Plane talking: Bogan Air ATSB report
Thread Starter
Plane talking: Bogan Air ATSB report
I haven't seen this posted elsewhere, so here it is.
Let’s translate the wording of today’s ATSB report into an ‘incorrect aircraft configuration’ in a 177-180 seat Jetstar A320 on approach to Melbourne Airport from Newcastle on 28 July this year into plain but commercially insensitive English.
A co-pilot with only 300 hours experience on the type and a moderately A320 experienced captain screwed it up so badly, with passengers on board, that they didn’t regain adequate control of the jet until it was at a radio altitude of 166 feet (or about 145 feet measured from the underbelly) off the ground, after which they continued to screw up before finally making an uneventful second approach and landing.
It was an incident with some similarities to the safety standard lapses that contributed to CASA’s decision to ground Tiger Airways, which just goes to show that the safety regulator is nothing if not courageous and diligent in the pursuit of deficient safety cultures and training issues.
And it also shows that the ATSB, which works its limited dollars very hard, and produces investigation reports that are truly useful and insightful in their contribution to air safety, nevertheless knows where to bury anything likely to offend the larger gorillas in the aviation jungle, which in this case is deep within its regular compendium of ‘shorter investigations’.
(It’s a two layer coffin-for-the-controversial, first the report goes into the secondary compilation of investigations which will also included a number of general aviation incidents, and which then get referenced in the official summary, which is as far as the general media is expected to go, where they are written down in a way makes it easy to turn items into news reports that completely miss the main points.)
So, here we are on Jetstar on what could have been a very final approach to Melbourne back on 28 July . The flight has passed Essendon Airport and has turned right to descend onto runway 34 at the main Melbourne Airport at Tullamarine.
Let’s go to the narrative in the full report that the media is apparently supposed not to read, and add emphasis in bold to some of the words.
As the aircraft descended through 1,000 ft radio altitude (RA), the Captain noted that the descent rate was about 1,200 feet per minute (fpm). The Captain called ‘sink rate’ and the FO responded by reducing the descent rate to below 1,000 fpm. At that time, the landing checklist had not been completed.
The aircraft was established on final approach at about 800 ft RA.
The FO recalled that his workload was high during the approach. As a result, he had focused on the aircraft’s vertical profile and runway alignment, relying on the Captain for decision making and situation awareness. The Captain was not aware of this.
During the approach, the Captain observed the arriving and departing traffic on runway 34, and received a landing clearance from ATC. At about the same time, the 500 ft RA automatic callout alert activated, which neither crew member reported hearing.
When at 245 ft RA, the Captain realised that the landing checklist had not been completed. At the same time, the crew received a ‘TOO LOW FLAP’ aural and visual warning from the aircraft’s enhanced ground proximity warning system (EGPWS).
The Captain identified that the aircraft was in the incorrect configuration and immediately called for a go-around. The FO initiated the go-around and applied take-off/go-around thrust. Prior to establishing a positive rate of climb, the crew received a second ‘TOO LOW FLAP’ warning.
During the go-around, the FO’s workload significantly increased. As a result, he did not call for Flap 1 to be selected, leaving the Captain to select Flap 1 independently. To further compound the FO’s workload, a master caution warning for an air conditioning pack fault was received after the go-around had commenced.
In preparation for the second approach, the Captain had considered assuming the pilot flying duties, but elected to ask the FO if he was comfortable with continuing the pilot flying duties, to which the FO replied he was. The FO conducted the second approach without further incident.
Jetstar’s operating instructions are for the A320 to have been established for landing at not less than 1000 feet above the runway with the correct flap setting selected.
The first officer told the ATSB that he had not conducted a go-around on an A320 except in a simulator before this incident.
In its own review into the incident Jetstar found (Catch 22 anyone) *that:
the increased level of assistance from the captain and a high workload state had removed the first officer from the decision making process and reduced his situational awareness.
The FO may have experienced cognitive overload during the approach and go-around.
The Captain reported a high workload from directing and monitoring the FO, while conducting his normal duties, reducing his cognitive capacity and situation awareness of the aircraft’s configuration.
The ATSB then quotes from the Jetstar response as follows.
As a result of this occurrence, Jetstar Airways has advised the ATSB that they intend to take, or have taken, the following safety actions:
provide the Captain and FO with a remedial training and coaching program
conduct a review of their command upgrade training to ensure it specifically 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, in particular, the subjects related to command of flight/leadership, cockpit authority gradient, and flight crew assertion.
Jetstar has been flying A320s for seven years, and has almost 70 of the single aisle family, including A321s in its total franchise.
Comment This incident would have been highly relevant to the Senate committee hearings into pilot training and airline safety standards earlier this year which had concluded before it occurred.
It is a poor reflection on Jetstar, and would have probably caused concerns at some level in CASA. The public should be informed about incidents like this, and that means it should have been dealt with in a higher profile manner.
Jetstar has reacted thoroughly to the report, which is a positive, if not a necessity for management, who are individually on notice by the director of safety at CASA, John McCormick, that they are responsible for pilot standards and training outcomes.
A co-pilot with only 300 hours experience on the type and a moderately A320 experienced captain screwed it up so badly, with passengers on board, that they didn’t regain adequate control of the jet until it was at a radio altitude of 166 feet (or about 145 feet measured from the underbelly) off the ground, after which they continued to screw up before finally making an uneventful second approach and landing.
It was an incident with some similarities to the safety standard lapses that contributed to CASA’s decision to ground Tiger Airways, which just goes to show that the safety regulator is nothing if not courageous and diligent in the pursuit of deficient safety cultures and training issues.
And it also shows that the ATSB, which works its limited dollars very hard, and produces investigation reports that are truly useful and insightful in their contribution to air safety, nevertheless knows where to bury anything likely to offend the larger gorillas in the aviation jungle, which in this case is deep within its regular compendium of ‘shorter investigations’.
(It’s a two layer coffin-for-the-controversial, first the report goes into the secondary compilation of investigations which will also included a number of general aviation incidents, and which then get referenced in the official summary, which is as far as the general media is expected to go, where they are written down in a way makes it easy to turn items into news reports that completely miss the main points.)
So, here we are on Jetstar on what could have been a very final approach to Melbourne back on 28 July . The flight has passed Essendon Airport and has turned right to descend onto runway 34 at the main Melbourne Airport at Tullamarine.
Let’s go to the narrative in the full report that the media is apparently supposed not to read, and add emphasis in bold to some of the words.
As the aircraft descended through 1,000 ft radio altitude (RA), the Captain noted that the descent rate was about 1,200 feet per minute (fpm). The Captain called ‘sink rate’ and the FO responded by reducing the descent rate to below 1,000 fpm. At that time, the landing checklist had not been completed.
The aircraft was established on final approach at about 800 ft RA.
The FO recalled that his workload was high during the approach. As a result, he had focused on the aircraft’s vertical profile and runway alignment, relying on the Captain for decision making and situation awareness. The Captain was not aware of this.
During the approach, the Captain observed the arriving and departing traffic on runway 34, and received a landing clearance from ATC. At about the same time, the 500 ft RA automatic callout alert activated, which neither crew member reported hearing.
When at 245 ft RA, the Captain realised that the landing checklist had not been completed. At the same time, the crew received a ‘TOO LOW FLAP’ aural and visual warning from the aircraft’s enhanced ground proximity warning system (EGPWS).
The Captain identified that the aircraft was in the incorrect configuration and immediately called for a go-around. The FO initiated the go-around and applied take-off/go-around thrust. Prior to establishing a positive rate of climb, the crew received a second ‘TOO LOW FLAP’ warning.
During the go-around, the FO’s workload significantly increased. As a result, he did not call for Flap 1 to be selected, leaving the Captain to select Flap 1 independently. To further compound the FO’s workload, a master caution warning for an air conditioning pack fault was received after the go-around had commenced.
In preparation for the second approach, the Captain had considered assuming the pilot flying duties, but elected to ask the FO if he was comfortable with continuing the pilot flying duties, to which the FO replied he was. The FO conducted the second approach without further incident.
Jetstar’s operating instructions are for the A320 to have been established for landing at not less than 1000 feet above the runway with the correct flap setting selected.
The first officer told the ATSB that he had not conducted a go-around on an A320 except in a simulator before this incident.
In its own review into the incident Jetstar found (Catch 22 anyone) *that:
the increased level of assistance from the captain and a high workload state had removed the first officer from the decision making process and reduced his situational awareness.
The FO may have experienced cognitive overload during the approach and go-around.
The Captain reported a high workload from directing and monitoring the FO, while conducting his normal duties, reducing his cognitive capacity and situation awareness of the aircraft’s configuration.
The ATSB then quotes from the Jetstar response as follows.
As a result of this occurrence, Jetstar Airways has advised the ATSB that they intend to take, or have taken, the following safety actions:
provide the Captain and FO with a remedial training and coaching program
conduct a review of their command upgrade training to ensure it specifically 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, in particular, the subjects related to command of flight/leadership, cockpit authority gradient, and flight crew assertion.
Jetstar has been flying A320s for seven years, and has almost 70 of the single aisle family, including A321s in its total franchise.
Comment This incident would have been highly relevant to the Senate committee hearings into pilot training and airline safety standards earlier this year which had concluded before it occurred.
It is a poor reflection on Jetstar, and would have probably caused concerns at some level in CASA. The public should be informed about incidents like this, and that means it should have been dealt with in a higher profile manner.
Jetstar has reacted thoroughly to the report, which is a positive, if not a necessity for management, who are individually on notice by the director of safety at CASA, John McCormick, that they are responsible for pilot standards and training outcomes.
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
Tick tock tick tock
It is a poor reflection on Jetstar, and would have probably caused concerns at some level in CASA. The public should be informed about incidents like this, and that means it should have been dealt with in a higher profile manner.
Jetstar has reacted thoroughly to the report, which is a positive, if not a necessity for management, who are individually on notice by the director of safety at CASA, John McCormick, that they are responsible for pilot standards and training outcomes.
Jetstar has reacted thoroughly to the report, which is a positive, if not a necessity for management, who are individually on notice by the director of safety at CASA, John McCormick, that they are responsible for pilot standards and training outcomes.
So why are CASA to busy chasing chopper pilots or reactively bullying industry people when this sort of incident takes place?
I guess the real question is does CASA have the guts to do anything about it or are they just to scared to take on QF?
Nothing replaces experience. Period.
The ATSB has even reclassified the way it ranks and rates investigations in an attempt to fluff up the numbers, mainly because it cannot keep up with the workload. And don't forget all the Airservices issues!!
Gee who would have thought all these problems with the ATSB, Airservices, CASA all have the same root cause - Bureaucratic empires run by bureaucrats.
REMOVE THE POLITICS OUT OF SAFETY!
Last edited by gobbledock; 12th Dec 2011 at 08:49.
Join Date: Jul 2008
Location: south pacific vagrant
Posts: 1,334
Likes: 0
Received 0 Likes
on
0 Posts
So.
One A320 operator has instances of inadvertant descents below cleared levels (VMC AFAIK) and gets grounded, while another has multiple instances of aircraft in incorrect configurations resulting in approaches that get badly out of shape close to the ground and..............well, CASA? What say thee?
One A320 operator has instances of inadvertant descents below cleared levels (VMC AFAIK) and gets grounded, while another has multiple instances of aircraft in incorrect configurations resulting in approaches that get badly out of shape close to the ground and..............well, CASA? What say thee?
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
More ticking more tocking
waren9
The worm like CASA has thy testicles gripped firmly and robustly between thy Ministers hand and thy Ministers protectors hand - the CASA Board.
Any day now, keep watching the news, it is coming...tick tock
One A320 operator has instances of inadvertant descents below cleared levels (VMC AFAIK) and gets grounded, while another has multiple instances of aircraft in incorrect configurations resulting in approaches that get badly out of shape close to the ground and..............well, CASA? What say thee?
Any day now, keep watching the news, it is coming...tick tock
The FO wasn't a 300 hour cadet,
Pilot information
The Captain held an Air Transport Pilot (Aeroplane) Licence with a total of 9,775 hours, of which about 4,280 hours were on the A320.
The FO held a Commercial Pilot (Aeroplane) Licence with a total of 1,966 hours, of which about 300 hours were on the A320.
But I do agree that there seems to be an elevated series of incidents with Transport Category Aircraft of late, especially from one particular operator!
I also note that the ATSB (in this incident) hasn't called for a response from the regulator. So what would be a good idea is to compile all similar incidents together, then send to the ATSB as a repcon citing concern that the regulator should be made aware of these incidents. Due to the nature of a repcon CASA will be forced to respond!
Cheers
Pilot information
The Captain held an Air Transport Pilot (Aeroplane) Licence with a total of 9,775 hours, of which about 4,280 hours were on the A320.
The FO held a Commercial Pilot (Aeroplane) Licence with a total of 1,966 hours, of which about 300 hours were on the A320.
I also note that the ATSB (in this incident) hasn't called for a response from the regulator. So what would be a good idea is to compile all similar incidents together, then send to the ATSB as a repcon citing concern that the regulator should be made aware of these incidents. Due to the nature of a repcon CASA will be forced to respond!
Cheers
Join Date: Jul 2011
Location: East Coast
Posts: 12
Likes: 0
Received 0 Likes
on
0 Posts
From the cheap seats...
Was in the cheap seats on this flight.
Read the article then checked my calendar, as I have vivid memories of an unexplained night go-around in fine weather conditions on a Willy-Tulla trip. Sure enough, that's the one....
Approach seemed normal enough, though I can't speak with much authority on the 320. Field in sight (from the cheap seats) and around we go.
Silence from the cockpit in the ensuing minutes and the sheepish PA following spoke volumes - something had clearly happened in the big seats up front.
Everyone makes mistakes, but when 2 people are making mistakes at the same time I start asking questions.
Read the article then checked my calendar, as I have vivid memories of an unexplained night go-around in fine weather conditions on a Willy-Tulla trip. Sure enough, that's the one....
Approach seemed normal enough, though I can't speak with much authority on the 320. Field in sight (from the cheap seats) and around we go.
Silence from the cockpit in the ensuing minutes and the sheepish PA following spoke volumes - something had clearly happened in the big seats up front.
Everyone makes mistakes, but when 2 people are making mistakes at the same time I start asking questions.
F/O was not a 300 hour Cadet, but had nearly 2,000 hours and 300 on type.
I would suggest, he was probably an "Accelerated Cadet" if he did not, as reported, hold an ATPL.
Perhaps he was too busy wondering how he'll make his mortgage repayments next month!
I would suggest, he was probably an "Accelerated Cadet" if he did not, as reported, hold an ATPL.
Perhaps he was too busy wondering how he'll make his mortgage repayments next month!
Join Date: Apr 2008
Location: On a long enough timeline the survival rate for everyone is zero
Posts: 731
Likes: 0
Received 0 Likes
on
0 Posts
Not quite the same, but seems to be similar circumstances with low time-on-type issues.
Hard landing - Darwin Airport, Northern Territory, 7 February 2008, VH-NXE, Boeing Company 717–200 Investigation Number:AO-2008-007[.pdf]
- Third Party Training
Originally Posted by ATSB
The copilot reported having voiced concerns to a number of check captains in respect of difficulty experienced with landings in the 717. That included following a hard landing that occurred 3 days before this occurrence, and again before the occurrence at Darwin itself. The copilot did not otherwise pursue the matter with the operator’s training organisation or senior management. The aircraft operator reported that the check captain who flew with the copilot during the initially reported hard landing, held the view that the copilot’s concerns had been adequately resolved.
The aircraft operator had identified a number of issues in relation to the reporting by pilots of training difficulties to senior management, and with training on the 717 being overseen by the Manager Pilot Training and Checking, who was responsible for pilot training across all aircraft types. Although there was no dedicated 717 training manager, the operator reported that the Head of Pilot Training 717 was the technical captain for the 717 fleet. Together with the 717 check and training captains, the Head of Pilot Training 717 was available to flight crews to discuss any training issues.
The aircraft operator had identified a number of issues in relation to the reporting by pilots of training difficulties to senior management, and with training on the 717 being overseen by the Manager Pilot Training and Checking, who was responsible for pilot training across all aircraft types. Although there was no dedicated 717 training manager, the operator reported that the Head of Pilot Training 717 was the technical captain for the 717 fleet. Together with the 717 check and training captains, the Head of Pilot Training 717 was available to flight crews to discuss any training issues.
Join Date: Aug 2009
Posts: 509
Likes: 0
Received 0 Likes
on
0 Posts
Jetstar pilots sent back to school after flying too low on approach
TWO Jetstar pilots have been ordered into remedial training after a misunderstanding between them caused their Airbus A320 to descend within 75m of the ground well short of Melbourne Airport.
It took two warning signals from the aircraft's safety systems before the Captain and the First Officer, who was at the controls, realised they were far too low on approach and the Captain aborted the landing.
The July 28 incident, similar to several instances which led to Tiger Airways being grounded, is being taken so seriously by Jetstar that it will become a case study in its pilot courses.
It happened as the Airbus A320 was making its final approach.
The official report said the First Officer was concentrating on the aircraft's runway alignment and its positioning for landing, relying on the captain for decision making and awareness of the height.
However the captain was unaware of that.
It took two warning signals from the aircraft's safety systems before the Captain and the First Officer, who was at the controls, realised they were far too low on approach and the Captain aborted the landing.
The July 28 incident, similar to several instances which led to Tiger Airways being grounded, is being taken so seriously by Jetstar that it will become a case study in its pilot courses.
It happened as the Airbus A320 was making its final approach.
The official report said the First Officer was concentrating on the aircraft's runway alignment and its positioning for landing, relying on the captain for decision making and awareness of the height.
However the captain was unaware of that.
It will take at least Two smoking holes in the ground before CASA and Qantas are hung drawn and quartered.
The first will be put down to "pilot error" and Olivia Wirth will state philosophically that the simple law of averages finally caught up with Qantas..and there won't be another accident for another Forty plus years.
Then there will be a second accident....
And if that isn't enough, the Third will do it.
The Minister will then headhunt either an EASA or FAA heavy hitter to clean up the mess.
The first will be put down to "pilot error" and Olivia Wirth will state philosophically that the simple law of averages finally caught up with Qantas..and there won't be another accident for another Forty plus years.
Then there will be a second accident....
And if that isn't enough, the Third will do it.
The Minister will then headhunt either an EASA or FAA heavy hitter to clean up the mess.
Join Date: Oct 2005
Location: 45 yards from a tropical beach
Posts: 1,103
Likes: 0
Received 0 Likes
on
0 Posts
Pilot information
The Captain held an Air Transport Pilot (Aeroplane) Licence with a total of 9,775 hours, of which about 4,280 hours were on the A320.
The FO held a Commercial Pilot (Aeroplane) Licence with a total of 1,966 hours, of which about 300 hours were on the A320.
The Captain held an Air Transport Pilot (Aeroplane) Licence with a total of 9,775 hours, of which about 4,280 hours were on the A320.
The FO held a Commercial Pilot (Aeroplane) Licence with a total of 1,966 hours, of which about 300 hours were on the A320.
Unstabilised approach; landing checklist not complete by 300 feet. What was going on? By most company SOPs, with the FO as PF, the 'Go Around' should have been performed at 1,000' AAL.
Training? Standards? Who is in charge? Where is our profession going?
Now taken up by more mainstream media:
Jetstar pilots sent back to school after flying too low on approach | News.com.au
One of the more worrying things with this incident is the fact that it is buried in the ATSB's incident summary file.
It is time to bring this to Senator Xs attention (if it isn't already)! Senator X has to demand the Minister's response to the Senate Inquiry now!
It is past the three month time limit and the disengaged Minister and regulator need to be put on notice!
Doesn't this journo realise that this is just 'spin' to placate the ATSB!
Jetstar pilots sent back to school after flying too low on approach | News.com.au
One of the more worrying things with this incident is the fact that it is buried in the ATSB's incident summary file.
It is time to bring this to Senator Xs attention (if it isn't already)! Senator X has to demand the Minister's response to the Senate Inquiry now!
It is past the three month time limit and the disengaged Minister and regulator need to be put on notice!
The July 28 incident, similar to several instances which led to Tiger Airways being grounded, is being taken so seriously by Jetstar that it will become a case study in its pilot courses.
Doesn't this journo realise that this is just 'spin' to placate the ATSB!
Last edited by Sarcs; 12th Dec 2011 at 20:33.
This quote taken from one of Ben's reader comments is spot on (hope he doesn't mind if it is borrowed):
From 'Fight Club'.
This more than highlights, I think, the reasoning or 'Risk Management used in today's LCC!
As gobbledock puts it "tick..tock".
“Narrator: A new car built by my company leaves somewhere traveling at 60 mph. The rear differential locks up. The car crashes and burns with everyone trapped inside. Now, should we initiate a recall? Take the number of vehicles in the field, A, multiply by the probable rate of failure, B, multiply by the average out-of-court settlement, C. A times B times C equals X. If X is less than the cost of a recall, we don’t do one.
Business woman on plane: Are there a lot of these kinds of accidents?
Narrator: You wouldn’t believe.
Business woman on plane: Which car company do you work for?
Narrator: A major one. “
Business woman on plane: Are there a lot of these kinds of accidents?
Narrator: You wouldn’t believe.
Business woman on plane: Which car company do you work for?
Narrator: A major one. “
From 'Fight Club'.This more than highlights, I think, the reasoning or 'Risk Management used in today's LCC!
As gobbledock puts it "tick..tock".
Join Date: Jun 2006
Location: Wherever the hotel drink ticket is valid
Posts: 281
Likes: 0
Received 0 Likes
on
0 Posts
This more than highlights, I think, the reasoning or 'Risk Management used in today's LCC!
In my part of the industry (technically not LCC
), I note a number of key safety issues where management seem absolutely intent on maintaining the appearance of safety, rather than actually using prerogative to establish better practices. As long as the numbers are black at the bottom of the spreadsheet, the bums are in the seats (crew-wise), and they can point to a company policy which looks like they are safety minded, they will pay no mind to quality assurance or trying to get best possible results out of their people.This seems to be modern management practice - don't worry about people, worry about dollar signs and decimal points. It's not just our industry, it's everywhere. Sadly we count the cost in serious safety incidents, and perhaps one day in blood.
Two cents poorer,
Icarus
Join Date: Jan 2008
Location: Sonoma, CA, USA
Age: 79
Posts: 143
Likes: 0
Received 0 Likes
on
0 Posts
Pilot pressure caused errors
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.
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: Apr 2002
Location: FUBAR
Posts: 3,348
Likes: 0
Received 0 Likes
on
0 Posts
Maybe a little exaggeration on the part of the press, but I am all for it if it alerts the public to the circumstances the airlines are subjecting them to (via P2F) in the name of low(er) air fares.
When, & only when , the public complain (unfortunately it will probably take a very large/very public accident to achieve this) something MAY be done, in spite of the bean counters wishes for this to continue unabated.
Without this ghoulish intervention, it is all downhill.
When, & only when , the public complain (unfortunately it will probably take a very large/very public accident to achieve this) something MAY be done, in spite of the bean counters wishes for this to continue unabated.
Without this ghoulish intervention, it is all downhill.