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On 21 July 2007, an Airbus Industrie A320-232 aircraft was being operated on a scheduled international passenger service between Christchurch, New Zealand and Melbourne, Australia. At the decision height on the instrument approach into Melbourne, the crew conducted a missed approach as they did not have the required visual reference because of fog. The pilot in command did not perform the go-around procedure correctly and, in the process, the crew were unaware of the aircraft's current flight mode. The aircraft descended to within 38 ft of the ground before climbing.

The aircraft operator had changed the standard operating procedure for a go-around and, as a result, the crew were not prompted to confirm the aircraft's flight mode status until a number of other procedure items had been completed. As a result of the aircraft not initially climbing, and the crew being distracted by an increased workload and unexpected alerts and warnings, those items were not completed. The operator had not conducted a risk analysis of the change to the procedure and did not satisfy the incident reporting requirements of its safety management system (SMS) or of the Transport Safety Investigation Act 2003.

As a result of this occurrence, the aircraft operator changed its go-around procedure to reflect that of the aircraft manufacturer, and its SMS to require a formal risk management process in support of any proposal to change an aircraft operating procedure. In addition, the operator is reviewing its flight training requirements, has invoked a number of changes to its document control procedures, and has revised the incident reporting requirements of its SMS.

In addition to the safety action taken by the aircraft operator the aircraft manufacturer has, as a result of the occurrence, enhanced its published go-around procedures to emphasise the critical nature of the flight crew actions during a go-around.

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Download Preliminary Report
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Preliminary report released 30 October 2007

While the crew conducted a go-around the aircraft failed to go into the Speed Reference System (SRS) mode and the aircraft descended below decision height.

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General details
Date: 21 Jul 2007 Investigation status: Completed 
Time: 0800 EST Investigation type: Occurrence Investigation 
Location   (show map):Melbourne Aerodrome Occurrence type:Incorrect configuration 
State: Victoria Occurrence class: Operational 
Release date: 01 Mar 2010 Occurrence category: Serious Incident 
Report status: Final Highest injury level: None 
Aircraft details
Aircraft manufacturer: Airbus Industrie 
Aircraft model: A320 
Aircraft registration: VH-VQT 
Serial number: 2475 
Type of operation: Air Transport High Capacity 
Damage to aircraft: Nil 
Departure point:Christchurch, NZ
Destination:Melbourne, Vic.

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Last update 13 May 2014