Preliminary report
Preliminary report released 30 October 2007
This preliminary report details factual information established in the investigation’s early evidence collection phase and has been prepared to provide timely information to the industry and public. Preliminary reports contain no analysis or findings, which will be detailed in the investigation’s final report. The information contained in this preliminary report is released in accordance with section 25 of the Transport Safety Investigation Act 2003.
History of the flight
On 21 July 2007, an Airbus A320-232 aircraft, registered VH-VQT, was being operated on a scheduled international regular public transport service between Christchurch, New Zealand and Melbourne, Australia.
Following an uneventful flight from New Zealand, the crew were conducting an instrument landing system (ILS) approach to runway 27 at Melbourne. Weather conditions were forecast to include fog, which had subsequently eventuated and was likely to necessitate an instrument approach to the minimum altitude on the approach. The likelihood of the crew having to conduct a missed approach was high, as aircraft ahead of VQT had already conducted missed approaches because of the low visibility and fog. The crew had been aware of these conditions prior to departure and had flight planned accordingly. They had also conducted a briefing on the likelihood of having to conduct a missed approach prior to commencing the descent into Melbourne.
At the decision height on the ILS approach, the crew did not have the prescribed visual reference and commenced a missed approach. During the initial part of the missed approach, the crew were not aware that the aircraft had not transitioned to the expected flight guidance modes1 for the missed approach. When the aircraft did not respond as expected, the crew took manual control of the aircraft. The crew were subsequently processed by air traffic control (ATC) for another approach to Melbourne Airport. This second approach also resulted in the crew conducting a missed approach and the aircraft was subsequently diverted to Avalon Airport, where it landed uneventfully. During the second missed approach, the aircraft systems functioned correctly.
Summary
On 21 July 2007, an Airbus Industrie A320-232 aircraft was being operated on a scheduled international passenger service between Christchurch, New Zealand and Melbourne, Australia. At the decision height on the instrument approach into Melbourne, the crew conducted a missed approach as they did not have the required visual reference because of fog. The pilot in command did not perform the go-around procedure correctly and, in the process, the crew were unaware of the aircraft's current flight mode. The aircraft descended to within 38 ft of the ground before climbing.
The aircraft operator had changed the standard operating procedure for a go-around and, as a result, the crew were not prompted to confirm the aircraft's flight mode status until a number of other procedure items had been completed. As a result of the aircraft not initially climbing, and the crew being distracted by an increased workload and unexpected alerts and warnings, those items were not completed. The operator had not conducted a risk analysis of the change to the procedure and did not satisfy the incident reporting requirements of its safety management system (SMS) or of the Transport Safety Investigation Act 2003.
As a result of this occurrence, the aircraft operator changed its go-around procedure to reflect that of the aircraft manufacturer, and its SMS to require a formal risk management process in support of any proposal to change an aircraft operating procedure. In addition, the operator is reviewing its flight training requirements, has invoked a number of changes to its document control procedures, and has revised the incident reporting requirements of its SMS.
In addition to the safety action taken by the aircraft operator the aircraft manufacturer has, as a result of the occurrence, enhanced its published go-around procedures to emphasise the critical nature of the flight crew actions during a go-around.
Occurrence summary
| Investigation number | AO-2007-044 |
|---|---|
| Occurrence date | 21/07/2007 |
| Location | Melbourne Aerodrome |
| State | Victoria |
| Report release date | 01/03/2010 |
| Report status | Final |
| Investigation level | Systemic |
| Investigation type | Occurrence Investigation |
| Investigation status | Completed |
| Mode of transport | Aviation |
| Aviation occurrence category | Incorrect configuration |
| Occurrence class | Serious Incident |
| Highest injury level | None |
Aircraft details
| Manufacturer | Airbus |
|---|---|
| Model | A320 |
| Registration | VH-VQT |
| Serial number | 2475 |
| Sector | Jet |
| Operation type | Air Transport High Capacity |
| Departure point | Christchurch, NZ |
| Destination | Melbourne, Vic. |
| Damage | Nil |