Aviation safety investigations & reports

Incorrect configuration for landing involving Airbus A320, VH-VQK, Ballina/Byron Gateway Airport, New South Wales, on 18 May 2018

Investigation number:
AO-2018-042
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

On the morning of 18 May 2018, an Airbus A320 aircraft, registered VH-VQK, was being operated on a regular public transport flight by Jetstar Airways. The flight departed from Sydney, New South Wales for Ballina/Byron Gateway Airport, New South Wales.

The flight crew conducted a go-around on the first approach at Ballina because the aircraft’s flight path did not meet the operator’s stabilised approach criteria. On the second approach, at about 700 ft radio altitude, a master warning was triggered because the landing gear had not been selected DOWN. The flight crew conducted a second go-around and landed without further incident on the third approach.

Flight path of VH-VQK during incident flight

Source: Google Earth annotated by ATSB.

What the ATSB found

The flight crew did not follow the operator’s standard procedures during the first go-around and subsequent visual circuit at 1,500 ft. In particular, the flaps remained at Flaps 3 rather than Flaps 1 during the visual circuit. This created a series of distractions leading to a non-standard aircraft configuration for a visual circuit. Limited use of available aircraft automation added to the flight crew’s workload.

During the downwind leg following the first go-around, the flight crew did not select the landing gear DOWN as they had commenced the configuration sequence for landing at the Flaps 3 setting. Furthermore the flight crew incorrectly actioned the landing checklist, which prevented the incorrect configuration for landing being identified and corrected.

Safety message

Unexpected events during approach and landing phases can substantially increase what is often a high workload period. Adherence to standard operating procedures and correctly monitoring the aircraft and approach parameters provides assurance that a visual approach can be safely completed. The selection of inappropriate auto-flight modes, unexpected developments, or any confusion about roles or procedures can contribute to decisions and actions that increase the safety risk to the aircraft and its passengers.

The ATSB SafetyWatch highlights the broad safety concerns that come out of our investigation findings and from the occurrence data reported to us by industry. Handling of approach to land is one of these priorities.

Download final report
[Download  PDF: 537KB]
 
 
 

The occurrence

Context

Safety analysis

Findings

General details
Date: 18 May 2018   Investigation status: Completed  
Time: 1100 EST   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): near Ballina/Byron Gateway Airport   Investigation phase: Final report: Dissemination  
State: New South Wales   Occurrence type: Incorrect configuration  
Release date: 10 December 2019   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Airbus  
Aircraft model A320-232  
Aircraft registration VH-VQK  
Serial number 2651  
Operator Jetstar Airways  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Nil  
Departure point Sydney, NSW  
Destination Ballina/Byron Gateway, NSW  
Last update 20 July 2020