ATSB releases report on mishandled go-around at Melbourne

The Australian Transport Safety Bureau (ATSB) released the final report AO-2007-044 of their investigation into a serious incident during a go around involving an Airbus A320 at Melbourne, Australia.

On July 21, 2007 an Airbus A320-232 aircraft was being operated on a scheduled international passenger service for Jetstar 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.

BFU: Final report on A320 crosswind landing mishap

The German Federal Bureau of Aircraft Accident Investigation (BFU) released the final report 5X003-0/08 of their investigation into a serious incident involving an Airbus A320 at Hamburg Airport in March 2008.  The left wing of the A320 had made contact with the ground during an attempted cross-wind landing.

Lufthansa Airbus A320-211 file photo - ASN

Because of the weather associated with hurricane Emma, on 1 March 2008  Lufthansa Airbus A320 registered D-AIQP left Munich Airport (MUC) on a scheduled flight to Hamburg (HAM) at 12:31 about two hours behind schedule, with a crew of five and 13

2 passengers. Given the ATIS weather report including wind of 280°/23 kt with gusts of up to 37 kt, during the cruise phase of the flight the crew decided on an approach to Runway 23, the runway then also in use by other traffic. During the approach to land, the aerodrome controller gave several updates on the wind. Immediately prior to touchdown, the wind was reported as 300°/33 kt, gusting up to 47 kt. At the time of the decrab-procedure there was no significant gust.
The initial descent was flown by autopilot and the co-pilot assumed manual control from 940 ft above ground.
After the aircraft left main landing gear had touched down, the aircraft lifted off again and immediately adopted a left wing down attitude, whereupon the left wingtip touched the ground. The crew initiated a go-around procedure. The aircraft continued to climb under radar guidance to the downwind leg of runway 33, where it landed at 1352 hrs. No aircraft occupants were injured. The aircraft left wingtip suffered damage from contact with the runway.

This serious landing incident took place in the presence of a significant crosswind and immediate causes are as follows:

• The sudden left wing down attitude was not expected by the crew during the landing and resulted in contact between the wingtip and the ground.
• During the final approach to land the tower reported the wind as gusting up to 47 knots, and the aircraft continued the approach. In view of the maximum crosswind demonstrated for landing, a go-around would have been reasonable.

The following systematic causes led to this serious incident:

• The terminology maximum crosswind demonstrated for landing was not defined in the Operating Manual (OM/A) and in the Flight Crew Operating Manual (FCOM), Vol. 3, and the description given was misleading.
• The recommended crosswind landing technique was not clearly described in the aircraft standard documentation.
• The limited effect of lateral control was unknown.