Let’s translate the wording of today’s ATSB report into an ‘incorrect aircraft configuration’ in a 177-180 seat Jetstar A320 on approach to Melbourne Airport from Newcastle on 28 July this year into plain but commercially insensitive English.

A co-pilot with only 300 hours experience on the type and a moderately A320 experienced captain screwed it up so badly, with passengers on board, that they didn’t regain adequate control of the jet until it was at a radio altitude of 166 feet (or about 145 feet measured from the underbelly) off the ground, after which they continued to screw up before finally making an uneventful second approach and landing.

It was an incident with some similarities to the safety standard lapses that contributed to CASA’s decision to ground Tiger Airways, which just goes to show that the safety regulator is nothing if not courageous and diligent in the pursuit of deficient safety cultures and training issues.

And it also shows that the ATSB, which works its limited dollars very hard, and produces investigation reports that are truly useful and insightful in their contribution to air safety, nevertheless knows where to bury anything likely to offend the larger gorillas in the aviation jungle, which in this case is deep within its regular compendium of ‘shorter investigations’.

(It’s a two layer coffin-for-the-controversial, first the report goes into the secondary compilation of investigations which will also included a number of general aviation incidents, and which then get referenced in the official summary, which is as far as the general media is expected to go, where they are written down in a way makes it easy to turn items into news reports that completely miss the main points.)

So, here we are on Jetstar on what could have been a very final approach to Melbourne back on 28 July . The flight has passed Essendon Airport and has turned right to descend onto runway 34 at the main Melbourne Airport at Tullamarine.

Let’s go to the narrative in the full report that the media is apparently supposed not to read, and add emphasis in bold to some of the words.

As the aircraft descended through 1,000 ft radio altitude (RA), the Captain noted that the descent rate was about 1,200 feet per minute (fpm). The Captain called ‘sink rate’ and the FO responded by reducing the descent rate to below 1,000 fpm. At that time, the landing checklist had not been completed.

The aircraft was established on final approach at about 800 ft RA.

The FO recalled that his workload was high during the approach. As a result, he had focused on the aircraft’s vertical profile and runway alignment, relying on the Captain for decision making and situation awareness. The Captain was not aware of this.

During the approach, the Captain observed the arriving and departing traffic on runway 34, and received a landing clearance from ATC. At about the same time, the 500 ft RA automatic callout alert activated, which neither crew member reported hearing.

When at 245 ft RA, the Captain realised that the landing checklist had not been completed. At the same time, the crew received a ‘TOO LOW FLAP’ aural and visual warning from the aircraft’s enhanced ground proximity warning system (EGPWS).

The Captain identified that the aircraft was in the incorrect configuration and immediately called for a go-around. The FO initiated the go-around and applied take-off/go-around thrust. Prior to establishing a positive rate of climb, the crew received a second ‘TOO LOW FLAP’ warning.

During the go-around, the FO’s workload significantly increased. As a result, he did not call for Flap 1 to be selected, leaving the Captain to select Flap 1 independently. To further compound the FO’s workload, a master caution warning for an air conditioning pack fault was received after the go-around had commenced.

In preparation for the second approach, the Captain had considered assuming the pilot flying duties, but elected to ask the FO if he was comfortable with continuing the pilot flying duties, to which the FO replied he was. The FO conducted the second approach without further incident.

Jetstar’s operating instructions are for the A320 to have been established for landing at not less than 1000 feet above the runway with the correct flap setting selected.

The first officer told the ATSB that he had not conducted a go-around on an A320 except in a simulator before this incident.

In its own review into the incident Jetstar found (Catch 22 anyone)  that:

  • the increased level of assistance from the captain and a high workload state had removed the first officer from the decision making process and reduced his situational awareness.
  • The FO may have experienced cognitive overload during the approach and go-around.
  • The Captain reported a high workload from directing and monitoring the FO, while conducting his normal duties, reducing his cognitive capacity and situation awareness of the aircraft’s configuration.

The ATSB then quotes from the Jetstar response as follows.

As a result of this occurrence, Jetstar Airways has advised the ATSB that they intend to take, or have taken, the following safety actions:

  • provide the Captain and FO with a remedial training and coaching program
  • conduct a review of their command upgrade training to ensure it specifically focuses on the development of a positive cockpit authority gradient and the command of flight capabilities
  • incorporate this incident into the command upgrade training course as a case study
  • conduct a review of their recurrent human factors training, in particular, the subjects related to command of flight/leadership, cockpit authority gradient, and flight crew assertion.

Jetstar has been flying A320s for seven years, and has almost 70 of the single aisle family, including A321s in its total franchise.

Comment This incident would have been highly relevant to the Senate committee hearings into pilot training and airline safety standards earlier this year which had concluded before it occurred.

It is a poor reflection on Jetstar, and would have probably caused concerns at some level in CASA. The public should be informed about incidents like this, and that means it should have been dealt with in a higher profile manner.

Jetstar has reacted thoroughly to the report, which is a positive, if not a necessity for management, who are individually on notice by the director of safety at CASA, John McCormick, that they are responsible for pilot standards and training outcomes.

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