedures.

The ATSB investigation also found that reporting of the occurrence had not met the requirements of the Transport Safety Investigation Act 2003.

This incident has prompted the operator to change its go-around procedures. The aircraft manufacturer has also changed its published procedures to emphasise some crucial flight crew actions in go-around manoeuvres.

The Chief Commissioner of the ATSB, Mr Martin Dolan, said that the investigation was a good example of how safety investigators could work with operators to improve transport safety.

"We can often learn as much or more from occurrences like this as we can from investigating tragic accidents," Mr Dolan said. "A thorough analysis of what happened, and why, can contribute to improved safety, as it did in this case."

"I would like to remind all transport operators that doing our safety job well relies, in part, on the timely reporting of accidents and incidents," Mr Dolan added.

Full details of the incident and investigation can be found in ATSB's investigation report (Report number AO-2007-044).

 

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Last update 01 April 2011