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Thai 777 disobeyed pull up orders for 50 seconds in Melbourne incident

A Thai International 777-300 which flew too low approaching Melbourne Airport in 2011 twice disobeyed tower instructions to pull up and go around according to a report by the Australian Transport Safety Bureau.

The ATSB says the 50 second delay in response by the big Boeing’s pilots could have proven ‘more hazardous’ had air traffic control been trying to warn it of nearby aircraft or an immediate risk of collision with the ground.

The report is not a good read from the point of view of anyone flying Thai International, which had a similar yet different in its technical details incident with another of its 777s approaching Melbourne airport in 2007.

In this incident the flight was making a winter night time approach in rain showers to the airport at the end of a flight from Bangkok when the tower noticed that it was too low at a point abreast of Essendon having turned to approach the runway from the south.

According to the route advisories in place at the time of the incident pilots were warned of construction cranes below the approach path the Thai 777 was following in the rain and dark that night.

The ATSB report says:

Shortly after clearing the aircraft to conduct a visual approach, the tower controller observed that the aircraft was low on the approach and asked the flight crew to check their altitude. At that time, the aircraft was descending through about 1,100 ft and was about 7 NM (13 km) from the runway threshold. This placed the aircraft significantly below the standard approach path height of about 2,500 ft at that point in the approach and below the relevant SMSA of 1,950 ft. As a result, the tower controller instructed the crew to conduct a go-around, but with no effect. The controller issued additional instructions to go-around about 35 seconds and 47 seconds after issuing the initial instruction.  

While the flight crew did arrest the aircraft’s descent, the time delay between the tower controller’s initial go-around instruction and selection of go-around thrust was about 50 seconds. On this occasion, the tower controller issued the go-around instruction because the aircraft’s was unusually low on the approach. Equally, however, that instruction may have been issued to ensure separation from other traffic or terrain. In that case, a delay of 50 seconds could have resulted in a more hazardous situation.

Before the Thai jet began to climb away for the twice directed go around for a new approach it had descended to 948 feet when 12 kilometres from the perimeter of the airport when it should have been at 2400 feet. (International convention uses imperial measures for the vertical and metric for the horizontal. Yes, it is silly. )

The report notes that Thai International said it would try not to do this again. Actually it said:

In response to this occurrence, Thai Airways International issued a notice to flight crews that emphasized the importance of constant angle non-precision approaches and adherence to the segment minimum safe altitudes. Other actions included a review of the training in support of non-precision approaches and the provision of additional information relating to the use of the aircraft’s autopilot flight director system.

In its findings  the ATSB says the crew may have experienced ‘automation shock’ when the 777 surprised them with  sudden pitch up during the approach. It suggests that the captain of the Thai jet was unfamiliar with the automated systems on the 777, which is a somewhat damning thing to say about the airline’s training standards however politely expressed.

Modern air transport aircraft are equipped with ever increasing levels of automation that, when used appropriately, can greatly reduce flight crew workload. While flight crews retain the option of flying the aircraft manually, the use of automation is generally preferred and often provides increased levels of safety and efficiency. To effectively manage the aircraft and flight path, however, flight crews need to maintain a thorough understanding of the relevant automatic flight systems. Worldwide, errors associated with the use and management of automatic flight systems have been identified as causal factors in more than 20% of approach and landing accidents.

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  • 1
    Aidan Stanger
    Posted February 19, 2013 at 12:56 pm | Permalink

    You’ve got international convention the wrong way round!

    Not any more. Thanks

  • 2
    wildsky
    Posted February 19, 2013 at 2:28 pm | Permalink

    “(International convention uses imperial measures for the vertical and metric for the horizontal. Yes, it is silly.)”

    My understanding (based on Annex 5 to the Convention on International Civil Aviation which is called “Units Of Measurement To Be Used In Air And Ground Operations”) is that SI (metric) units apply universally but that feet, nautical miles and knots are acceptable alternatives with no date set to replace them.

    Any reference by the ATSB to metric units for altitude, height, speed and distance in relation to aircraft are for the convenience of the reader unfamiliar with common aviation unit of measurement.

    So No, it is not silly. If you want silly, try taking on the risk assessment of converting the whole world of aviation to SI units…

  • 3
    ltfisher
    Posted February 19, 2013 at 4:42 pm | Permalink

    Sticking to the important aspects of this report I am amazed that ‘automation shock’ should be involved. Isn’t it the sort of thing that a student pilot gets experience of from the first time he/she gets into an aircraft with an old fashioned auto pilot, and should keep getting experience of as he/she moves up to the top line aircraft? Really this whole episode scares me, and apparently ATSB also who as far as I can recall aren’t in the habit of naming the airline involved in an incident in the first line of their reports.

  • 4
    Geoff
    Posted February 19, 2013 at 6:41 pm | Permalink

    ben – I haven’t downloaded the full report but the digest states the aircraft was doing a VOR approach to RWY 34. If the pilot had been cleared for a night visual approach it would only have been when established on the Vasis/Papis.

    I have had similar experiences when I was an ATC and I believe Air Asia had similar problem at Coolangatta some time ago as well as Korean Air and the Nimitz VOR. I suppose VOR approaches are acceptably safe but I wonder how many times some crews actually fly them “in anger”.

    I have no idea why 34 does not have an ILS but there is probably a good reason.

    I think that 1000 feet is still a more sensible way to express separation between aircraft than 300 metres and 500 metres is too wasteful.

  • 5
    Ronnie Moore
    Posted February 19, 2013 at 9:49 pm | Permalink

    Lovely way of describing the issue Ben – that naughty 777 deserves to be spanked, don’t you think? I guess we all know what you mean. Judging by the results of the “investigation” and ” response” (your beautiful interpretation of the gentle Thai way of trying not to do that again) the pilots must have entered some incorrect values or used some inappropriate modes of the superb 777 autopilot and were also caught surprised and unprepared for an order to go around which did not seem to be immediately actioned. And don’t ATC deserve praise for monitoring this otherwise routine approach and averting what could have been a descent short of the runway on that profile. What disturbs me most is whether the report actually identified the cockpit error, such that crews will be able to avoid a crash short of that runway in future. What would have happened if they had continued that approach – there are plenty of virtual runways = highways to land on if you are too low on those approaches in the rain at night!!

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