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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.

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Safety issues

AO-2009-066-SI-01 - AO-2009-066-SI-02 - 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  
Location   (show map):1.5 km north of Sydney Airport Investigation type: Occurrence Investigation 
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 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
 
 
 
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Last update 14 November 2018