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Updated: 28 August 2017

Completion of the draft investigation report has been delayed by the involvement of the investigator in charge on other aviation safety investigations and tasks. The draft report is now anticipated for release to directly involved parties (DIP) for comment in September 2017. Feedback from those parties over the 28-day DIP period on the factual accuracy of the draft report will be considered for inclusion in the final report, which is anticipated to be released to the public in November 2017.

 

Updated: 19 December 2016

Completion of the draft investigation report has been further delayed by competing priorities and workload of the investigator in charge. It is now anticipated for release to directly involved parties (DIP) for comment in March 2017. Feedback from those parties over the 28-day DIP period on the factual accuracy of the draft report will be considered for inclusion in the final report, which is anticipated to be released to the public late May 2017.

 

Updated: 7 September 2016

Completion of the draft investigation report has been delayed by competing priorities and workload of the investigator in charge. It is now anticipated for release to directly involved parties (DIP) for comment in December 2016. Feedback from those parties over the 28-day DIP period on the factual accuracy of the draft report will be considered for inclusion in the final report, which is anticipated to be released to the public no later than February 2017.

 

Updated: 8 December 2015

On 5 July 2015, shortly after another aircraft commenced its take-off, two aircraft conducted simultaneous missed approach/go-arounds at Melbourne Airport, Victoria, during Land and Hold Short Operations (LAHSO) at night. There was no loss of separation between any of the aircraft.

The aircraft involved in the occurrence included a Boeing:

  • 737-800, registered VH-VXS (VXS), operating a scheduled passenger flight from Sydney, New South Wales, to Melbourne
  • 737-800, registered VH-VYE (VYE), operating a scheduled passenger flight from Canberra, Australian Capital Territory, to Melbourne
  • 777-31HER (777), registered A6-EBU, operating a scheduled passenger flight from Melbourne to Singapore.

Land and Hold Short Operations

LAHSO is a procedure involving dependant operations on two intersecting runways. Aircraft land and depart from one runway while aircraft landing on the other runway hold short of the intersection with the crossing runway.

LAHSO is conducted by Airservices Australia (Airservices) at Melbourne and Adelaide, South Australia Airports and is subject to a number of documented conditions and procedures for air traffic control and participating operators. The Department of Defence also operates LAHSO at Darwin Airport, Northern Territory. Approved Australian and New Zealand Operators may participate in LAHSO.

At the time of the occurrence, the LAHSO runway configuration at Melbourne Airport was runways 27/34 (R27/34)[1] for arrivals and runway 27 (R27) for departures (Figure 1). The flight crew of VXS were assigned an instrument landing system approach to R27. The flight crew of VYE were assigned a visual approach to R34.

Figure 1: Melbourne Airport layout showing the runways and taxiways and the intended arrival runway for VXS and VYE

Figure 1: Melbourne Airport layout showing the runways and taxiways and the intended arrival runway for VXS and VYE

Source: Airservices, modified by the ATSB

Air traffic control information

The Melbourne Aerodrome Control (ADC) or tower controller position was staffed by an On-the-Job Training Instructor (OJTI) and a trainee controller. It was the trainee’s fourth shift under training. The trainee previously held ADC ratings at two overseas airports.

The two other controllers in Melbourne Tower at the time were filling the combined Surface Movement Control and Airways Clearance Delivery positions and the Melbourne Coordinator (Coordinator) role respectively. As the Shift Manager had previously finished their shift at 1800 Eastern Standard Time[2], the Coordinator also held Operational Command Authority (OCA) for Melbourne Tower.

OCA was defined as having overall responsibility for the provision of an operational service. This did not include authority to make operational decisions, such as directing a controller to issue an urgent operational control instruction. In this instance, the ADC position was responsible for traffic separation but, as detailed in the Airservices National ATS Administration Manual, ‘…may accept advice from the OCA holder’.

The occurrence

At 1808, the flight crew of the 777 reported ready for departure off R34. The departure from this runway, rather than from the designated departure runway for LAHSO, was an operational requirement due to the aircraft’s weight and the resulting increased length of runway needed for take-off. At that time, VXS was on about a 7 NM (13 km) final for R27 and VYE was on a right base for R34, with about 5.5 NM (10 km) to run.

After confirming that the 777 flight crew was ready for an immediate departure, and discussing the situation with the OJTI, the ADC trainee instructed the 777 flight crew to line up on R34.

At 1809, the ADC trainee issued the 777 flight crew with a clearance for an immediate take-off. At that time, VXS was on about a 4 NM (7.4 km) final for R27 and VYE was turning right base and about 3.5 track miles[3] (6.5 km) from the threshold of R34.

As the flight crew of the 777 commenced the take-off roll, the Coordinator voiced concern to the ADC trainee and OJTI that the traffic scenario involving the three aircraft was not going to work.

At 1810, after instructing VXS’s flight crew to reduce to minimum speed, the ADC trainee advised them that, in the event of a missed approach, there was traffic departing and landing on the crossing runway and they should climb to 4,000 ft ‘expeditiously’. The trainee’s intent was to pre-warn the flight crew of the need to expedite their climb in the event of a missed approach. However, VXS’s flight crew interpreted the transmission as a requirement for an immediate missed approach and expedited their climb to 4,000 ft.

After observing VXS commencing a missed approach from R27, and with the 777 still on the take-off roll on R34, the Coordinator directed the ADC trainee to send VYE around. The ADC trainee issued the instruction to VYE’s flight crew and they commenced a go-around.

The Coordinator reported that their instruction to the ADC trainee was given under a duty of care to prevent a potential safety occurrence and not as part of their OCA role. However, the ADC trainee and OJTI reported that they considered the required runway separation between the departing 777 and VYE would have been achieved had VYE continued the approach.

The ADC trainee identified that VYE, in the go-around manoeuvre, could encounter wake turbulence from the departing 777. The trainee and OJTI discussed the situation and determined that instructing VYE to turn right would keep the aircraft out of the 777’s wake turbulence envelope. The ADC trainee instructed VYE’s flight crew to turn right and ‘track’ 360°.

The ADC trainee’s intention was to issue a heading instruction but they used phraseology consistent with a procedural tracking requirement. VYE’s flight crew read back ‘heading 360°’, which was 14° right of R34’s magnetic heading of 346°.

The minimum vector altitude,[4] which has application in instrument meteorological conditions[5] or at night, in that area was 2,000 ft. At the time the ADC trainee issued the instruction to VYE, the aircraft’s altitude was about 1,400 ft and climbing. At about 1811, when VYE crossed the intersection of R34 and R27, the aircraft was in the right turn and above 2,000 ft.

VXS and VYE subsequently landed at Melbourne and the 777 continued to Singapore.

Additional information

At the time of the occurrence, Airservices’ ADCs at Melbourne and Adelaide Airports had completed compromised separation training in the visual simulator in visual conditions by day. They had not been trained in compromised separation recovery in the case of simultaneous missed approaches/go-arounds at night.

Following the occurrence, Airservices initiated an investigation. This investigation identified a number of safety issues and safety action was commenced by Airservices in response.

In addition, there has been extensive correspondence between Airservices and the Civil Aviation Safety Authority (CASA) regarding the occurrence. Concerns were raised by CASA on the effectiveness of the risk controls in the case of simultaneous missed approaches/go-arounds at night, during LAHSO. Airservices agreed to conduct a review of LAHSO as part of ongoing safety management activities to ensure the LAHSO procedure was being applied to ensure the level of associated risk is ALARP[6].

On 10 November 2015, in consideration of CASA’s concerns, Airservices suspended LAHSO at night at Melbourne and Adelaide Airports, until at least March 2016. Airservices reported that they would continue to progress a number of improvements and report back to CASA on a regular basis.

On 12 November 2015, a number of changes to LAHSO were implemented by Airservices and promulgated to industry by Australian Aeronautical Information Publication Supplement H92/15 LAND AND HOLD SHORT OPERATIONS (LAHSO). These changes included:

  • definitions for the terms ‘active’ and ‘passive’ LAHSO runways
  • additional radio phraseology when an arriving aircraft operating on a flight number call sign cannot participate in LAHSO
  • additional runway wind conditions for LAHSO
  • the requirement for pilots to ensure that their aeroplane can land safely within the landing distance available for LAHSO
  • the requirement for crews that would normally be able to participate in active or passive LAHSO to advise air traffic control when they cannot meet those criteria
  • the requirement for crews to provide early advice to air traffic control of experiencing wind shear
  • the requirement for air traffic control to nominate the active and passive LAHSO runways on the Automatic Terminal Information Service (ATIS).[7]

In addition, Airservices Safety Bulletin Changes to AIP Land and Hold Short Operations (LAHSO) of 23 October 2015[8] advised that LAHSO would no longer be conducted after wind shear was reported.

Ongoing investigation

The investigation is continuing and will include examination and analysis of:

  • available occurrence data for similar occurrences
  • LAHSO procedures, approvals, associated operational risk assessments and risk controls
  • compromised separation recovery training for Airservices’ Aerodrome Controllers
  • operational command authority
  • On-the-Job Training Instructor training and guidelines
  • team resource management for Airservices’ controllers.

The information contained in this web update is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this web update. As such, no analysis or findings are included in this update.

 

__________

  1. Runways are named by a number representing the magnetic heading of the runway.
  2. Eastern Standard Time (EST) was Coordinated Universal Time (UTC) + 10 hours.
  3. Actual distance in NM remaining to be flown.
  4. Defined in the Australian Aeronautical Information Publication GEN 2.2 DEFINITIONS AND ABBREVIATIONS as ‘The lowest altitude which a controller may assign to a pilot in accordance with the Radar Terrain Clearance chart.’
  5. Instrument meteorological conditions (IMC) describes weather conditions that require pilots to fly primarily by reference to instruments, and therefore under Instrument Flight Rules (IFR), rather than by outside visual references. Typically, this means flying in cloud or limited visibility.
  6. As Low as Reasonably Practicable.
  7. An automated pre-recorded transmission indicating the prevailing weather conditions at the aerodrome and other relevant operational information for arriving and departing aircraft.
  8. Available at www.airservicesaustralia.com.
 
General details
Date: 05 July 2015 Investigation status: Active 
Time: 18:20 EST Investigation type: Occurrence Investigation 
Location   (show map):Melbourne Airport Occurrence type:Missed approach 
State: Victoria Occurrence class: Operational 
 Occurrence category: Incident 
Report status: Pending Highest injury level: None 
Expected completion: January 2018  
 
Aircraft 1 details
Aircraft manufacturer: The Boeing Company 
Aircraft model: 737-838 
Aircraft registration: VH-VXS 
Serial number: 33725 
Operator: Qantas Airways Ltd. 
Type of operation: Air Transport High Capacity 
Sector: Jet 
Damage to aircraft: Nil 
Departure point:Sydney, NSW
Destination:Melbourne, Vic.
Aircraft 2 details
Aircraft manufacturer: The Boeing Company 
Aircraft model: 737-838 
Aircraft registration: VH-VYE 
Serial number: 33993 
Operator: Qantas Airways Ltd. 
Type of operation: Air Transport High Capacity 
Sector: Jet 
Damage to aircraft: Nil 
Departure point:Canberra, ACT
Destination:Melbourne, Vic.
Aircraft 3 details
Aircraft manufacturer: The Boeing Company 
Aircraft model: 777-31HER 
Aircraft registration: A6-EBU 
Serial number: 34484 
Operator: Emirates 
Type of operation: Air Transport High Capacity 
Sector: Jet 
Damage to aircraft: Nil 
Departure point:Melbourne, Vic.
Destination:Changi, Singapore
 
 
 
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Last update 17 October 2017