The ATSB report into a double go-around in fog at Melbourne Airport on July 21, 2007 by a Jetstar A320 flown by two stressed pilots given inappropriate training by the Qantas subsidiary is a compelling study in luck as well as management incompetence.
This is also the safety investigator’s final report into an incident that was only properly investigated after Crikey and Aviation Business published details of a near disaster that had been brushed aside as inconsequential by the airline and CASA.
While it is important to note that the airline has since taken remedial steps to deal with the safety issues identified by the ATSB, it is a reminder that lives were placed in jeopardy by the mismanagement of training and piloting standards at Jetstar and that the proper reporting and enforcement of air safety obligations in Australia cannot be taken for granted.
The critical factor in the incident that risked 140 lives that foggy night at Tullamarine is already well known from the ATSB preliminary report of October 30, 2007, available at the same link as above.
On initiating the go-around procedure because of poor visibility on reaching a decision point at the end of the flight from Christchurch, the captain put the engine throttles in the wrong notch or ‘detent’, that of flexi thrust rather than full Take Off/Go around power, or the TOGA detent.
This left the jet with insufficient power to perform to the pilots expectations.
But only in the final report are the reasons for what happened in the next few minutes, and why things went so dangerously wrong, explored in detail, including the inexplicable action of Jetstar in replacing the manufacturer’s fool proof go-around procedure with one that seriously handicapped pilot awareness of the state of the aircraft after commencing such a procedure. (The ATSB couldn’t locate any relevant documents in its pursuit of a rationale for those changes.)
There was confusion and stress in the cockpit. The only ATSB report that is in the same league for documenting confusion, and training shortcomings, in an Australian jet airliner was that dealing with the 1999 Qantas QF1 crash landing at Bangkok’s old airport.
For the first 8 seconds after electing to go-around the Jetstar A320 continued to gather speed but sink, dropping to a position where the tail of the jet was 38 feet above the unseen runway.
In the sequence of two missed approaches both pilots remembered only one of two episodes of aural or synthetic voice warnings about situations they couldn’t comprehend, each pilot remembering a different set of these warnings with only the full story told by the flight data recorders.
Of obvious concern to the ATSB, but apparently of no concern to CASA, which is responsible for granting air operator certificates and enforcing the observance of standards and regulations, are the training and safety breach reporting obligations of Jetstar at that time.
The ATSB details the risks that arose from Jetstar’s process of giving an external trainer the initial responsibility of familiarising pilots with the Airbus fly-by-wire system and then endorsing them for line operations itself.
It returns to the confusion in the cockpit other than from the aural warnings in this extract:
The training risks that Jetstar exposed itself to are highlighted.
Jetstar broke the rules in relation to reporting the details of a safety breach. The ATSB finds that it did not do so deliberately, and that accords with my own experience at the time of dealing with an airline that had little grasp as to what had really happened to that flight, or even what its reporting obligations were.
As the ATSB says:
It was a time when the story was the business model, rather than the actual standards that are required to keep the passengers, or the brand, safe.
Postscript: The Australian and International Pilots Union has issued this statement:
The answer to that question is at least three relevant incidents, which are alluded to but not dealt with in detail in the report.