Updated with Jetstar statement in full

The ATSB has given an insight into the failed state of flight safety standards in Jetstar that saw phone txting distract a captain to the extent that a landing at Singapore in 2010 had to be aborted at very low altitude.

It concerns the conduct of a flight from Darwin to Singapore on 27 May 2010 in an Airbus A321 which could have been configured with close to 220 seats.

Using a re-enactment of the flight in a Jetstar flight simulator, the ATSB found that during the descent to Changi Airport there was a two minute period between about 2800 feet and 1000 feet “where no control manipulations or systems activation was recorded.”

It says “In contrast, during that period, a number of tasks should have normally been completed in preparation for landing, including:

  • selecting the landing gear down
  • selecting the flaps to ‘Config 3’ and then ‘full’
  • arming the ground spoilers
  • selecting auto brake
  • completing the landing checklist, and
  • checking the flight parameters

The report also finds that the captain, who was the pilot-not-flying, but required to oversee the performance of the first officer who had assumed that role, had left his mobile phone on after leaving Darwin, and that when it came within range of a Singapore mobile network, began to download various messages.

“Somewhere between 2,500 ft and 2,000 ft in the descent, the crew heard noises associated with incoming text messages on the captain’s mobile phone. The first officer requested that a missed approach altitude of 5,000 ft be set into the Flight Control Unit (FCU) and, after not getting a response from the captain, repeated the request.

“The FO recalled that, after still not getting a response from the captain, he looked over and, on seeing the captain preoccupied with his mobile phone, set the missed approach altitude himself.

“The captain stated that he was in the process of unlocking and turning off his mobile phone at that time and did not hear the call for the missed approach altitude to be set in the FCU.“

 At this point the first officer says he heard an alarm indicating the jet had descended below 1000 feet .

 “The FO indicated that at this point, it was his usual practice to perform a visual scan of the cockpit instrumentation. He further stated that he felt ‘something was not quite right’ but could not identify what it was.

“The captain reported that he did notice that the landing gear was still up and that the flaps were at ‘Config 2’.

“He also stated that he was not maintaining a focus on the stable approach criteria as he was the Pilot Not Flying (comment: which is an appalling admission.) Neither crew member initiated the landing checklist.”

The next section of the ATSB report reads like one of those 1960s inquiries into a British charter airline crash in terms of general cluelessness or lack of focus in the cockpit.

“At 720 ft radio altitude reading, a master warning and associated continuous triple chime for ‘Landing Gear Configuration’ activated. The FO stated that, on hearing that warning, he noted a red light in the landing gear lever and an ECAM message ‘LG not DN’ displayed on the E/WD. In combination, that signified that the landing gear had not been selected down.

“At about 650 ft RADALT, or 4.5 seconds after the commencement of the master warning chime, the landing gear was selected down. At 503 ft RADALT, or about 7 seconds after the landing gear was selected down, a ‘Config 3’ selection was made by the crew. The captain stated that he ‘instinctively’ reached out and selected gear down and ‘Config 3’ upon hearing the master warning.

“The FO reported feeling ‘confused’ by the captain’s action, as he was preparing to conduct a go-around. Neither the captain nor the FO communicated their intentions at that time.

“Eleven seconds after the landing gear was selected down, a ‘Too Low Gear’ Enhanced Ground Proximity Warning System (EGPWS) alarm sounded. That signified that the aircraft had descended below 500 ft RADALT with the landing gear still not secured in the down position (the landing gear was still in transit to the down position at that time).”

Think about the situation. A Jetstar flight with up to 220 or more passengers on board, is low over the ground at Changi Airport, its wheels up until the last moment, and its flaps incorrectly set for a landing, while a person behaving like a moron in charge of jet airliner is so absorbed in his phone he is unaware of the dangerous situation that he has allowed to occur.

His first officer can’t even get his attention. This is an Australian flag carrier, about which, if the report is to be believed CASA did diddly squat possibly because it might just be totally cravenly gutless when it comes to looking out for passenger welfare in anything owned by or flown by Qantas.

I don’t care what CASA does in the background. Can we please see it do it in the foreground?

A full nine seconds after the ground proximity warning triggered the flight crew commenced a go-around.

“The FO made the standard ‘go around flap’ call and selected Take Off/Go-Around power on the thrust levers, initiating an automated go-round procedure. The recorded data showed an initial pitch-up command, consistent with the commencement of the go-around, at 392 ft. Both crew stated that they were unaware of the minimum height reached before the aircraft climbed, but believed that they initiated the go‑around just below 800 ft RADALT.”

The jet landed safety after the go-around, and after a discussion about fatigue and other matters both pilots then operated the return service to Darwin.

This is an astonishing report in that it details a failure of safety standards in Jetstar that ought to have caused action by CASA, the Civil Aviation Safety Authority, the some body that exhibited such courage, diligence and concern in relation to Tiger Airways, yet is totally, utterly missing from this document.

The ATSB discharged its duty to detail the safety relevant events in detail,  and however makes this astonishing cop-out observation near both the start and finish of the report, which anyone interested in their safety on Jetstar services should download and read in full.

It said: “The investigation did not identify any organisational or systemic issues that might adversely impact the future safety of aviation operations. However, following this occurrence, the aircraft operator proactively reviewed its procedures and made a number of amendments to its training regime and other enhancements to its operation.”

Note the word “future”. The conduct of this particular flight was incompetent, and reflects on the safety of flight obligations of Jetstar, and calls into serious doubt the oversight the board of Qantas and the senior management of its subsidiary Jetstar are required by law to exercise in relation to safety outcomes in the low cost carrier.

Jestar has responded to the ATSB report as follows:

JETSTAR STATEMENT ON JQ57 REPORT
19 April 2012

Jetstar is using an incident involving cockpit distraction on one of its flights as part of its regular training for pilots.

On 27 May 2010, JQ57 from Darwin to Singapore cancelled its initial approach into Changi Airport because pilots detected the aircraft was not fully configured for landing by the time it reached 500ft. The aircraft, an A321, landed safely and without incident shortly afterwards.

These cancelled landings – called ‘go arounds’ – are standard procedure for all airlines and happen every day at airports around the world.

A report released today by the Australian Transport Safety Bureau into JQ57 showed that the pilots – both highly experienced and with a combined total of 17,000 flying hours – became distracted by a combination of factors. This distraction led to the pilots’ deciding to perform a go-around.

The ATSB report made no findings against Jetstar, nor did it find any fault with Jetstar’s policies or procedures. The safety of the aircraft was never compromised.

Jetstar’s Chief Pilot, Captain Mark Rindfleish, said: “We take a very conservative approach to how far before touchdown an aircraft should be completely configured for landing. In the case of JQ57, pilot distraction meant all the landing checklist items weren’t completed before the aircraft passed an altitude of 500 feet, at which point a go-around was required under our operating procedures.

“Human factors, like distraction, are why airlines have so many procedural safeguards built into how they fly. The combination of factors on JQ57 has provided new learnings and the opportunity to add to these safeguards, which we take very seriously.”

As well as making JQ57 a case study in its training on the potential for cockpit distraction, Jetstar has also:
*    Added an item to the takeoff checklist providing a reminder to pilots to ensure their mobile phones are switched off. This is a result of the investigation finding one of the pilot’s phones was inadvertently left on and automatically picked up messages on approach to Changi Airport, adding to distraction in the cockpit.
*    Increased the mandatory distance for the landing checklist to be completed from 500ft above the airport to 1,000ft as an additional safeguard.
*    Through training, reinforced the importance of crew ensuring they use mandatory rest periods in between duties effectively.

 

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