Aviation safety investigations & reports

Operational non-compliance involving Airbus A380, 9V-SKQ, near Sydney Airport, NSW, on 9 February 2020

Investigation number:
AO-2020-011
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final report

Download Final report
[Download  PDF: 241KB]
 

Safety summary

What happened

On 9 February 2020, an Airbus A380 aircraft, registered 9V-SKQ was being operated by Singapore Airlines on a scheduled passenger service from Singapore to Sydney, New South Wales.

During the approach to runway 16 right at Sydney, the aircraft encountered windshear and in response, the flight crew commenced the windshear recovery procedure and missed approach. During this time, air traffic control (ATC) instructed the flight crew to turn right onto a heading of 270°. The flight crew read back the heading, however, did not include the direction of the turn. Air traffic control did not correct the incomplete readback and the flight crew commenced turning the aircraft left instead of right.

Air traffic control issued a safety alert to the flight crew, advised them of a Bombardier DHC-8 aircraft about 6 NM (11 km) on final for runway 16 left, and instructed them to turn right and climb immediately. Air traffic control then instructed the flight crew of the DHC-8 to make a right turn in order to maintain separation with the A380. This resulted in a loss of separation between the DHC-8 and a Boeing 737 aircraft on approach to runway 16 right.

What the ATSB found

The ATSB found that the flight crew were likely experiencing high workload as a result of conducting the windshear recovery and published missed approach procedure. This, in combination with an expectation that they would be turning left, contributed to them mishearing the ATC instruction to turn right. As a result, the aircraft was turned left. In addition, the flight crew omitted information from their readback and ATC did not correct the flight crew’s incomplete readback, which was a missed opportunity to correct the misheard instruction.

What has been done as a result

Singapore Airlines issued a notice to flight crew, highlighting strategies to manage high workload situations, as well as reiterating the importance of correct readbacks and acknowledgement from ATC.

Safety message

Compliance with ATC published procedures, such as readback procedures, provides assurance that instructions are correctly understood, which is especially important during high workload periods and/or in times of high traffic density. This incident highlights the importance of flight crew completing full readbacks, as well as controllers correcting any readback discrepancies immediately. The ATSB’s aviation research and analysis report Radiotelephony Readback Compliance and its Relationship to Surface Movement Control Frequency Congestion (20060053) provides further information regarding readback compliance.   

 

Download Final report
[Download  PDF: 241KB]
 
 
 

The investigation

General details
Date: 09 February 2020   Investigation status: Completed  
Time: 11:22 AEDT   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): Sydney Airport   Investigation phase: Final report: Dissemination  
State: New South Wales   Occurrence type: Operational non-compliance  
Release date: 07 April 2021   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Airbus  
Aircraft model A380-841  
Aircraft registration 9V-SKQ  
Serial number 79  
Operator Singapore Airlines  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Nil  
Departure point Singapore  
Destination Sydney, New South Wales  
Last update 07 April 2021