Plane talking: Bogan Air ATSB report
Join Date: Aug 2006
Location: Oz
Posts: 179
Likes: 0
Received 0 Likes
on
0 Posts
Now on the front page of smh.com.au
A JETSTAR Airbus A320 slipped to within 51 metres of the ground during a botched, aborted landing at Melbourne airport, as pilots fumbled with wrong flap settings and a cacophony of cockpit alarms, Australian Transport Safety Bureau investigators have found.
A sequence of mistakes on a July 28 evening flight from Newcastle to Melbourne left the pilot flying the plane - a cadet recruit with just 300 hours Airbus flying experience - overwhelmed. The captain sitting next to him was so busy trying to recover the situation that his capacity was also compromised.
On landing approach the plane was variously descending too fast, the flaps weren't extended properly and an altitude alert went unheard by both pilots.
Advertisement: Story continues below
The first officer may have experienced ''cognitive overload'', Jetstar told investigators.
The captain reported a ''high workload'' in supervising the first officer, ''reducing his cognitive capacity and situation awareness of the aircraft's configuration'', the airline said.
At 75 metres, the captain realised the plane wasn't configured properly for landing, just as the ground warning system sounded and a message on a screen flashed: ''Too Low Flap'' - the flaps were on the wrong setting.
The captain called off the landing and the first officer throttled the engines to climb as a second terrain warning sounded.
Mentally overloaded, the first officer failed to reset the flaps, leaving it to the captain.
Compounding matters, another alarm went off due to an air conditioning fault.
The Australian and International Pilots Association had warned a Senate inquiry this year about the risk of fast-tracking inexperienced pilots to airline cockpits.
But a Jetstar spokeswoman yesterday defended its methods.
''Any pilot who sits behind the controls of a Jetstar aircraft has the skills and qualifications to be there,'' she said.
''Go-arounds [aborted landings] are not uncommon and are a part of our systems of checks and balances for safe operations.''
In a separate incident, two Jetstar pilots made separate engine power calculation mistakes prior to take-off from Darwin for Bali on June 12.
The first power calculation was made with the incorrect aircraft weight, then with the wrong length of runway, compounded by a pilot short-cut to bookmark the wrong data table for cross checking the calculations by the second pilot.
Jetstar later told all pilots that take-off calculations have to be checked independently and the practice of bookmarking data tables ''must cease immediately''.
Read more: Jetstar botched landing at Melbourne Airport | Pilot pressure caused errors
A sequence of mistakes on a July 28 evening flight from Newcastle to Melbourne left the pilot flying the plane - a cadet recruit with just 300 hours Airbus flying experience - overwhelmed. The captain sitting next to him was so busy trying to recover the situation that his capacity was also compromised.
On landing approach the plane was variously descending too fast, the flaps weren't extended properly and an altitude alert went unheard by both pilots.
Advertisement: Story continues below
The first officer may have experienced ''cognitive overload'', Jetstar told investigators.
The captain reported a ''high workload'' in supervising the first officer, ''reducing his cognitive capacity and situation awareness of the aircraft's configuration'', the airline said.
At 75 metres, the captain realised the plane wasn't configured properly for landing, just as the ground warning system sounded and a message on a screen flashed: ''Too Low Flap'' - the flaps were on the wrong setting.
The captain called off the landing and the first officer throttled the engines to climb as a second terrain warning sounded.
Mentally overloaded, the first officer failed to reset the flaps, leaving it to the captain.
Compounding matters, another alarm went off due to an air conditioning fault.
The Australian and International Pilots Association had warned a Senate inquiry this year about the risk of fast-tracking inexperienced pilots to airline cockpits.
But a Jetstar spokeswoman yesterday defended its methods.
''Any pilot who sits behind the controls of a Jetstar aircraft has the skills and qualifications to be there,'' she said.
''Go-arounds [aborted landings] are not uncommon and are a part of our systems of checks and balances for safe operations.''
In a separate incident, two Jetstar pilots made separate engine power calculation mistakes prior to take-off from Darwin for Bali on June 12.
The first power calculation was made with the incorrect aircraft weight, then with the wrong length of runway, compounded by a pilot short-cut to bookmark the wrong data table for cross checking the calculations by the second pilot.
Jetstar later told all pilots that take-off calculations have to be checked independently and the practice of bookmarking data tables ''must cease immediately''.
Read more: Jetstar botched landing at Melbourne Airport | Pilot pressure caused errors
Last edited by ga_trojan; 13th Dec 2011 at 00:26.
Join Date: Apr 2002
Location: FUBAR
Posts: 3,348
Likes: 0
Received 0 Likes
on
0 Posts
Ah. . . sorry mate, what did I say to disagree with you ? ? 
Sure, (if you read the link ! ) as always, the Press hammed it up a little, but Yep., I would rather my cojo is experienced, which part of my previous suggested otherwise ?
Sure, (if you read the link ! ) as always, the Press hammed it up a little, but Yep., I would rather my cojo is experienced, which part of my previous suggested otherwise ?
Join Date: Oct 2009
Location: Alabama, then Wyoming, then Idaho and now staying with Kharon on Styx houseboat
Age: 61
Posts: 1,437
Likes: 0
Received 0 Likes
on
0 Posts
ATSB
From the ATSB website (my bold):
The operator conducted an investigation and determined that the following factors had contributed to the incident: incomplete approach brief, loss of situation awareness, improper coaching techniques and cognitive overload. As a result, the operator intends to:
The operator conducted an investigation and determined that the following factors had contributed to the incident: incomplete approach brief, loss of situation awareness, improper coaching techniques and cognitive overload. As a result, the operator intends to:
- provide the Captain and FO with a remedial training and coaching program
- conduct a review of their command upgrade training to ensure it focuses on the development of a positive cockpit authority gradient, and the command of flight capabilities
- incorporate this incident into the command upgrade training course as a case study
- conduct a review of their recurrent human factors training.
a) Incomplete approach brief - Why? Was it a training issue, normalised deviance, error or violation, complacency, operational pressures, resource deficient, technologies, communication, fatigue, PIC/FO skills gradient?
b) Loss of situation awareness - Again,Why? Was it a training issue, normalised deviance, error or violation, complacency, operational pressures, resource deficient, technologies, communication, fatigue, PIC/FO skills gradient?
c) Improper coaching techniques and cognitive overload - Once more Why? Was it a training issue, normalised deviance, error or violation, complacency, operational pressures, resource deficient, technologies, communication, fatigue, PIC/FO skills and experience gradient?
Furthermore, are the root causes in this case related to just this crew or do they apply across the spectrum of this operator? Are we seeing an emerging pattern?
And yet again, where is the regulator in all of this? Do we even have one? Are the executive lawyers and out of touch former pilots running CASA even capable of managing these issues? Doesn't appear that way.
Over to you Senator Xenophon. Tick tock tick tock
Join Date: Jan 2008
Location: Denver, CO
Posts: 265
Likes: 0
Received 0 Likes
on
0 Posts
Sad Thing...
Not a pilot...
But looking back over years gone by, "pilot pressure" was caused by flying new designs which didn't have the benefit of the engineering a framer can now put into a "B-whatever" or an "A-whatever."
Now pressure seems to be coming from tertiary and rather unimportant things like meeting schedule, fuel burn, et cetera.
Certainly not sticking up for the P2F crowd or the fact that such programs exist, merely commiserating about times past when flying was still a lucrative career and pax respected the captain of a flight.
But looking back over years gone by, "pilot pressure" was caused by flying new designs which didn't have the benefit of the engineering a framer can now put into a "B-whatever" or an "A-whatever."
Now pressure seems to be coming from tertiary and rather unimportant things like meeting schedule, fuel burn, et cetera.
Certainly not sticking up for the P2F crowd or the fact that such programs exist, merely commiserating about times past when flying was still a lucrative career and pax respected the captain of a flight.
Bottums Up
You lot at the coalface, complaining about safety and falling standards are forgetting a fundamental of airline operational management.
Because you don't understand the business side, and aren't at the head-shed, you can't possibly possess a credible opinion. Only decision that are made in a remote head office, often away from the annoying distractions of operating an aeroplane, can be deemed to be valid and therefore implemented.
If these decisions and practices don't work the way the designer meant them to work, it is your fault for not being able to read minds, or make the unworkable work.
In the history of aviation no idea of merit has originated from outside head office. Every one knows that.
ps, i include myself in the collective "your".
Because you don't understand the business side, and aren't at the head-shed, you can't possibly possess a credible opinion. Only decision that are made in a remote head office, often away from the annoying distractions of operating an aeroplane, can be deemed to be valid and therefore implemented.
If these decisions and practices don't work the way the designer meant them to work, it is your fault for not being able to read minds, or make the unworkable work.
In the history of aviation no idea of merit has originated from outside head office. Every one knows that.
ps, i include myself in the collective "your".
Join Date: Oct 2009
Location: Alabama, then Wyoming, then Idaho and now staying with Kharon on Styx houseboat
Age: 61
Posts: 1,437
Likes: 0
Received 0 Likes
on
0 Posts
To be sure
Claret, to be sure! I forgot, people who fly planes know nothing about safety, risk or managing a business and finance.
Now, I am late for my flight to Cloud Cuckoo Land.................
Now, I am late for my flight to Cloud Cuckoo Land.................
Join Date: Jan 2008
Location: Australia
Posts: 159
Likes: 0
Received 0 Likes
on
0 Posts
Not a pilot, but a question starting from this quote:
There appears to be almost universal condemnation amongst pilots about having a low-hours pilot in the RHS, not just here, but in other threads too. Everybody starts with NIL hours experience on type, so how are pilots expected to transition from NIL hours to 'adequate experience' (my words, whatever the criteria might be) without at some stage being in the RHS with minimal hours?
A sequence of mistakes on a July 28 evening flight from Newcastle to Melbourne left the pilot flying the plane - a cadet recruit with just 300 hours Airbus flying experience - overwhelmed. The captain sitting next to him was so busy trying to recover the situation that his capacity was also compromised.
Join Date: Nov 1999
Location: The Land Downunder
Posts: 765
Likes: 0
Received 0 Likes
on
0 Posts
Actually, even though the Co Pilot was an 'advanced cadet' he did have 330 hours on type and almost 2000 hours in total. So to say that he was inexperienced is a bit of a stretch.
Join Date: Apr 2001
Location: Adrift upon the tides of fate
Posts: 1,840
Likes: 0
Received 0 Likes
on
0 Posts
I thought it was interesting that when the headline first appeared in the electronic editions of the daily papers, the word "Jetstar" was conspicuous by it's absence. The headline referred to an "airbus" close to disaster.
I see it has now been amended, with "Jetstar" replacing "airbus". Too hard to keep quiet?
I see it has now been amended, with "Jetstar" replacing "airbus". Too hard to keep quiet?
Join Date: Mar 2007
Location: Look up and wave
Posts: 359
Likes: 0
Received 0 Likes
on
0 Posts
The effo may have had just under 2000 hours, but what were those hours comprised of?
If they were say 1600 hours doing circuits in a trainer as an instructor, then 300 hours on the bus he would have been out of his depth.
If they were say 500 hours single engine charter, 500 hours in a piston twin charter operation then the rest in something like a conquest or a kingair, the bus would have been a walk in the park and he should be all over it like a rash.
There is hours, then there is hours.
If they were say 1600 hours doing circuits in a trainer as an instructor, then 300 hours on the bus he would have been out of his depth.
If they were say 500 hours single engine charter, 500 hours in a piston twin charter operation then the rest in something like a conquest or a kingair, the bus would have been a walk in the park and he should be all over it like a rash.
There is hours, then there is hours.
Join Date: May 2001
Location: Sydney
Age: 60
Posts: 1,542
Likes: 0
Received 0 Likes
on
0 Posts
David1300,
The traditional way in Australia to gain experience was either the RAAF or to go out into GA and get 3-6000 hours on light aircraft before joining a domestic airline to fly as a turboprop F/O for a few years before a jet. Alternatively you joined Qantas after said hours and flew in the jump-seat for T/O and LDG for another 4-12 years before landing the Jet!
It can be done quicker but to put cadets straight into a A320?
[esp with some Captains
]
The traditional way in Australia to gain experience was either the RAAF or to go out into GA and get 3-6000 hours on light aircraft before joining a domestic airline to fly as a turboprop F/O for a few years before a jet. Alternatively you joined Qantas after said hours and flew in the jump-seat for T/O and LDG for another 4-12 years before landing the Jet!
It can be done quicker but to put cadets straight into a A320?
[esp with some Captains]
Join Date: Jul 2011
Location: East Coast
Posts: 12
Likes: 0
Received 0 Likes
on
0 Posts
Correct Mach082.
Doing GF1 2000 times does not make one a 2000hr pilot....
But hey - who's listening....
Would be interesting to know the backgrounds of those at the helm, as we're all currently guessing. A maxed out low experience guy and a Captain failing in his duty of oversight (for whatever reason) certainly seems to fit the bill right now though.
The go around was pretty sporting by RPT standards btw...
Doing GF1 2000 times does not make one a 2000hr pilot....
But hey - who's listening....
Would be interesting to know the backgrounds of those at the helm, as we're all currently guessing. A maxed out low experience guy and a Captain failing in his duty of oversight (for whatever reason) certainly seems to fit the bill right now though.
The go around was pretty sporting by RPT standards btw...
Join Date: Aug 2006
Location: Australia
Posts: 165
Likes: 0
Received 0 Likes
on
0 Posts
Hate to point out the obvious to fellow aviators, but generally there are a number of factors that lead to an incident like this.
Pointing at the hours of pilots may or may not be relevant.
There would most likely be a number of factors at play, (outsourced training providers, fatigue, cultural factors, SOPs etc) the list is almost endless.
Don't rush to blame the pilots involved, as easy as that may be.
This is where a governing body should be investigating the reasons behind this incident, if in fact the operator has not recognised the deficiencies and addressed them appropriately.
Pointing at the hours of pilots may or may not be relevant.
There would most likely be a number of factors at play, (outsourced training providers, fatigue, cultural factors, SOPs etc) the list is almost endless.
Don't rush to blame the pilots involved, as easy as that may be.
This is where a governing body should be investigating the reasons behind this incident, if in fact the operator has not recognised the deficiencies and addressed them appropriately.
Join Date: Oct 2007
Location: gold coast QLD australia
Age: 86
Posts: 1,345
Likes: 0
Received 0 Likes
on
0 Posts
Enough of this Boganair. Believe me QF had the monopoly of bogans for years before JQ came into being. We used to fly dreadful things called funjets, and smoking was ok, that included pot, and the DPS and NAN flights were a health hazard, to say nothing of the behaviour of our (what do Virgin call em) guests? JQ is a dream to those days. Off subject I know, but I fly JQ a lot and the PAX are simply normal people, some very good people, enough of the smart remarks, QF is no angel, neither are some that fly it.
Join Date: Nov 1999
Location: The Land Downunder
Posts: 765
Likes: 0
Received 0 Likes
on
0 Posts
It is quite common every else in the world to put 200 hour pilots into the right hand seat of all sorts of medium to heavy jets and it generally does not cause a problem. Apart from the cadets being 'australians', why are 200 hour pilots in Australia seemingly not as capable as everywhere else in the world, which is what some seem to be suggesting.
But once again, this particular FO had 2000 hours flying time under his belt.
But once again, this particular FO had 2000 hours flying time under his belt.
Join Date: May 2001
Location: Sydney
Age: 60
Posts: 1,542
Likes: 0
Received 0 Likes
on
0 Posts
I would go with our stats.
Another issue is standard of new hires, it was once common for 8-9 out of 10 applicants with all min qualifications to not be accepted.
This was once a valued profession.
Another issue is standard of new hires, it was once common for 8-9 out of 10 applicants with all min qualifications to not be accepted.
This was once a valued profession.
Join Date: Aug 2011
Location: goulburn
Posts: 393
Likes: 0
Received 0 Likes
on
0 Posts
I think that the only certain thing here is that the operator will only address the deficiencies within the financial constraints they impose on the organisation and what they can get away with.
There is a pattern emerging here that goes way beyond individual crew roles. This could arguably be starting to approach the level of approach systemic failure.
The ATSB report clearly documents issues that should concern us all and especially on the once steadfast rule of two heads in the cockpit.
The question is how long will this be allowed to continue and when will the company be called to account?
There is a pattern emerging here that goes way beyond individual crew roles. This could arguably be starting to approach the level of approach systemic failure.
The ATSB report clearly documents issues that should concern us all and especially on the once steadfast rule of two heads in the cockpit.
The question is how long will this be allowed to continue and when will the company be called to account?
Join Date: Apr 2008
Location: Bradford
Age: 54
Posts: 27
Likes: 0
Received 0 Likes
on
0 Posts
Computers - only as clever as the coder...
Just a thought - but why do Airbus allow spurious, low-importance alerts (like aircon) to give audible warnings within a short time-frame of somewhat more important ones (ground proximity... terrain...). Surely there couold be a list of warning that just push the rest into the background until the comuter can see thigs are a little more normal (ie on the ground or with AP engagement parameters) I'm not trying to write the software but you catch my drift?
If these 2 are dumb enough to use the same table look-up via bookmark on a vital independant cross-creck, rather than actual check for themselves, I am not so sure it was anyting but human error
If these 2 are dumb enough to use the same table look-up via bookmark on a vital independant cross-creck, rather than actual check for themselves, I am not so sure it was anyting but human error
Join Date: Jul 2011
Location: East Coast
Posts: 12
Likes: 0
Received 0 Likes
on
0 Posts
-438 - Agree that incidents are usually the result of many causal factors, however I have seen the blame game over my time swing a little too far towards the Reason Model, shall we call it ie. "the system set me up/it wasn't my fault" etc.
If you want to accept the mantle of professional aviator, you should be prepared to execute your duties regardless of the distractions or limitations the system throws at you. Granted, I have the benefit of working in a small, professional and motivated team, where organisational problems can be raised and rectified without fear of reprisal. Anyone care to comment on whether that sounds like the environment at Jet*??
If 2 guys are having issues managing the mundane task of landing an aeroplane, how are they going to fare when the aviation gods throw them something a little less routine?
If you want to accept the mantle of professional aviator, you should be prepared to execute your duties regardless of the distractions or limitations the system throws at you. Granted, I have the benefit of working in a small, professional and motivated team, where organisational problems can be raised and rectified without fear of reprisal. Anyone care to comment on whether that sounds like the environment at Jet*??
If 2 guys are having issues managing the mundane task of landing an aeroplane, how are they going to fare when the aviation gods throw them something a little less routine?
