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ATSB decides not to investigate 2nd more recent Jetstar botched landing approach

Jetstar had another incident in which a landing approach was bungled, this time at Cairns on 3 November, which the ATSB has decided not to investigate.

Yet that incident which result in a go-around being flown at Cairns had some key issues in common with a Jetstar go-around at Melbourne Airport on 28 July, in which the independent safety agency not only conducted an investigation, but released a very disturbing report on Monday of this week.

This is what Plane Talking believes to have been the key sequence of events during the Cairns incident.

An experienced high-hours Airbus A320 type rated captain was the pilot flying the A321 as it made its approach, when with the landing gear lowered and flap 2 selected, the captain called for flap 3, but the first officer, believed to have been a cadet with minimal type experience, put the wing in the flap 1 setting, triggering stall warnings.

The captain immediately pushed the engine throttles to the TOGA (take off/go around) maximum thrust setting starting a go-around, however shortly afterwards, when he called ‘go-around flap’ which requires the pilot not flying to select one less stage of flap, the junior pilot in carrying out this action actually reduced the flaps one further stage to zero, degrading the required response from the jet and worsening the stall risk.

As it is currently understood, the captain didn’t in making his go-around call realise that the cadet/first officer had caused the stall warnings by decreasing rather than increasing flap and the cadet didn’t have the knowledge or experience that would instantly make him or her aware that the previous error made the captain’s instruction to reduce flap inappropriate.

At this stage the captain became fully aware of the reasons for predicament the jet was in, and recovered control with a correctly configured wing and completed the go around safely.

Jetstar has provided the following information concerning this incident.

 

There are some clear differences between what Jetstar says and what Plane Talking has been told as to the warnings that triggered the go-around decision, and by definition, a go-around is triggered by an approach that has been compromised.

But this is all beside the point, which is that it is contrary to the public interest and its obligations in relation to independent air safety investigations for the ATSB not to inquire into this incident.

It is a second go-around which raises questions about the training standards and effective cockpit resource management or CRM in Jetstar operations. The Melbourne incident was appalling, yet as earlier reported, the ATSB consigned it to the relative oblivion of a compendium of ‘short investigations’ and constructed the report in a way in which the full enormity of the situation required careful consideration of the foot notes rather than the main text.

That incident involved a first officer making assumptions about what the captain was going to do,  and which the captain didn’t share, and it involved a Jetstar A320 with 177-180 seats being flown ridiculously close to the ground in an unstable configuration in a situation where the under-performance of the junior pilot is actually identified by Jetstar as causing the captain to be distracted and less effective than he should have been.

In this incident a very junior pilot makes a major blunder, and the captain is left unaware of it until its effects are compounded by a go-around check list in which the flap setting is claimed to have been reduced to zero instead of flap 2 at  a point when the 221 passenger airliner had put its wheels down and was close to its originally intended touch down.

It is disconcerting for Australia’s independent air safety investigator to choose not to inquire into this incident.

CRM breakdowns can end in air crashes. Jetstar has experienced at least two cockpit resource management related incidents in three months. Will someone, the Minister, CASA, or the ATSB do something about a situation which is cause for alarm. Or will it all continue to get swept out of view, unlike the situation that led to CASA grounding Tiger Airways?

Travellers deserve consistent, fearless and independent public administration of air safety in this country. They aren’t getting it.

Updated The ATSB has responded as follows:

The ATSB is aware of a go-around event at Cairns on 3 November 2011 and is aware of public speculation about the nature of the event. The ATSB sought information from Jetstar to clarify the circumstances and is satisfied that the event was not reportable under the TSI Act. The ATSB is also satisfied that a number of the matters raised in your email are incorrect. In particular, we are satisfied that there was no stall warning and no activation of aircraft flight envelope protection systems and that, as a precautionary go-around, the procedure was conducted from an altitude well above that for which stabilised approach criteria apply. The ATSB does not consider any further action on this event by the ATSB is necessary.

 

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  • 1
    FatCat
    Posted December 14, 2011 at 7:43 pm | Permalink

    The ATSB response might be technically correct, in terms of this single incident.

    But what processes do they have when there is an increase in the number of these sorts of incidents that fall just below the threshold where a full investigation is required? Is their mandate only to investigate incidents above that threshold? Or can they initiate a deeper investigation where a pattern is emerging? After all, that is what CASA effectively did with Tiger.

  • 2
    johnny7713
    Posted December 14, 2011 at 8:18 pm | Permalink

    Reading through the Transport Safety Investigation Act 2003 posted on the ATSB site (and bearing in mind that I’m not a lawyer, let alone one practising Australian law), brings me to the following conclusion:

    Section 21 (1)(a) states: “the ATSB may investigate any transport safety matter;”
    Where transport safety matter is defined by Section 23 (2) as:
    “For the purposes of this Act, a transport safety matter also
    includes something that occurred that affected, is affecting, or
    might affect, transport safety.”

    To me that means the ATSB has the mandate to investigate events, even if they do not meet the required reporting criteria. Whether the ATSB actually has sufficient resources to investigate non-reportable events that may be indicators of underlying safety issues is a wholly different question.

    The interesting question is of course, if no warnings triggered, why was there a go-around? One possibility [*warning, complete speculation ahead*]: as far as I know the speed indication tape on the A320 Primary Flight Display has markings which identify the stall speed. When the FO selected flaps 1 the stall speed would have increased. The expected behaviour, had the proper flaps been selected, would be for the stall speed to decrease. So when the Captain was expecting the markings to go down to a lower speed, they suddenly jumped up instead. Faced with this rather unexpected behaviour the Captain decided to go-around and troubleshoot rather than continue the approach, which is (in my opinion) a sensible course of action. [*end of speculation*]

  • 3
    John Thomas
    Posted December 14, 2011 at 11:10 pm | Permalink

    What a circus…

  • 4
    LongTimeObserver
    Posted December 15, 2011 at 7:50 am | Permalink

    “Circus” is far too kind. A complete and total procedural f’ckup, a challenge & response and CRM failure!

  • 5
    ghostwhowalksnz
    Posted December 15, 2011 at 8:01 am | Permalink

    I see a pattern here .
    The airline issues a bland review which leaves out factual information so as to not scare the horses.
    Flames coming out engines ( in other instances) are just minor ‘surges’, no flames.

    Planes not configured for landing approach and would crash become ‘no stall warning AND no activation of flight envelope protection system’.

    Interesting they run both the stall warning and envelope protection ( whatever that is ) together, so maybe there was one but not the other ???

    My weasel words alert was pricked by this cleverly crafted denial

  • 6
    johnny7713
    Posted December 15, 2011 at 8:10 am | Permalink

    ghostwhowalksnz:

    Stall warning are the various alarms that go off to alert the pilots the aircraft is getting near to stalling.
    Envelope protection is the part of the Airbus flight control system that intervenes to prevent a pilot input that would cause the plane to drop out of the sky. It provides protection against leaving the flight envelope. In this case the plane would prevent the pilot from pulling up into a stall and I believe even add power and lower the nose a bit (not to below the horizon) to fly out of the stall. I’m no expert though.

  • 7
    David Klein
    Posted December 15, 2011 at 9:09 am | Permalink

    johnny7713,

    I feel your comment that the ATSB may not have the resources to investigate non-reportable events may have merit. However the resources issue may be more in the form of public service budgetary constraints, in the same manner as CASA dramatically reduced overseas surveillance on QF by field office inspectors, due draconian decisions by Head Office bean counters to save funds by limiting all overseas travel. Unfortunately the ATSB would have to deal with the same style of public service bean counting boffins and many of their investigations would be conducted at a desk top level.

  • 8
    flyboy125
    Posted December 15, 2011 at 11:22 am | Permalink

    The common themes in both these incidents are very-low-experience first officers and arguably inadequate supervision by the incident Captains.

    In the first incident, whilst a go-around was eventually instigated, the Captain allowed the aircraft to be placed in an undesirable state close to the ground by an “L Plate” pilot due to a breakdown in the Captain’s own Situational Awareness (not realising landing flap wasn’t set until the “too low Flaps” automatic callout and inability to recall the “500” foot automatic callout). From reading the analysis of this incident there seemed to be minimal awareness by the Captain of the FO’s task saturation during the approach and thus the need to more carefully monitor the approach and/or be directive with actions required to ensure a safe approach was flown (or aborted before having to be saved by an automated callout “Too low Flaps”).

    The second incident is concerning also in that once the initial error was made by the FO and the GA initiated the FO then proceeded to further compound the problem by selecting the Flaps Up (and the Captain allowing this to occur). The total loss of SA by the FO is alarming. The failure of the Captain to prevent the Flaps from being retracted further is equally worrying (there has been more than one aircraft accident caused by similar such uncontrolled actions).

    The issue of “L plate” pilots was fiercely debated during and after the Senate Enquiry into Pilot Training and Standards. Jetstar’s Bruce Buchanan defied the expert recommendations by extolling the virtues of Jetstar’s Competency Based Training / A320 FO tailored training course (far superior to employing experienced pilots according to Bruce). Those reassurances (which never made much sense back then) seem very hollow now.

    Questions also need to be raised regarding adequate supervision on the Flight Deck for these “L Plate” pilots. One of Buchanan’s other statements regarding his new generation of ‘just add water’ pilots was that they would fly with carefully selected supervisory captains (my recollection of his words, not a quote) such that they could develop their skills along the way.

    The obvious question then is, were these two Captains Check and Training Captains? From the descriptions of how they inadvertently allowed these incidents to deteriorate as they did, it would seem highly unlikely that they were. Speaking from many years of flying instruction, it is an instructor’s responsibility to ensure that he/she always provides a safe platform from which their students may learn. Allowing students to make errors (and recover from them) is an essential part of the learning process but this is never acceptable if it places the aircraft is an undesirable state close to the ground. It is also essential that the instructor recognise when their own limits are being reached (ie instructor SA starting to breakdown or before the point where their own superior flying skills would be significantly tested in effecting a safe recovery) and initiate corrective action at/before that point. Translate this to the role of an airline Captain where this “post graduate learning” is being undertaken with 150-200 passengers on board and the requirement for adequate supervision should be sacrosanct.

    The ATSB may have written these incidents off but CASA should be paying very close attention. The flying public deserves better.

  • 9
    sardine
    Posted December 15, 2011 at 4:03 pm | Permalink

    If (according to Jetstar & CASA) none of the warnings activated, what caused the pilot to specifically apply TOGA power? Making mistakes are one thing, but I start to worry about coverups, which is a slippery slope toward disaster.

    The number of amateur mistakes made by Jetstar is becoming concerning, whether it’s these approaches, unauthorised procedure changes, etc.

    I worry about a time when workload is naturally higher due to weather, ATC or faults, then one of these mistakes happens.

  • 10
    ltfisher
    Posted December 16, 2011 at 4:07 am | Permalink

    I am intrigued by the Jetstar comment that “go-around are not uncommon..”. I have racked my memory trying to recall the last time that I was on a commercial flight that had to do a go-around, but I cannot recall an occasion in the last 30 years. I wonder if fellow correspondents might ask themselves the same question. Contrary to the Jetstar comment as far as I am concerned go-arounds are indeed uncommon. The real worry of course is what happens when the present pool of very experienced captains drys up through retirements and the flying public is left with pilots prematurely promoted from the right hand seat.

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