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.