ASN Wikibase Occurrence # 73323
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| Date: | Saturday 21 July 2007 |
| Time: | 08:00 |
| Type: |  Airbus A320-232 |
| Owner/operator: | Jetstar Airways |
| Registration: | VH-VQT |
| MSN: | 2475 |
| Year of manufacture: | 2005 |
| Engine model: | IAE V2527-A5 |
| Fatalities: | Fatalities: 0 / Occupants: |
| Aircraft damage: | None |
| Category: | Incident |
| Location: | Melbourne-Tullamarine Airport, VIC (MEL/YMML) -
 Australia
|
| Phase: | Approach |
| Nature: | Passenger - Scheduled |
| Departure airport: | Brisbane International Airport, QLD (BNE/YBBN) |
| Melbourne-Tullamarine Airport, VIC (MEL/YMML) | |
| Investigating agency: | ATSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
An Airbus 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.0
Accident investigation:
 |
|
Sources:
http://www.atsb.gov.au/publications/investigation_reports/2007/aair/ao-2007-044.aspx
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 05-Mar-2010 00:38 | harro | Added |
| 08-Aug-2016 19:04 | Dr.John Smith | Updated [Total fatalities, Other fatalities, Narrative] |
Corrections or additions? ... Edit this accident description
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