Aviation safety investigations & reports

Incorrect aircraft configuration - Boeing 767-300, VH-OGP, 1.5 km north of Sydney Airport, NSW, 26 October 2009

Investigation number:
AO-2009-066
Status: Completed
Investigation completed

Summary

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Alternate: [Download  DOC: 425KB]
 

At 0735 Eastern Daylight-saving Time on 26 October 2009, VH-OGP, a Qantas Airways Boeing 767-300, initiated a go-around manoeuvre from an approach into Sydney Airport, New South Wales. The aircraft immediately returned for a normal landing. The go-around was initiated due to the crew becoming aware that the aircraft was not properly configured for landing. Almost simultaneously, the 'Too Low Gear' automated warning activated, which indicated that the aircraft's landing gear was not extended.

The incorrect aircraft configuration was the result of several interruptions and distractions during the approach. These interruptions and distractions resulted in a breakdown in the pilots' situational awareness.

The investigation identified a number of minor safety issues in the operator's procedures and monitoring systems and Qantas Airways has advised of safety action in response.

Download Final Report
[Download  PDF: 373KB]
 
 
Alternate: [Download  DOC: 425KB]
 

Safety Issues

Go to AO-2009-066-SI-01 - Go to AO-2009-066-SI-02 - Go to AO-2009-066-SI-03 -

Inconsistent monitoring messages in company documentation

The conflicting requirements and definitions in the operator’s publications in relation to the pilot not flying role had the potential to diminish the importance of monitoring as an essential element in an aircraft’s safe operation.

Safety issue details
Issue number: AO-2009-066-SI-01
Who it affects: Qantas Airways
Status: Adequately addressed

Correlation between flight data and incident reports

There was no correlation between the results of the operator’s Flight Operational Quality Assurance and Air Safety Incident Report investigations.

Safety issue details
Issue number: AO-2009-066-SI-02
Who it affects: Qantas Airways
Status: Adequately addressed

Monitoring of landing gear through Flight Operational Quality Assurance

There were no soft and hard triggers in the operator’s Flight Operational Quality Assurance system to monitor the selection of the aircraft’s landing gear during an approach.

Safety issue details
Issue number: AO-2009-066-SI-03
Who it affects: Qantas Airways
Status: Adequately addressed
General details
Date: 26 October 2009   Investigation status: Completed  
Time: 0735 ESuT   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): 1.5 km north of Sydney Airport    
State: New South Wales   Occurrence type: Incorrect configuration  
Release date: 18 October 2011   Occurrence class: Operational  
Report status: Final   Occurrence category: Serious Incident  
  Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer The Boeing Company  
Aircraft model 767  
Aircraft registration VH-OGP  
Serial number 28153  
Type of operation Air Transport High Capacity  
Damage to aircraft Nil  
Departure point Melbourne, Vic.  
Destination Sydney, NSW  
Last update 14 November 2018