An internal Jetstar document sent to Crikey reveals that the Qantas subsidiary is taking the risks posed by unsafe flying practices by its pilots extremely seriously, and also reveals an additional incident involving an unsafe approach to Proserpine Airport, date unknown.
The document could be read as confirmation of strong safety action by the airline, yet also as confirmation that it has for years been less safe than desirable, and, by inference, inadequately overseen by CASA, the body that grounded its smaller competitor Tiger, as an imminent risk to public safety.
The document has been re-organised and written in lay terms to avoid publishing any unique identifiers that might lead to action against the sender.
Headed as being concerned with Stabilised Approaches to airports, the document was circulated some time before December last year to sections of the airline with a direct involvement in safety and was authorized by the Chief Pilot.
This would have coincided with the time during which the ATSB was at an advanced stage in its inquiry into and report on the Singapore Airport pilot txting distraction, the agreed version of which was published last Thursday.
It says that in keeping with a revised and more conservative set of standards for approaches to landings all Jetstar aircraft must be fully configured and stable by the time they have descended to 1000 feet height above ground.
By way of background, the dangerous circus documented in the ATSB report into the Singapore incident shows that the A321 involved was never fully configured for landing until the first officer went ahead with a go around decision to abort a landing after he couldn’t get the attention of a captain we are supposed to believe couldn’t turn off a mobile phone that was downloading txt messages in a jet that had a lowest radar altitude reading of 392 feet, from a unit which is located some 20 feet above the part of the jet’s underside closest to the ground.
The Jetstar cockpit was in such disarray that both pilots told the ATSB they thought they were no lower than 800 feet during the entire episode, despite being in charge of a modern airliner equipped with multiple altimeters, and alive with the sound of warning alarms generated by a manifestly negligent and unprofessional approach to Changi Airport.
Jetstar apparently thought so highly of their professionalism that it allowed both men to fly the return sector to Darwin that day, while CASA, according to the report did nothing that it could contribute to the ATSB’s final report even though this is an airline it permits to hold an Australian AOC.
After outlining the new more conservative landing approach standards which Plane Talking understands are almost universally adopted by airlines flying passenger jets, the documents says:
Prior to the introduction of this refined policy it appeared to be a common practice to configure late enough that landing configuration was achieved just as 1000’ was reached. This may have been through a desire for efficiency (less drag for longer) or even to demonstrate the ability to fly the ‘optimal’ approach. Jetstar has had some recent incidents whereby the stabilised approach criteria was not followed, either due to a misunderstanding of the policy or loss of situation awareness. The investigations into these occurrences have identified misconceptions or reversions back to the previous stabilised approach criteria by the operating crew. Whilst it was not the intention of the previous policy, misinterpretation of the policy led crew to believe that it was considered preferable to be stabilised at 1000’ and only mandatory at 500’ in visual conditions.
Distractions can arise from a variety of sources and can affect anyone in any situation, including in-flight. They have the ability to narrow someone’s attention and if not identified or managed, can result in a loss of situation awareness.
Recent investigations have found a loss of situation awareness, caused by a number of sequential distractions, leading to an incomplete configuration on final approach, and the stabilised approach criteria being missed by crew members.
A part of the document refers to the use of flight operations quality assurance data (based on examining quick access in-flight data) to identify landing flap selections later than desirable and sustained sink rates in excess of those permitted below 1000’.
It refers to two examples where distraction has been a key contributing factor starting with an approach to Queensland’s Proserpine airport in daylight visual meteorological conditions, an incident that appears to have escaped media attention to date, but may have been reported to the ATSB.
On that occasion a safety officer at Proserpine Airport was supposed to turn on the PAPI or Precision Approach Path Indicator lights for inbound arrivals to allow pilots to have a visual cue for confirming or correcting their descent down the intended glide slope.
However the crew became briefly distracted by an instrumentation issue, and when they had dealt with that they noticed the PAPI lights weren’t on, and while discussing what they might do about this neither pilot acknowledged the 1000 feet and 500 feet radar altimeter alerts.
When the ground safety officer eventually switched on the glide slope guidance lights the pilot not flying the approach thought their appearance meant there was another unidentified aircraft in the area, and at close range the crew received an aural ‘too low flap’ warning that flap had not been extended in advance of the landing for the altitude they had descended to and they made a go around from a low height.
The document also discusses the low altitude go around made by a Jetstar flight descending onto Melbourne Airport last July that has been extensively covered here.
These examples were used to emphasise that Jetstar pilots could have avoided the Melbourne and Proserpine incidents had they fully set up the jets for a landing much sooner than they did.