Vietnam B789 at Melbourne on Sep 19th 2019, tower observes landing gear not down

Last Update: August 25, 2022 / 20:20:43 GMT/Zulu time

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Photo of Vietnam Airlines VN-A870, Boeing 787-9 Dreamliner — Vietnam Airlines VN-A870, Boeing 787-9 Dreamliner (Photo credit: GerardvdSchaaf / Flickr / License: CC by)

Incident Facts

Date of incident
Sep 19, 2019

Classification
Incident

Airline
Vietnam Airlines

Flight number
VN-781

Departure
Ho Chi Minh City, Vietnam

Destination
Melbourne, Australia

Aircraft Registration
VN-A870

Aircraft Type
Boeing 787-9 Dreamliner

ICAO Type Designator
B789

A Vietnam Airlines Boeing 787-9, registration VN-A870 performing flight VN-781 (dep Sep 18th) from Ho Chi Minh City (Vietnam) to Melbourne,VI (Australia), was on final approach to Melbourne's runway 34 when tower observed the landing gear was not extended. The crew initiated a go around from about 500 feet AGL, positioned for another approach and landed safely on runway 34 about 17 minutes later.

The ATSB reported: "During approach to land, Melbourne Air Traffic Control advised the crew that the aircraft’s landing gear was observed not to be extended. The crew initiated a missed approach." The occurrence was rated an incident, a short investigation was opened.

On Aug 25th 2022 the ATSB reported that the investigation into the incident was terminated without report due to being highly unlikely that "further investigation would identify any systemic safety issues or important safety lessons."

The ATSB released folloiwng safety message:

Unstable approaches are known to be a hazard to aircraft operations. According to the International Air Transport Association, between 2012–2016, there was an average of 6 accidents per year, which were preceded by an unstable approach.[9] The Flight Safety Foundation approach-and-landing accident reduction task force identified several factors that contributed to unstable approaches, which included:

- crew fatigue
- crew or air traffic control-induced circumstances resulting in insufficient time to plan, prepare and conduct a safe approach, which includes accepting requests from controllers to fly higher/faster or to fly shorter routings than desirednot recognising deviations
- not adhering to parameter-deviation limits
- belief that the aircraft will be stabilised at the minimum stabilisation height or shortly thereafter
- confidence by the PM that the PF will achieve a timely stabilisation.

In March 2019, the United States National Transportation Safety Board published Safety Alert 077 Stabilized approaches lead to safe landings. This reiterated that, failing to maintain a stabilised approach could lead to a landing with too much speed or too far down the runway, and ultimately to a runway excursion, loss of control or collision with terrain. The alert went on to urge pilots of all types and classes of aircraft to comply with standard operating procedures and industry best practice for stabilised approach criteria and go-arounds.

The ATSB summarized the sequence of events:

On 19 September 2019, at about 0725 Eastern Standard Time, the crew of a Vietnam Airlines Boeing 787-9 aircraft, registered VN-A870, operating a scheduled passenger service from Ho Chi Minh City, Vietnam, were on descent into Melbourne, Australia. The captain was the pilot flying (PF) and the first officer was the pilot monitoring (PM). Visual meteorological conditions were present at Melbourne Airport for the arrival.

The crew had planned to track via the ARBEY 4A standard terminal arrival route (STAR) prior to conducting the runway 34 RNAV-Z approach. The aircraft was descended in accordance with instructions from air traffic control.

At 0757:15, while the aircraft was maintaining 6,000 ft, the Melbourne approach controller requested that the crew cancel all speed restrictions and hold their speed for as long as possible. The PM responded that they were maintaining 240 kt and the approach controller replied ‘just the best you can do, thank you’.

At 0758:03, the approach controller provided the crew with their clearance to descend via the STAR to 2,500 ft and that they were cleared for the RNAV-Z approach to runway 34. From 0758:28 to 0801:02, the crew incrementally reduced the aircraft’s speed from 240 kt to 185 kt and selected 2 stages of flaps (flaps-1 then flaps-5).

During the STAR, a tailwind, in combination with the instruction from air traffic control to hold their speed for as long as possible resulted in an average groundspeed of about 280 kt, requiring the crew to use the speedbrake to decelerate and descend.

At 0802:13, after the aircraft had commenced the turn to intercept the approach, the approach controller instructed the crew to contact the Melbourne tower controller. After initial frequency congestion, the PM contacted the tower controller and confirmed they were cleared for the approach.

At 0804:18, the aircraft passed the final approach fix, 4 NM (7 km) from the runway, at 1,493 ft, about 157 ft below the intended glidepath. The aircraft configuration remained at flaps-5 with the landing gear up. The airspeed was about 186 kt, which was 26 kt above the maximum procedure approach speed of 160 kt and about 36 kt above their calculated flaps-30 approach reference speed of 150 kt. The autopilot captured the glidepath at 0804:25, just beyond the final approach fix, at an altitude of 1,493 ft, which was about 1,059 ft above field elevation (AFE). At 0804:30, the tower controller cleared them to land.

At about 0804:45, the Essendon Fields Airport tower controllers, located about 8 km south-east of Melbourne Airport, visually identifed that the landing gear was retracted. The aircraft was descending through 1,305 ft (871 ft AFE) at an airspeed of 181 kt and about 3.0 NM (6 km) from the runway 34 threshold. At about that time, the PM reportedly prompted the PF to continue the configuration for landing.

The Essendon tower controller advised the Melbourne tower controller via an internal coordination hotline ‘Vietnam 781 check wheels’. At 0804:56, the Melbourne tower controller relayed this to the crew as ‘Vietnam 781 check wheels’, at which time the aircraft was at 960 ft radio altitude (RA). However, the PM misheard the advisory call as a ‘check wind’ request from the tower and replied ‘Vietnam 781, wind three-six-zero [360] twenty-five [25] knots’. The Melbourne tower controller immediately recognised the advisory call was misunderstood and provided a second call to the crew ‘Vietnam 781 check your wheels, they were observed up’.

At 0805:06, as the aircraft descended through 1,014 ft (780 ft RA and 580 ft AFE) at 183 kt with flaps-5 and the landing gear up, the crew received a master warning alert with an associated ‘CONFIG GEAR’ message. In response, the PM moved the landing gear handle to the down position, while the PF announced ‘go-around’ and selected the autothrottle take-off go‑around[8] button. The PF disconnected the autopilot and the PM reported to tower ‘Vietnam 781 go-around’. The aircraft’s lowest recorded altitude was 862 ft (600 ft RA and 428 ft AFE) at about 1.5 NM (3 km) from the runway 34 threshold. Following the go-around, a second approach was conducted without further incident.