Aviation safety investigations & reports

Flap overspeed and altitude exceedance during go-around Airbus A321, VH-VWY, Cairns Airport, Qld on 3 September 2012

Investigation number:
AO-2012-116
Status: Completed
Investigation completed

Summary

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What happened

On 3 September 2012, an Airbus A321, registered VH-VWY and being operated by Jetstar Airways, was being flown on a scheduled passenger flight from Melbourne, Victoria to Cairns, Queensland. During a visual approach to runway 15 at Cairns, the aircraft drifted slightly high on profile and the captain instructed the first officer, who was the pilot flying, to go around. During the go-around, the aircraft exceeded the flap limit speed and climbed to 2,700 ft, exceeding the 2,000 ft limit assigned by air traffic control.

What the ATSB found

The ATSB found that the first officer had a low level of expectancy of, and was not mentally prepared for, a go-around. Although the initial steps in the go-around procedure were implemented effectively, the first officer’s attention focussed on airspeed management and they did not retard the thrust levers from the take-off go-around detent to the climb detent at an appropriate point during the go-around. Consequently, the aircraft’s auto-thrust system was not activated to reduce the amount of thrust. After the initial breakdown in applying the go-around procedure, the crew experienced a high workload, which significantly limited their capacity to resolve the situation.

The ATSB found that this occurrence had similar features to many previous go-around occurrences. In summary, all-engine go-arounds in modern air transport aircraft are often a challenging task when there is a requirement to level-off at a low altitude, and many pilots have had limited preparation for such tasks. 

What's been done as a result

Following this and a number of related occurrences, Jetstar Airways included ‘unscripted’ go‑arounds in its recurrent training sessions. One of these sessions also emphasised the importance of moving the thrust levers to the climb detent without delay.

In August 2013, as a result of a detailed review of similar go-around occurrences, the French Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile (BEA) issued a series of recommendations about go-around issues to the European Aviation Safety Agency.

Safety message

A go-around with all aircraft systems available to the crew is a normal but infrequently flown, dynamic manoeuvre, requiring a very methodical series of actions on the part of the flight crew, at relatively high tempo, particularly when level-off at a low altitude is planned. This occurrence serves as a reminder of the importance of being mentally prepared to conduct a go-around, even in fine conditions.


Download final report
[Download  PDF: 1.82MB]
 
 
Alternate: [Download  DOCX: 1.3MB]
 

Safety Issue

Go to AO-2012-116-SI-01 -

Go-around preparedness

All-engine go-arounds in modern air transport aircraft are often a challenging task when there is a requirement to level-off at a low altitude, and many pilots have had limited preparation for this task.

Safety issue details
Issue number: AO-2012-116-SI-01
Who it affects: All operators and flight crew of modern air transport aircraft
Status: Adequately addressed
General details
Date: 03 September 2012   Investigation status: Completed  
Time: 0925 EST   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): Cairns Airport    
State: Queensland   Occurrence type: Airframe overspeed  
Release date: 03 November 2014   Occurrence class: Operational  
Report status: Final   Occurrence category: Incident  
  Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Airbus  
Aircraft model A321  
Aircraft registration VH-VWY  
Serial number 1408  
Operator Jetstar Airways  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Nil  
Departure point Melbourne, Vic.  
Destination Cairns, Qld  
Last update 14 November 2018