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Jetstar A320 Go Around Melbourne

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Jetstar A320 Go Around Melbourne

Old 1st Nov 2007, 03:07
  #61 (permalink)  
Keg

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Question

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 isnít responding they may run out of time and run into something.

This is essential, basic, piloting. You donít sit there in disbelief. You check your essentials, such as the position of the throttle levers. You must trust your instruments. If they say DONíT 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?
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Old 1st Nov 2007, 03:21
  #62 (permalink)  
 
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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 isnít responding they may run out of time and run into something.

This is essential, basic, piloting. You donít sit there in disbelief. You check your essentials, such as the position of the throttle levers. You must trust your instruments. If they say DONíT 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?
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Old 1st Nov 2007, 03:47
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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!! Good bloke or not, it smacks of cronyism, destabilizes the company and leads to non standard dangerous practices such as Jetstars' "TOGA TAP"
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Old 1st Nov 2007, 05:49
  #64 (permalink)  
 
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Unome, excuse my ignorance, but what is this toga tap procedure they do?
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Old 1st Nov 2007, 07:49
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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.
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Old 1st Nov 2007, 08:22
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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?

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

Last edited by UNOME; 1st Nov 2007 at 08:41.
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Old 1st Nov 2007, 08:23
  #67 (permalink)  
 
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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.
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Old 1st Nov 2007, 08:42
  #68 (permalink)  
 
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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........"
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Old 1st Nov 2007, 10:34
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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!
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Old 1st Nov 2007, 10:35
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Angel

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??"
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Old 1st Nov 2007, 10:47
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You gonna rotate somewhere in your procedure there, Unome?

You have flown these things, haven't you?
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Old 1st Nov 2007, 11:48
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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!! 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 wasnít 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.
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Old 1st Nov 2007, 11:49
  #73 (permalink)  
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Lightbulb

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.
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Old 1st Nov 2007, 12:40
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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.

Last edited by What The; 1st Nov 2007 at 16:52.
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Old 1st Nov 2007, 13:01
  #75 (permalink)  
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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!
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Old 1st Nov 2007, 14:30
  #76 (permalink)  
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Exclamation

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.
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Old 1st Nov 2007, 14:46
  #77 (permalink)  

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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.

Last edited by Chimbu chuckles; 1st Nov 2007 at 15:28.
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Old 1st Nov 2007, 15:22
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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
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Old 1st Nov 2007, 20:27
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Why don't you guys read all of what Keg wrote?
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Old 1st Nov 2007, 23:15
  #80 (permalink)  
Keg

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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.

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.
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