Aviation safety investigations & reports

Go-around event Melbourne Airport, Victoria, 21 July 2007, VH-VQT, Airbus Industrie A320-232

Investigation number:
AO-2007-044
Status: Completed
Investigation completed

Summary

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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.

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Preliminary

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Preliminary report released 30 October 2007

While the crew conducted a go-around the aircraft failed to go into the Speed Reference System (SRS) mode and the aircraft descended below decision height.

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General details
Date: 21 July 2007   Investigation status: Completed  
Time: 0800 EST   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): Melbourne Aerodrome    
State: Victoria   Occurrence type: Incorrect configuration  
Release date: 01 March 2010   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Airbus Industrie  
Aircraft model A320  
Aircraft registration VH-VQT  
Serial number 2475  
Type of operation Air Transport High Capacity  
Damage to aircraft Nil  
Departure point Christchurch, NZ  
Destination Melbourne, Vic.  
Last update 14 November 2018