Originally Posted by
Old Akro
JammedStab
Also, the diag on p3 does not have any (flown) altitude references whatsover, so it does not give any illustration to the issue at all. The diagram also conflicts with para 3 of page 2 which says that the minimum altitude of 984 ft was reached at 6.4nm. The diagram shows this point as before the 6.5nm point.
I agree that the crew was sloppy and contravened the procedure. But my point is that it was some time before the go around instruction. As far as I can see at the time of the go -around instruction the aircraft was legal.
I also question whether or not the crew heard or understood the first go-around instruction. This question is heightened by the ATSB reports use of 2 contradictory references to the crews radio response to the go-around. In my opinion, this is enough to raise questions about the voracity of the report. If the crew did not hear or understand the initial go-around command, then the ATSB's criticism of the crew not obeying the go-around instruction is not valid.
If you compare the diagram(or table or chart) on page 17 with the diagram on page 3, it is quite easy to figure out what happened. There may be some minor discrepancies which is always annoying, but it is plainly clear that minimum altitudes were broken for a significant period of time. Most safety experts will tell you that a go-around should have been done prior to being called for by ATC after they discovered their error. Therefore whether they heard the ATC call clearly is irrelevant.
Whether the crew did hear ATC properly or not I cannot confirm but we can always bring up endless possibilities. What if there instruments were erronous, what if there was a temporary medical issue unknown to the crew, what if......
Bottom line.....it appears ATC did an excellent job.
Therefore mostly pilot error in this case but it would help to have an ILS at a busy airport. Slightly sloppy report likely due to administration errors.