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.