Jetstar A320 Go Around Melbourne [Archive]

reil

6th Sep 2007, 01:49

I just found out what actually happened and I am appalled!!!!
Apparently the aircraft was coming in to land and actually HIT THE GROUND before taking off again some 45 minutes later. There is an internal investigation being held by Qantas. Initial findings put Jetstar pilots low salaries to blame along with substandard training. Most concerning is the revelation that this is not the first time this has happened, if fact it occurs regularly. It seems that Jetstar's safety record is being propped up by mainline safety figures just to make it look good. The only reason that this hasn't made it to the papers yet is that all the passengers on the Jetstar flights were told that this was a normal occurance and because none of them had more than a year eleven education they all believed it!
This is a massive cover up and I think the travelling public deserves to know the truth! Who do you think I should call, A Current Affair or Today Tonight?

The Kavorka

6th Sep 2007, 07:29

reil...

All true, I saw a JQ aircraft do a GA and the wing came off and they continued onto the Gold Coast..they problem wasn't found until the next day.

Sack them all I say, they should stop employing pilots who obviously cannot operate such an advanced machine!!

Ultralights

6th Sep 2007, 07:40

everyone knows you have to sacrifice at least 4 goats to conduct a safe GA! sadly they could only find 3 employees, opps, goats...

hence the close call.... :rolleyes:

blueloo

6th Sep 2007, 07:43

carpe jugulum - if that is true, there must have been many noisy warnings on flight deck to attract their attention?

cunninglinguist

7th Sep 2007, 02:17

Correct Kavorka, and on arrival CG, they removed the other wing to decrease drag and balance it up. I believe it is still flying on a cat D MEL.
Word on the street is, if AJ gets wind of the savings to be had flying with no wings/engines, he will convert the whole fleet.
We will receive a modest ( .0001% ) payrise for the inconvenience, apparently. I have already contacted today tonight and current affairs and am currently in negotiations for the story.

carpe_jugulum

7th Sep 2007, 03:14

blueloo - never said there weren't any warnings/bells/whisltes on the flight deck......

However, in the vein of most of the other posters on this thread - we all know the diferential girdle spring on the ambiphasient lunar wang shaft causes no end of troubles in most 320s when on approach........:)

Islander Jock

7th Sep 2007, 04:02

This is why I love working at a regional airport.
GA's, hydraulic failures, aborted takeoffs etc etc and that's just the 717s. No one givsa. The crews just do what they are paid to - professionally deal with the situation without the bu11**** journalistic hype.

Unemployed

13th Sep 2007, 08:46

well....... lets just wait for the report to be published....... :)

Unemployed

13th Sep 2007, 08:54

have just found the other thread.....same incident....

The Kavorka

13th Sep 2007, 23:27

Unemployed..

Why don't you go through all the bins around the JQ head office in Bourke St..you might find something there!!:yuk::yuk:

Bula

14th Sep 2007, 01:18

couldn't agree more

blow.n.gasket

14th Sep 2007, 05:40

Don't tell me they serve that Neil Perry crap too.:bored:

Air Ace

21st Sep 2007, 01:15

Gone very quiet for a factual event that went within a few seconds of disaster? :confused:

Bula

21st Sep 2007, 22:56

near seconds from disaster.......... i was driving down the road and applied the brakes.. near secodns from disaster

High-Bypass

21st Sep 2007, 23:18

Is this the same J* flight in which the captain used his leatherman to remove the cockpit door before departure so the passengers could casually walk up the front and have a chat with the pilots at any time during the flight?

My Aunt was sitting back in row 15, she said as they got closer to ML, the aircraft felt like it was descending. Everyone feared for their lives.

My neighbour was sitting in row 23, he said he felt the vibration in his seat as the conjoined master protrusion valve opened and he could feel the filicitic fluid bypassing the dalastraphic sump which is why the aircraft started to descend.

Well done to the pilots who managed the approach by sending command inputs via text messages from their phones to the onboard FMC. :D

blow.n.gasket

30th Oct 2007, 10:32

Here is the ATSB report.

http://www.atsb.gov.au/publications/investigation_reports/2007/AAIR/aair200705576.aspx

Keg

30th Oct 2007, 12:12

Crikey and Ben Sandilands take on the event:

The preliminary report by the Australian Transport Safety Bureau into a double missed approach to Melbourne Airport in fog by a Jetstar A320 on 21 July points to a critical error that caused the jet to sink close to the ground instead of climbing away as intended.

The report needs to be read in full, not the one line summary. While the ATSB reports are non-judgmental and conducted solely with a view to learning from safety incidents and improving flight safety, it discloses some disconcerting details about the flight:

The pilot in command set the engine throttles at the wrong setting to conduct a go around;
With the engines incorrectly set the aircraft did not transition to the speed reference mode the pilots had anticipated and sank toward the ground instead of climbing away;
The jet was 43 feet above the ground before the wheels were retracted and the engine thrust had recovered sufficiently for the jet to climb as the pilots had originally intended.

It is clear from the preliminary report that Jetstar’s repeated claims that an automated system on the jet had failed were incorrect.

It is equally clear that Jetstar management was unaware of the seriousness of the situation the flight had been placed in until after 2 August when it began an internal investigation of the incident.

The ATSB notes that when the incident was first reported to it by Jetstar, on 26 July, the information provided led it to assess the incident as "not meeting the criteria of a reportable matter under the Transportation Safety Investigation Act."

The safety investigator says that in response to media reports on 11 September of a potentially serious incident it contacted Jetstar which provided additional information.

The ATSB re-assessed it to be of sufficient seriousness to warrant the immediate initiation of an investigation.

The independent safety investigator says that its further inquiries into this Jetstar incident will focus on flight training standards, Jetstar’s incident reporting procedures, aircraft system operations and maintenance, provision of information to flight crews, and transition training (from other types of jets).

Crikey notes that these are all areas which are not only core responsibilities and obligations under Jetstar’s airline operator certificate, but the continuing responsibility the Civil Aviation Safety Authority under its oversight and enforcement obligations in law.

The subsequent and final report of the ATSB into this near thing at Tullamarine could prove to be seat-of-the-pants reading.

But more to the point, this process will greatly improve public safety.

Shot Nancy

30th Oct 2007, 12:21

Lets all read the ATSB report http://www.atsb.gov.au/publications/investigation_reports/2007/AAIR/aair200705576.aspx before commenting further.
Report page 5 is very interesting.

Keg

30th Oct 2007, 13:00

Geez, the report cites the crew as 'adequately rested'. I suppose they have to say that (or why didn't they stand themselves down) but that would have required 700 departure from NZ, which means an 0600 sign on, which means wake up about 0500 NZ time....0300 EST. If they're an Aussie based crew then the term 'adequate' is going to be quite equivocal.

I hated early morning starts in NZ for that precise reason!

QFinsider

30th Oct 2007, 19:06

Before we degenerate into a Q v J* battle, I think the most pertinent part of the event is the timeline...
It would appear from my reading that there was an attempt from the to reduce the impact of an ASIR. The ATSB state "following media reports further information was sought from the company". That would imply to me that the information was NOT forthcoming from the company in the first instance. The report did not acurately reflect the occurence.
There is no way the ATSB would "database" a report alleged to contain information pertaining to an autoflight failure...It is clear to me that the report if any, downplayed the seriousness of the incident. Any attempt by J* to say further information came to light after the event is crap.

The FDR and the QAR would most certainly hold data pertaining to an EGPWS warning at 43' RALT.

So I wonder will anyone be held repsonsible or will J* claim to be at the same standard as Qf- As they are a group airline??

Yeah yeah all you wannabes, I certainly know about QF1- you can't hide a golf course...But to me the disclosure by J* was well below what would be expected if the airline were fair dinkum Q group.
Let's get "group audit" in there, "group safety" too....
Mind you the midget won't allow it. Funny thing is Qantas own him, not the other way around..

toolish

30th Oct 2007, 21:43

Yep, very poorly handled by JQ, heads should roll for the cover up but of course won't.(not talking crew here I believe they have already taken sufficent medicine)

Keg

30th Oct 2007, 22:43

Hmmm. When a crew makes an error and fails to report, action is taken against the crew- a recent thread on PPRUNE WRT fuel pumps springs to mind. It'll be interesting to see if there is a proportional response to when a 'company' fails to report or will that failing to report just be seen as an 'error' that we 'learn from'. :rolleyes:

I don't suspect that I'll ever find out the answer.

Pundit

30th Oct 2007, 22:51

This incident is potential one of the worst we have ever been made aware of in Australia. The only difference between this and Monach / Seaview / Lochardt River is we have living.

ATSB must broaden its investigation to cover the management and cutural issues within JQ or more broadly low cost carriers!

Ultralights

30th Oct 2007, 23:55

heres a good laugh, lifted from Todays SHM...

Jetstar near miss blamed on throttles

Stephen Moynihan
October 31, 2007
Advertisement
A JETSTAR flight that came within moments of landing on a runway its crew could not see had its engine throttles in the wrong setting, according to an investigation released yesterday.

On the morning of July 21, the Jetstar A320 from Christchurch with 138 passengers made two attempts to land at a fog-bound Melbourne Airport.

So heavy was the fog that the pilot made the decision to keep the plane on autopilot and land using instruments. Earlier flights had aborted their landings because of poor visibility.

When the fog proved too thick for the Jetstar crew to see the runway lights, the pilot decided to abort the landing. Engine power was increased for the plane to climb, but instead it continued to descend with wheels lowered. At its lowest point, the jet was approximately 15 metres from the ground.

The pilot switched to manual control and reached higher altitude, and after permission from air traffic control attempted to land again. After the second attempt was aborted, the plane touched down safely at Avalon.

a near miss? did the ground have its transponder on?

Capt Kremin

31st Oct 2007, 00:15

For Boeing people, this incident is broadly similiar to deciding to go around, thinking you have hit the TOGA switches, whilst actually not doing so.

The ATSB graph reveals some confusion on the part of the crew.

It also reveals;
Failure of the PF to engage the correct go-around mode.
Failure of the PNF the verify and ensure the correct mode had been selected.
Attempts by Jetstar management to blame the aircraft systems!

For Jetstar to say that this was not a serious incident, and hence was not initially worthy of an ASIR, is total crap.

nick charles

31st Oct 2007, 02:18

Yet another reason for two engine go arounds to be included in simulator training. Most pilots become very proficient at single engine GAs but a two engine GA is a rarely performed manoeuvre.

Boeing pilots have the luxury of a "one click" or "two click" option.

The company performance and culture in this matter leave much to be desired.

Veruka Salt

31st Oct 2007, 04:30

Not setting THR LVRs in the TOGA detent is one of the harder mistakes to make in an Airbus . . . . . just move them all the way to the forward stop! There are no switches to push as such.

amos2

31st Oct 2007, 09:33

It's unfortunate that the crew is for the high jump, Capt probably been demoted and the F/O on shaky ground, but, that go around was way, way, outside acceptable tolerances! We all know that.

Seems to me the Flight Dept tried to protect the crew, and good on them for that, however, the s**t has hit the fan, and I would think that there may be some Flight Dept changes also!

mebro

31st Oct 2007, 10:39

Its really scary that the 2 pilots didnt know their aircarft Systems VERY WELL.

I would like to get a copy of the CVR to see what kind of SOPS were or were not followed, which would have prevented this from happening, all be it at very very high workload of the first approach.

Whats more appalling, is the safety culture demonstrated by the handful of personnel within the organisation to sweep it under the table.

When one does not acknowledge a problem and or a mistake there can be no remedy nor learning to prevent such incidents happening again which is the most sacriest indeed

amos2

31st Oct 2007, 11:44

Why on earth would you like a copy of the CVR?

Would you like us to have a copy of the CVR of every flight you do?

Keg

31st Oct 2007, 12:05

At the end of the day the crew made and error. We all make errors from time to time. Whilst it's important to get to the bottom of it and ensure that everyone (J*, QF, whoever operates airliners with autoflight systems really) learns the lessons gleaned, to my thinking the real issue is the organisational response.

J* protecting the crew by not reporting to the ATSB? If the crew reported the incident then they don't need further protection. It's not like CASA or the ATSB is going to recommend demotion or other sanction along those lines, that's not what the they do in instances like this.

So the question is why wasn't it reported to CASA? Was it a mere oversight and a simple error? If so, what caused the oversight? An overloaded safety department? Time pressures? What about if it was a deliberate decision to not report? Was this due to negligence or deliberate omission? Like a 'choose your own adventure' book the answers to each of these questions leads to various outcomes. Most of those outcomes are very unpleasant and none of them paint a pretty picture of the organisational culture.

What is most interesting is how quickly things can go from being 'stable' to seriously out of shape. A reminder for all of us that no matter whether you're a LCC or a 'legacy' carrier that aviation is very unforgiving and that no one has a mortgage on being error free.

Henry The Octopus

31st Oct 2007, 12:08

All this and one of the worlds supposed "leading aviation safety regulators" is effectively handing over safety responsibility (i.e another means of self regulation) to the very industry it is supposed to be monitoring! It's all been done before and failed miserably.
Note the recent report on the Metro in QLD that was within 10 minutes of running out of fuel on it's only remaining engine, the recent fuel exhaustion incident in the Brasilia at Jundee in WA, the overall shortage of experienced pilots and you can't help but think that the holes are all starting to line up for the big one!
Just my 2 cents worth.
Henry the Octopus

permFO

31st Oct 2007, 12:09

I'm not sure what report has been read by most people but the one I read stated that the incident was reported to the ATSB and they also did not consider it serious enough to investigate. Try Googling the term "Mode Trap" and find out just how "simple" the go-around is on an Airbus.

QFinsider

31st Oct 2007, 12:19

Yes Henry,
Unfortunately history does repeat. We have seen this crap repeated in countless other countries, we are such a cycle behind it isn't funny. Australia is still the backwater in the wrong hemisphere........

Perm FO
My contention is simple. Read the intro to the report. The ATSB said it was not investigating on the basis of what was provided to them...WHO provided it to them?? Look at the timeline??
If j* had provided all information, it is clear an investigation would be undertaken. It wasn't they didn't....
So if the ATSB is lying, and they have nothing to gain from this, then let J* insitute legal proceedings....
My bet is that J* were less than forthcoming in their information, as a result of information obtained from the media, the ATSB requested further information from the company....They have gone to print. They have made a legal enforceable statement with respect to the events surrounding this debarcle. Let us just see what the clowns at J* WRITE in reply..

:E

Shot Nancy

31st Oct 2007, 14:27

Dear permFO,
Dont google a thing, just push the thrust levers to TOGA.
How easier can it be?:ugh:

Bula

31st Oct 2007, 19:33

you have to love listening to some of the experts on this forum.......

Just wait for the final report you vultures :hmm:

Capt Kremin

31st Oct 2007, 21:19

I think the concern of most here is not that the crew screwed up but that Jetstar management, ever attempting to push the "Qantas group" safety message, is either actively trying to make these incidents go away, or fostering a non-reporting culture with it pilots.

THAT is the worry.

permFO

1st Nov 2007, 01:52

QF Insider- I would suggest that Qantas are not squeaky clean on providing information either. I recall that the ATSB only investigated the 737 EGPWS incident near Canberra because of media coverage of the incident. The ATSB were provided with the information on the incident via the normal process. As to a non-reporting culture attributed to Jetstar pilots,scan down the ATSB website and look at another prelim about CWT fuel pumps and a 737 an incident that could have had far more serious consequences.

blueloo

1st Nov 2007, 02:09

PermFO - I can lend you a pair of glasses if you are having trouble reading.

As far as I can see - QF Insider is not saying the pilots didnt report it - he is saying that JETSTAR management may have been a bit light on in the details. Which is the way I read the report too.

Then again maybe I am blind and cant read.

Keg

1st Nov 2007, 03:07

The latest from Crikey;
An international A320 captain who has reviewed the preliminary Australian Transport Safety Bureau (ATSB) report into the botched Jetstar aborted landing at Melbourne Airport in July, says there is one element in common with the disaster the same month when TAM crashed the same type of jet into a building after failing to stop on the runway at Sao Paulo Airport.
He says the incorrect positioning of the engine throttles is clearly identified in the ATSB report, and strongly indicated in disclosures from the continuing Brazilian investigation:

If you input the wrong throttle setting the jet will not respond as required. This is true of any passenger jet.

What happens immediately afterwards is crucial. If the pilots sit there wondering why it isn’t responding they may run out of time and run into something.

This is essential, basic, piloting. You don’t sit there in disbelief. You check your essentials, such as the position of the throttle levers. You must trust your instruments. If they say DON’T SINK as is indicated in this report you act immediately.

It is an issue of training standards, of operating standards, that the airline and the appropriate authorities have to answer for.

The ATSB says in the preliminary report that it is looking at those areas. But the questions as to how Jetstar could have allowed a bungle like the Melbourne incident to have occurred at all have not been answered.

The TAM crash killed 199 people, including 12 in the building it struck. There were 138 passengers on the Jetstar flight that sank toward the ground while its crew dealt with what they thought was a failure of an automated system on the Airbus but was in fact an error already nailed in the preliminary report.
In a response to the preliminary report Alan Joyce, the chief executive officer of Jetstar says:

Jetstar has undertaken a number of immediate safety actions which have included the clarification of and revision of procedures.

As is standard practice following a pilot incident report Jetstar provided an incident notification to the ATSB in a timely manner.

The airline recognises that its subsequent communication with the ATSB on this matter could have been improved.

Jetstar continues to co-operate fully with the ATSB investigation.
His full statement can be read here.

The preliminary report by the ATSB is here.

The response by permFO is interesting. So far the QF contributors to this thread (that I can pick) have taken up a few clear positions:

1. It looks like a simple crew error.
2. It looks like the response by J* was inadequate (I don't know for sure, that's just the way the ATSB report reads)
3. Was that inadequate response by J* due to simple error or something more sinister.
4. If disciplinary or 'corrective' action has been taken against the crew (I don't know if it has) then will proportional action be taken against J*?

How does permFO respond? Deflect and shift blame. I'm not an apologist for QF and have in the past hammered them when I thought they warranted it- and been sanctioned for such public remonstrations to boot- but what I don't bother playing is the line that 'you stuffed up so how can you judge me'. It's a victim game and it stops you from looking in the mirror and learning the lessons yourself.

QF pilots aren't perfect, J* pilots aren't perfect, QF management aren't perfect, J* management aren't perfect. With that on the table let's acknowledge that we need to keep looking in the mirror and not be scared about the reputations and so on. The day we stop looking in the mirror and being critical of ourselves is the the day we're in denial and many more steps closer to a prang.
Are you game to look in the mirror permFO?

Bula

1st Nov 2007, 03:21

On the money Keg.. though I wouldn't class Crickey.com as a reliable news source. Having read some of their previous exploits on this incident its should read something like

"Experienced international A320 flight sim journalist with a captain who has been taken out of context.......".. though as with all journalism I'm sure comments in previous articles were taken out of context.

"If you input the wrong throttle setting the jet will not respond as required. This is true of any passenger jet.

What happens immediately afterwards is crucial. If the pilots sit there wondering why it isn’t responding they may run out of time and run into something.

This is essential, basic, piloting. You don’t sit there in disbelief. You check your essentials, such as the position of the throttle levers. You must trust your instruments. If they say DON’T SINK as is indicated in this report you act immediately."

Did I misread something in the preliminary report? Throttle position --> airbus throttle human factors debate? Did the pilots no realise something was a miss and tried to correct the situation by following the bus golden rules?

UNOME

1st Nov 2007, 03:47

I am certain that many experienced Airbus pilots would be mortified at the Jetstar practice of "TOGA TAP".

Those in management who endorsed and taught this dangerous practice and now run away claiming "no knowledge" should be dismissed.

CASA is well aware of the truth.

Ultimately the animus, cronyism and nepotism of the three warring parties that attempt to manage Jetstar is what leads to this and other incidents.

Given that the "chosen mates" are now being slipped in through the back door in preparation for the 787 introduction, what other highlights can we expect?

Jetstar has copped massive criticism for the shonky and blantent unfairness of its employment/ promotion process. Take for example the JQ pilot (who had not flown an aircraft/ been involved in aviation for the past seven years, who has not flown a widebody, who has not flown longhaul,) being promoted to CHECK CAPTAIN A330 after just SIX MONTHS as an A320 F/O!! :hmm: Good bloke or not, it smacks of cronyism, destabilizes the company and leads to non standard dangerous practices such as Jetstars' "TOGA TAP" :(

Watchdog

1st Nov 2007, 05:49

Unome, excuse my ignorance, but what is this toga tap procedure they do?

Gnadenburg

1st Nov 2007, 07:49

I don't know if i'd be mortified at a procedure described in the manuals. Mainly to avoid the dumping of the active fligh plan in the FMGC whilst maintaing common sense levels of power on an intermediate GA.

Perhaps a TOGA TAP 13m AGL would be mortifying though.

UNOME

1st Nov 2007, 08:22

Can you please quote the reference to "TOGA TAP" in FCOM?

I am not an Airbus pilot however, my understanding is that a correctly performed go- around (as described in FCOM) will avail the pilot of two options;

1. Activate approach and thus perform another approach.

2. Enable alternate.

Selecting TOGA and engaging the "go around" mode ensures all systems are correctly sequenced. Once the FMA is read aloud and positive climb established, climb thrust can be safely set.

Why are Jetstar pilots (especially the hubristic, young and inexperienced Captains) attempting to reinvent fly-by-wire? :confused:

I was not there in the cockpit however, the management and cultural problems are all so evident anyway.

blow.n.gasket

1st Nov 2007, 08:23

How about something simple like covering and practicing these sort of events in the simulator during endorsement training! Just how far does $35k go? Obviously not far enough!
Once again this is not the fault of the pilots but rather the penny pinching ,bonus driven attitudes that are permeating Airline management ranks in Australia today.
Do these management clowns realy think that "worlds best practice" is achievable through world's best penny pinching practices?
As another poster wrote some time ago and got lambasted for the audacity when they wrote "JetStar trains to a cost not a standard,"
Well it certainly appears there may be a grain of truth in there somewhere.:bored:

Gnadenburg

1st Nov 2007, 08:42

I would be very interested to see any reference to "TOGA TAP" in FCOM.

If the TOGA tap is what I think it is. It is all through the manuals. Do Jetstar pilots have manuals ? Do they have the Flight Crew Training Manual ?

"Set the thrust levers at TOGA and then retard the thrust levers as required........"

amos2

1st Nov 2007, 10:34

Excuse me!...What manuals are you guys reading from?
The Airbus manuals I have? ...or some others that I'm not aware of?
A missed approach is not exactly a demanding chore!
In an A320, or any other type!
So, Keg, or others, tell me...when these guys carried out two missed approaches and then diverted to an alternate, why did they put in a 225?
And why did the company pull the FDR? Did the crew agree to this?
Aren't you guys concerned about these matters?
I would be!

UNOME

1st Nov 2007, 10:35

Gnad,

There is a significant difference between the Jetstar "TOGA TAP" and the correct procedure of; setting TOGA, calling "go-around flap", calling "flap at...", reading the FMA, callling positive climb, calling for gear up, calling for HDG or NAV, and then IF NECESSARY setting CLB thrust PRIOR TO accel alt. This is a dangerous "in house" manoeuvre, just ask CASA.

Can you identify any other Airbus operators in the world utilizing the term, and employing the practice of "TOGA TAP??"

amos2

1st Nov 2007, 10:47

You gonna rotate somewhere in your procedure there, Unome?

You have flown these things, haven't you?

Keith Myath

1st Nov 2007, 11:48

Gnadenburg:

If the TOGA tap is what I think it is. It is all through the manuals. Do Jetstar pilots have manuals ? Do they have the Flight Crew Training Manual ?

"Set the thrust levers at TOGA and then retard the thrust levers as required........"

Wow Gnadenburg, word perfect from FCOM 3.03.23, also described in FCTM 02.170.1.

No manuals anymore, just the wonderful young compact disc. As an aside, this technique has been suspended for the moment, toga must remain until LVR CLIMB announced on FMA. Wait for the increase in flap over speed occurrences.

UNOME

Toga Tap
I am certain that many experienced Airbus pilots would be mortified at the Jetstar practice of "TOGA TAP".

Those in management who endorsed and taught this dangerous practice and now run away claiming "no knowledge" should be dismissed.

CASA is well aware of the truth.

Ultimately the animus, cronyism and nepotism of the three warring parties that attempt to manage Jetstar is what leads to this and other incidents.

Given that the "chosen mates" are now being slipped in through the back door in preparation for the 787 introduction, what other highlights can we expect?

Jetstar has copped massive criticism for the shonky and blantent unfairness of its employment/ promotion process. Take for example the JQ pilot (who had not flown an aircraft/ been involved in aviation for the past seven years, who has not flown a widebody, who has not flown longhaul,) being promoted to CHECK CAPTAIN A330 after just SIX MONTHS as an A320 F/O!! :hmm: Good bloke or not, it smacks of cronyism, destabilizes the company and leads to non standard dangerous practices such as Jetstars' "TOGA TAP" :(

UNOME

Are you getting over you mortification and mock indignation? Have you hopped off your soapbox and finished slinging mud? Entirely pathetic behaviour, using such an unfortunate incident to throw so much **** at all and sundry.

Look at the incident and learn. The toga tap wasn’t executed correctly, nor was it an appropriate technique for the phase of flight (IMHO). If the toga tap had been executed correctly (no one would be the wiser) then the unsuitability of this technique may have remained as a latent failure within the system. I have seen this toga tap used (successfully) at DA with another airline, whilst not my choice of go around manoeuvre from DA, it is being used out there.

Keg

1st Nov 2007, 11:49

amos, I suppose a 225 was put in because the aircraft ended up at other than it's intended destination. Whilst the PIC's approval may be needed to pull the FDR it certainly isn't required to pull the QAR. I suspect (but can't be certain) that is where some/a lot/ all of the information has come from.

What The

1st Nov 2007, 12:40

And without a FOQA protocol in place, who needs the FDR?

Hung and quartered on the strength of data supposed to be used to develop strategies to enhance performance of flight crew!

Another example of why all Airline Pilots in this country need one strong united voice, not the rabble that currently exists.

I suspect that in the future we may see Pilots prosecuted on the basis of the data available from these devices for "Reckless Endangerment of an Aircraft".

I wish I had the confidence that the management of the Airlines would acknowledge that it is the cost cutting approaches undertaken during their reign that are developing affordable safety mentalities amongst some coal face employees.

I suspect that if it all turned sour, the coal face would be a lonely place to be as the blame was being handed out.

Remember this incident is about:

The reporting culture of JETSTAR CORPORATE,

The Flight Operations Management culture that exists, and

A lesson that it is quickly turned around by even contributors to this forum as being the fault of the "there but for the grace of god go I" Pilots on the day.:ugh:

Keg

1st Nov 2007, 13:01

I've got to say that this is the first I've heard of the 'TOGA Tap'. I have discussed with many captains a similar procedure on the 744 and 767 of hitting the TOGA switches and then instantly disconnecting the A/T. However the context of this discussion was always about doing a G/A from 2000' or so and not from DH.

If this TOGA tap is a company endorsed method of doing a G/A from minima then it probably does add considerably to the contributing factors on any crew error that may have occurred. If it's the company approved method then it also reminds me of a QF company approved method of always landing a F25 back in '99! :eek:

Keg

1st Nov 2007, 14:30

Whilst I don't always agree with Steve Creedy, he makes some interesting points here:

JETSTAR has admitted that its communications with air safety investigators over a controversial missed approach by one of its planes at Melbourne Airport were inadequate.

The Australian Transport Safety Bureau this week revealed it did not initially probe an incident involving a Jetstar A320 on July 21 because information supplied by the airline five days later suggested it was unnecessary.

Jetstar on August 2 started an internal investigation into the incident and discovered that an enhanced ground proximity warning system had activated during the missed approach.

However, the bureau says Jetstar did not tell it about the developments until more than a month later.

"On September 11, 2007, in response to media reports of a potentially serious incident at Melbourne Airport, the ATSB contacted the operator, who provided additional information on the incident," the report said.

"The ATSB reassessed it to be of sufficient seriousness to warrant the immediate initiation of an investigation."

The ATSB interim report this week revealed that the Jetstar flight JQ156 from Christchurch sank to within 43ft (13m) of the runway after the crew moved a thrust lever to a wrong setting during a missed approach in fog at Melbourne Airport on July 21.

The Airbus A320, which had its landing gear extended at the time and was on autopilot, began to climb only after the captain realised something was wrong and took control.

The Australian understands the captain thought that he pushed the throttles to the take-off/go-around (TO/GA) position, which was usual for a missed approach. While he had briefly pushed it towards that setting, however, he brought it back to the flexible take-off/maximum continuous thrust (FLX/MCT) position.

This retracted the flaps and slats to the Flap 3 position but the plane continued to descend on the glideslope, activating a "don't sink" warning on the enhanced ground proximity warning system (EGPWS).

The captain disconnected the autopilot and tried to fly the plane manually but it initially continued to descend to a low of 43ft above the runway.

It finally began to climb after further control inputs, and the crew retracted the landing gear and reconfigured the aircraft. The aircraft climbed to 650ft, remaining there for 17 seconds before starting a shallow descent.

"Shortly after commencing this descent, the thrust levers were moved to the TO/GA detent and coincident with that movement, another EGPWS don't sink warning was activated," the report said.

'After the thrust levers were moved to the TO/GA detent, the aircraft continued to climb and no further warnings or alerts were recorded."

A second attempt to land also resulted in a missed approach, before the aircraft headed to Avalon airport and landed normally.

Both the ATSB and Jetstar have come under fire in some sections of the media about their handling of the incident.

It prompted Jetstar to send a message to all crews requiring the use of full take-off thrust in all missed approaches. JQ 156's crew were sent for extra training and the airline published a flight standing order revising missed-approach procedures.

Jetstar chief executive Alan Joyce said the airline had responded proactively to the ATSB report. While he said the initial pilot incident report had been provided in a timely manner, he recognised that subsequent communication could have been improved.

The airline's spokesman, Simon Westaway, said the pilot report in July did not mention the ground proximity warning and it emerged only after the airline decided to launch a further investigation as part of its normal safety policy.

He admitted that the airline's first formal communication with the ATSB after the July report did not come until after the bureau launched its investigation on September 11.

He said that soon after that the airline was in a position to provide a draft document of its investigation, which had finished around the same time, and then a final version.

"We concede that the information flow to the ATSB could have been done more quickly," Mr Westaway said.

"But we certainly did voluntarily provide information and did so off our own bat, not through prompting by the bureau."

The ATSB said its investigation would focus on flight training standards, Jetstar's incident reporting procedures, aircraft system operations and maintenance, provision of information to flight crews, and transition training.

Chimbu chuckles

1st Nov 2007, 14:46

Keg you cannot be serious....hitting GA and then instantly disconnecting the A/T?

The Boeing equivalent of the TOGA TAP is probably hitting GA and then FLCH (with an appropriate altitude in the MCP) which will give you a nice 'gentle' GA rather than the hair on fire version with attendant potential low level alt cap.

While a reasonable concept for a GA above say 1000' in VMC it would be less than clever, in my view, at 200' in IMC.

There seems little inherantly wrong with the concept of TOGA TAP...just a shedload wrong with the application of the concept...that is a training and systems knowledge issue.

haughtney1

1st Nov 2007, 15:22

not wishing to get off thread but....are you serious Keg?
I've got to say that this is the first I've heard of the 'TOGA Tap'. I have discussed with many captains a similar procedure on the 744 and 767 of hitting the TOGA switches and then instantly disconnecting the A/T.

I can't honestly believe that guys still do this

Capt Kremin

1st Nov 2007, 20:27

Why don't you guys read all of what Keg wrote?

Keg

1st Nov 2007, 23:15

Chim, not sure what you're getting at?

I'm certainly not advocating utilising this procedure (either a 'TOGA Tap' or a possible Boeing equivalent) for an MDA G/A. From MDA (and really anywhere below about 2000' depending on what the missed approach altitude is) I'm an avid fan of getting to the missed approach altitude without undue delay and multiple mode changing except for tracking requirements with and then sorting out the remaining issues. :ok:

I'm talking about using this Boeing equivalent to get out of LOC and G/S slightly more quickly and with less fuss than turning off both F/D and then turning them back on again and only when we're slightly below the missed approach altitude. I'm a simple guy so the less playing liberace on the MCP the better. TOGA, thrust levers move forward slightly, aircraft pitches up, disconnect A/T, HDG SEL and then dial in the speed. Voila.

haughtney1

1st Nov 2007, 23:37

Capt Krem old son I did mate.....and if I did what he is saying..I'd lose my job:ok:

Sorry Keg....different ways to skin a cat and all that mate:8

Mstr Caution

2nd Nov 2007, 00:10

After reading this thread, I can't help but link this to previously discussed topics.

As mentioned by an earlier post, are the holes in the swiss cheese becomming more aligned?

* Jetstar boss AJ reported as stating, if pilots aren't getting burnt out within 5/6 years, their not working hard enough.

* The letter to Jetstar crew some time ago from senior experienced pilots, highlighting the need to lift there standards. Then management publically criticising the authors of the letter.

* The reluctance of J* managament to allow line flight operations audits by outside parties. Whether that be QF audit or the University of Texas.

Gnadenburg

2nd Nov 2007, 00:26

"Set the thrust levers at TOGA and then retard the thrust levers as required........"

Wow Gnadenburg, word perfect from FCOM 3.03.23, also described in FCTM 02.170.1.

Yes Keith. It is word perfect. Deliberately so and hence the "......"

I am putting two and two together as to WTF " TOGA TAP " is ?

I find it incredulous that Airbus endorsed contributors to this thread would be aghast at a TOGA TAP. It is a well documented and practical application of the ATHR sytem to work within posssible, everyday operational restricitions- intermediate GA for example.

But then again, it is bewildering why such a technique would be applied at the minima.

I have mentioned it here ad nauseum for years. Airbus aircraft in the GA phase can present serious challenges. Mode confusion and disorientation ( spatial and from glass presentations ). Three crashes and the more recent OEB suggesting a number of close calls on NPA's.

Chimbu again suggests the J* training department is ex-Ansett. Perhaps, if there is the rumoured standards issues at J*, they could invest in a sim programme entailing regular 90 day checks like the old AN system.

UNOME

2nd Nov 2007, 00:32

Amos

Not Airbus however... had the pilots concerned rotated sufficently, am I correct in believing that the aircraft would have entered "alpha floor," which, in this case, would have been a safer situation?

Keith Myath

I have my opinion and you, as an offended Jetstar pilot, have yours. I would ask you two things though;

1. Is there anything in my post(s) that is not factual?

2. Please identify the other operators that you have witnessed using a procedure known as "TOGA TAP"?

What has everyone learned from this incident?

1. Jetstar has cultural/ management problems.

2. They do not use Airbus recommended procedures.

3. You seem very pissed off at the truth. :bored:

El Kabong

2nd Nov 2007, 01:17

Alpha Floor is not available below 100'RA. (Just ask the A320 lumberjack).

Unome, I have to say that Chimbu and Gnad have got it absolutely right. There is nothing wrong with the "TOGA Tap" when carried out under the right circumstances i.e. A go-around from a reasonable altitude in VMC for lets say a runway incursion or the likes. At the minima with 8/8.......probably not. However what appears to be driving your "aghastness" is a hatred of the operator rather than a reasoned approach to the subject at hand.

UNOME

2nd Nov 2007, 01:46

El Kabong

As bad luck would have it, I am laid up for a few days with a crook leg and therefore drawn to Pprune...

In regard to Alpha Floor, I assumed that they commenced the go around at the minima, which for Cat 1, should be above 100' AGL.

In regard to Jetstar, I have only related the facts as they have been widely reported elsewhere. This includes in the offices at CASA.

I have no desire or need to join Jetstar and no hatred of Jetstar.

Many posters have highlighted the problems created by the Qantas/ Impluse/ Ansett, triangle of destruction, yet you allow them their say. Why attack me?

While I do not agree with the Jetstar practice of "TOGA TAP", I do agree that AFTER a positive climb is established, flap retracted one stage, gear retracted, the thrust could be reduced.

What ever happened to "flying the aircraft??"

AnQrKa

2nd Nov 2007, 02:28

TOGA "tap" was never intended to be used below engine out out accel. Why you would contemplate doing it anywhere near the mda is silly.

Chimbu chuckles

2nd Nov 2007, 03:10

Gnads it is a fact...I will quote for you the reply I got when chatting to an ex AN mate a few weeks ago and I asked him if he was interested in J*. "Nope...Flight Ops full of ex AN guys and they managed to find most of the idiots".

Maybe it's a Melbourne Club/Brisbane Club thing:ok:

Perhaps rather than 90 days they could just try big T little C ?

Haughtney....me too:ok:

Keg...for intermediate GA try GA/FLCH/HDG SEL...gets you out of LOC/GS without fuss...works a treat:ok:

Gnadenburg

2nd Nov 2007, 03:24

Was that me you were talking too? :}

But what of the standards issues? Perhaps they should invest in more regular training. Six monthly regulatory "checks" can only facilitate so much training.

Bazzamundi

2nd Nov 2007, 03:41

Stupid question but what happens if you fail a check or a sim with Jetstar? I heard a story the other day, but doubt it is true, that you have to pay for the next sim. Is this true or complete rubbish?

Chimbu chuckles

2nd Nov 2007, 03:46

complete rubbish.

El Kabong

2nd Nov 2007, 04:57

Sorry Unome, wasn't meant to be personal, just that any incident that occurs instigates an instant attack on J*, yet very little said if an incident should occur "elsewhere".

True that the "tap" may have been instigated at the minima but if the aircraft was allowed to descend below 100RA, the alpha floor is not activated. Alpha floor requires a combination of AoA and speed (varies depending on weight and config) and to be above 100' in order to activate.

Hope the leg gets better soon. I on the other hand have no excuse for trawling through the prune.

Jetsbest

2nd Nov 2007, 05:15

I disagree, not for this circumstance, but what about day VMC from say 500ft with the runway occupied and joining to the visual circuit?

Keeping TOGA in a light-weight aircraft until Engine-Out Accel means you're already at circuit altitude and things can get very rushed as one levels out while accelerating and trying to capture F1 and S-speed if yu haven't reduced to CLB thrust in a timely fashion.

Just a thought... :ok:

captaintunedog777

2nd Nov 2007, 09:00

In regard to Jetstar, I have only related the facts as they have been widely reported elsewhere. This includes in the offices at CASA.

What a joke CASA

Many posters have highlighted the problems created by the Qantas/ Impluse/ Ansett, triangle of destruction, yet you allow them their say. Why attack me?

Maybe you were attacked by the way you posted. Amazing you people seem to know more about the Bus than the operators with over 20 years experience.

THere is nothing wrong with the TOGA tap if done at a safe height. Obviously you clowns it is not done at the minima. The incident in question was not this but the thrust levers went to MCT instead of TOGA and not monitoring the PFD as to what mode the FMS was in. Which in the heat of the moment can be done. The Bus is a complex machine and hence these incidents do occur from time to time.

If you did not use the TOGA tap and are just under the height you intend to capture and went to TOGA you would very quickly accellerate and run the risk of overspeed from which many a bus driver can attest to. Especially if light. The procedure is to bring back the thrust lever when LEVER CLB is displayed on the FMS which is usually the acceleration height edited in the PERF page. And remember the whole situation occurs in a matter of seconds.

Flying a Bus is a completely different ball game to your out dated turbo prop or jet. Trust me.

topgun0007

2nd Nov 2007, 09:35

Tunedog,

You almost answered your own post.

Believe me the A320 is far from a sophisticated state of the art machine, it is as you allude to over 20 years old.

The problem is twofold, Airbus have had almost 26 years to sort this heap of crap out, and have failed dismally.

And those issues which have been addressed have had their usefullness eroded because the guys with 20 years experience insist on flying it the old way.

As Impulse / QF Link, the 717 operation was subject to LOSA and QF audits, in most areas I understand they came up fairly well.

But now, the blue shirts have taken hold and know better, go figure?

Almost every senior position in the C and t department is filled by ex AN boys club and the troops get a bit tired of it all.

They continually go outside the current cohort of pilots to get the experience they are looking for, what a crock.

Sh**load of experience in international ops inherent in the group already, loads of Boeing time there to.

An interesting question, when AN got a new type, they did not crew from externally to get the experience, so what has changed.

Trained right, pilots can transition to new types comfortably, been happening for years.

Just the GMFO trying to get a warm and fuzzy without spending the dollars on training I guess.:ugh:

Gunna cost a lot more when one bites the dust.

captaintunedog777

2nd Nov 2007, 11:00

Yep topgun

It is a heap of crap and complicated at that. Compared to a late generation boeing it is in the stoneage. Why they never updated it. I don't know. Prob cost or commonality.

But if you are not careful in situations like a go around, going to track mode when flying a managed approach approaching the minima or the other silly assed thing like puting a fix line within i think it is .2nm of the rway threshold where by the FMGC will dump all the flight plan data entered. This a/c will catch you.

Gnadenburg

3rd Nov 2007, 01:19

For all it's failings, those that struggle with Airbus the most, would appear to struggle on other types aswell.

But if you are not careful in situations like a go around, going to track mode when flying a managed approach approaching the minima or the other silly assed thing like puting a fix line within i think it is .2nm of the rway threshold where by the FMGC will dump all the flight plan data entered. This a/c will catch you.

" I think it is "- if the two preceding posters are from J*. I have flown my last passenger flight with that outfit. :confused:

captaintunedog777

3rd Nov 2007, 01:33

Sorry shags I am not

However. "I think it is" You wanna elaborate and contribute constructively. It has been a while since I flew a 320 and I can not recall specifics. It was an OEB.

True those who struggled with other types will fail the 320.

Gnadenburg

3rd Nov 2007, 01:41

Retracted with apologies. I thought you were current on type.

permFO

3rd Nov 2007, 02:58

So does this mean Gnadenburg that you will continue to fly with J*?

It is a strange aeroplane that requires the thrust levers to sort out a problem with the FMS. On the Boeing (if my memory serves me correctly), TO/GA wasn't required to restring the flight plan. The problem with the A320 is that it was designed by engineers and the flight crew were expected to fit in. The latest generation of aircraft have had the lessons of automation issues incorporated into their design.

The reason Ansett didn't need to get external experience for a new type was that they had a stable workforce and they didn't expand at the rate that airlines in Australia currently are. However when they got 747's and started International Operations they did get external experience and that ended with tears. They then went to get experience from Qantas and TJ was the best they could come up with.

max autobrakes

3rd Nov 2007, 12:11

BAZZAMUNDI WROTE:
Stupid question but what happens if you fail a check or a sim with Jetstar? I heard a story the other day, but doubt it is true, that you have to pay for the next sim. Is this true or complete rubbish?

CHIMBU CHUCKLES WROTE:
complete rubbish,.

Yet I look at the Collective agreement (AKA Group AWA) and find the following
23.6.7 If you fail any simulator flight check you will be given remedial training followed by a further check. If your performance is still considered unsatisfactory, you will be given the opportunity of further training prior to completing a further check. You may elect to have the final check conducted by a different Check Pilot.

MUTUAL OBLIGATIONS TO TRAINING
23.1.4 Provided you agree training may be undertaken in your own time on a non-paid basis.

Please explain!

Douglas Mcdonnell

4th Nov 2007, 01:02

The "TOGA TAP" has always been fraught with problems. One of the biggest issues here is Alteon. From what I understand the endorsement process has improved somewhat. As with most things in life though you get what you pay for. Perhaps in this case however you don't. I imagine it wont be long before the scapegoating commences.

DM

Much Ado

4th Nov 2007, 01:02

And your problem is max auto?

Gnadenburg

4th Nov 2007, 01:35

The "TOGA TAP" has always been fraught with problems.

What problems?

Gnadenburg

4th Nov 2007, 01:40

So does this mean Gnadenburg that you will continue to fly with J*?

I will fly with a blue shirt.

In other cases, I will check the Herald Sun to ensure it's VMC- don't want to be on board whilst some joker tries to break the sound barrier on Go Around.

I do similar when flying in the developing world.

permFO

4th Nov 2007, 03:07

Its a quaint superstition that you have that you will only fly with a blue shirt. It must cause you a bit of grief when you show up for work out of uniform.

The problem with the "TOGA tap" is that it is a non-documented procedure. There is a TO/GA procedure in FCOM and a procedure for going around from an intermediate altitude.

Other posts on this thread have shown that there are some who feel that they can apply a modified TO/GA procedure on a Boeing that will "fix" any problems associated with the manufacturer's procedure.

This is what occurred with the informal introduction of the TO/GA tap into Jetstar. The TO/GA tap was considered to be a modification to the FCOM TO/GA procedure that would "fix" the problem of flap overspeeds.

hongkongfooey

4th Nov 2007, 04:20

It is a strange aeroplane that requires the thrust levers to sort out a problem with the FMS. On the Boeing (if my memory serves me correctly), TO/GA wasn't required to restring the flight plan.

Ha!! bit rich having a go at the poor old bus, at least it has an alternate and secondary F/plan unlike the so called " NG " that leaves you with nothing except hard work, now thats what I call stone age :ok:
( comparing apples to apples, narrow bodies only )

Yes the 'Bus is harder to learn, but once you've got a handle on it ( 6 months or so ) it is a hell of alot more user friendly than the No Generation.

Douglas Mcdonnell

4th Nov 2007, 06:22

HongKong Fooey. Ive been flying the bus for about 20 years on and off and still struggle with the bloody thing!! The TOGA TAP was initially designed for the intermediate go around scenario ie, from say 1500ft up to 2000ft. The major issue with it is in my opinion anyway is that it overly complicates the procedure at a critical time. 200ft at night and or in IMC is not the place to be changing power configurations. TOGA is designed to get you away from the ground quickly and safely. The design of the 320 incorporates the positioning of the "throttles" into the TOGA detent to action the speed reference system. SRS. As far as I know the repositioning of the "throttles" back to MCT has never been endorsed by Airbus as a manufacturer.

Gnanden its only my opinion but I for one have always been sus on the procedure.

My thoughts are with the crew involved. I hope they have received the proper support post the incident.

Cheerio Doug.

Capt Kremin

4th Nov 2007, 08:40

I think this whole TOGA tap business, in reference to this incident is a bit of a furphy. I believe the crew initiated a go-around, or thought they did, and the situation deteriorated from there.

I have seen this situation demonstrated in the SIM, and believe me it was very nearly a major accident. Fortunately the crew recovered the situation by disconnecting the AP when the A/C did not perform as they expected. Think about it; they were less than 200 feet above the ground, in IMC, still locked on to the glideslope but the engines spooling up to max continuous thrust. It scared the crap out of me in the sim and we did it in VMC conditions. There was very little time to react.

The upshot of it all is that the crew made an error from which they recovered. We have all been there and hopefully learned from the experience. The performance of Jetstars management was not good however and they need to be much more forthcoming when these errors occur.

Mstr Caution

4th Nov 2007, 09:37

I think this whole TOGA tap business, in reference to this incident is a bit of a furphy. I believe the crew initiated a go-around, or thought they did, and the situation deteriorated from there.

I have to agree with you there Cpt K.

Just look at how many times the Left Auto Pilot was engaged & disengaged between the selection of MCT thrust setting until the aircraft eventually climbed away.

Shot Nancy

4th Nov 2007, 13:16

Just look at how many times the Left Auto Pilot was engaged & disengaged
AP1 or AP2 is either ON or OFF, despite what the report states.
SOPs provide the highest level of approach capability hence AP1+2 ON for ILS approach.
If you are not happy with what the AP is doing get rid of it and do it yourself.
Just love it when non-airbus types get invloved.

golow

4th Nov 2007, 21:22

AWA pilots pay $3000 for extra training.

Mstr Caution

4th Nov 2007, 23:32

AP1 or AP2 is either ON or OFF, despite what the report states.

What do you mean despite what the report states?

The report clearly states, both AP 1&2 where on for the approach & disconnected around the timestamp 21:51:40

AP1 was engaged again & then disconected shortly before timestamp 21:52:00

AP1 was engaged & then disconected again shortly after timestamp 21:52:20

Then AP1 was re-engeged yet again approaching timestamp 21:52:40

Thats straight from the QAR data!!

If you are not happy with what the AP is doing get rid of it and do it yourself.

I agree entirely with this statement, however on this occassion it appears that neither the AP nor manual flight were achieving the desired objectives over a period of approximately 50 seconds.

Just love it when non-airbus types get invloved.

During my 5000 hours or so on Airbus aircraft, I have always considered the go-around nothing short of a fairly straight forward procedure. To my recollection I can't recall ever descending below DH to the extent evident here. Nor have I ever experienced a "Dont Sink" message after conducting a missed approach. Maybe i've just had luck on my side.:8