Aviation safety investigations & reports

Operational non-compliance, Perth Airport, WA, 9 May 2008, PK-GEF, Boeing Company 737-8CX

Investigation number:
AO-2008-033
Status: Completed
Investigation completed

Summary

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On 9 May 2008, a Boeing Company 737-8CX aircraft, registered PK-GEF, was being operated on a scheduled passenger service between Denpasar, Republic of Indonesia and Perth, WA. On board were two flight crew, six cabin crew and 76 passengers.

The flight crew reported that, once established in the cruise, they reviewed their briefing material and noted that the threshold for runway 21 at Perth was displaced due to runway works.

On approach to land at Perth, the aerodrome controller issued the flight crew with the landing clearance, '... runway 21 displaced threshold, cleared to land'. When the aircraft was about 15 seconds from touchdown, the flight crew questioned the presence of cars on the runway and conducted a go-around.

On the second approach, the flight crew were again issued the landing clearance '... runway 21, displaced threshold, cleared to land'. The aerodrome controller recalled observing the aircraft on what appeared to be an approach to land on the closed section of the runway and instructed the flight crew to go around. The go-around instruction also included information to assist the flight crew in identifying where the aircraft was to be landed. That additional information, together with the high workload being experienced by the flight crew at that time, may have momentarily confused them, with the effect that they did not assimilate and act on the instruction to go around.

As a result of this incident, the airport operator undertook a number of safety actions. Those actions included: the review of its dispatch of Method of Works Plans (MWOP) to relevant stakeholders; the implementation of a more robust MWOP receipt and acknowledge system; and the establishment of a project safety group in support of all critical airside works.

Download Final Report
[Download  PDF: 1.03MB]
 
 
 
General details
Date: 08 May 2008   Investigation status: Completed  
Time: 1602 WST   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): Perth Airport    
State: Western Australia   Occurrence type: Operational non-compliance  
Release date: 09 June 2009   Occurrence class: Airspace  
Report status: Final   Occurrence category: Serious Incident  
  Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer The Boeing Company  
Aircraft model 737  
Aircraft registration PK-GEF  
Serial number 32363  
Type of operation Air Transport High Capacity  
Damage to aircraft Nil  
Departure point Denpasar Indonesia  
Destination Perth WA  
Last update 14 November 2018