February 27, 2011 – 10:43 am, by
Ben Sandilands
Qantas CEO Alan Joyce, Jetstar group CEO Bruce Buchanan and the Qantas head of safety, John Gissing, should be recalled for further examination by the Senate inquiry into pilot training and airline safety.
In what was a day packed full of surprises on Friday, the committee members heard and discussed some very important insights into their terms of reference, as well as Senator Nick Xenophon exposing a series of serious ‘stick shaker’ incidents involving Qantaslink turboprops, and Senator Bill Heffernan outing what
Plane Talking understands was a seriously amateurish incident in a Jetstar A330 that nearly landed at Singapore Airport last year with its wheels up.
Xenophon and Heffernan have ‘scooped’ the media with those disclosures, and the committee has been promised written replies concerning them which one would expect will be made public, since they are of immense relevance to the travelling public.
But the senators also ran out of time to fully explore some of the issues, some of which are unlikely to be completely resolved by the dozens of questions on notice taken by those who appeared.
Some pilots are understood to have contacted the members of the committee concerning pay and conditions figures quoted by Bruce Buchanan in his testimony on Friday morning.
However another issue that needs attention is the actual submission Qantas made to the hearing concerning the circumstances in which a Jetstar A320 nearly crashed at Melbourne’s Tullamarine Airport on July 21, 2007, while making a missed approach in fog at the end of a flight from Christchurch with about 140 people on board.
The bottom of the fuselage of that jet came to within six metres of the ground as the confused pilots attempted to make the jet climb away from the airport.
In their testimony to the committee both the chief commissioner of the ATSB, Martin Dolan, and the CEO of CASA, John McCormick, said the prime factor in that incident was the changing by Jetstar of the standard operating procedures for a missed approach some two weeks before the incident.
Yet the Qantas submission to the inquiry makes no mention of this, and tries to blame the pilots. This in itself is a nonsense, as Qantas and Jetstar are responsible for piloting standards.
The ATSB final report makes it clear that the pilots were confused because they had been instructed to check the throttle settings (which had been incorrectly set) much further down the check list that required by the manufacturer.
There are several critical elements in this. It was illegal for Jetstar to change the standard operating procedures for the missed approach. It was illegal for Jetstar to fail to conduct a safety systems management evaluation of the changes and the airline also failed to keep any written records that the ATSB could find in relation to these changes.
To quote from an earlier
report:
Before 1998 Australia allowed unique flight manuals, and thus their incorporated standard operating procedures or SOPS, to be devised by its airlines and approved by the equivalent of CASA today.
But since then, the only approved flight manual, or AFM, for any type of airliner flown by an Australian carrier is the one published by the manufacturer and approved by the certification authority in the jurisdiction that applied to it. Boeings thus have AFMs which are approved by the US authority and adopted by convention by other aviation regulators, and Airbuses have AFMs approved by the European authorities.
If Jetstar wanted to change any of its SOPs in relation to its A320s it was under strict legal obligation to obtain the approval of both Airbus and its certification authority. A formal variation of the certification paperwork in Australia would then ensue.
None of these steps were taken by Jetstar. It made a change to the SOP applying to missed approaches by an A320 that meant the pilots were no longer required to immediately confirm the correct flight mode of the jet. That mode should have been to put the jet into its go around mode by engaging the TOGA or take-off and go-around engine power detent. In fact they selected a lower, inadequate and potentially dangerous setting.
The ATSB report also says:
The operator had not conducted a risk analysis of the change to the procedure and did not satisfy the incident reporting requirements of its safety management system (SMS) or of the Transport Safety Investigation Act 2003.
These failures on the part of Joyce and Gissing were matters that brought Australia close to its first crash by an Australian registered jet airliner. They are inexcusable failures, and they would not have come to light but for media persistence. What CEO of an airline and what head of safety for that airline would be ignorant of their reporting obligations in law, or ignorant of the rules concerning changes to standard operating procedures?
Did they seriously think the committee would accept a submission that blamed those events on the pilots other than themselves, as the heads of the airline and of its safety respectively?
Perhaps they did. In Friday’s hearing Alan Joyce made an unsuccessful attempt to rewrite history by claiming that it wasn’t a media report, including one of mine in Crikey on September 11, 2007, which lead to the incident being fully investigated by the ATSB.