A320 mess Sydney

[wheels_down]

Interesting. Does the Airbus give you a alert should one keep climbing with Gear Down?

Well, if it was not for the associated buffeting, I wonder how long they would go on for, and at what height/speed serious damage starts to occur.

I don't think that's the big issue here. Consequences of playing with thrust at low level, 40kt excessive rotation, below minimum pitch angle could get a little hairy...

What happened

On 29 September 2018, a Jetstar Airways Airbus A320 aircraft, registered VH-VFK, was operating a scheduled passenger flight from Sydney, New South Wales to Melbourne, Victoria. While preparing for the flight and having difficulties with the electronic system used for calculating take-off performance figures, the flight crew reverted to the back-up procedure of manual calculations.

Shortly after take-off, the maximum flap extended speed was exceeded. As the aircraft climbed through 2,800 ft, the flight crew retracted the landing gear after realising it was still extended, resulting in a landing gear retraction overspeed.

Findings

These findings should not be read as apportioning blame or liability to any particular organisation or individual.

• The flight crew did not follow standard operating procedures to verify and update Flysmart database during sign on for the day.
• When using manual calculations to obtain performance speeds, the flight crew made an error which was not detected by independent validation. This resulted in a calculated rotation speed based on an aircraft weight significantly heavier than the actual take-off weight.
• The rotation rate commanded by the pilot flying was too low to prevent a flap overspeed, given the incorrect performance speeds and use of maximum take-off thrust.
• In an attempt to manage the airspeed, the pilot flying reduced the thrust from the take-off setting, rather than increasing the pitch, but the aircraft was below the safe altitude above the ground to do so.
• The landing gear was not retracted at the normal phase of the take-off. When the flight crew identified that the landing gear was still extended, they retracted it immediately, even though the aircraft was above the maximum landing gear retraction speed.

https://www.atsb.gov.au/publications...r/ao-2018-067/

[TimmyTee]

Does it seem that Jetstar aircraft are somewhat over-represented in these types of stuff ups in this country?

[Cessna Jockey]

There is no alert that I know of (yet to test that theory myself).

I don’t know the crew involved nor their rosters but worth mentioning from report:

The flight crew had recently completed their third sector for that day in a different aircraft and were required to change aircraft for this flight, which had a scheduled departure time of 2200 Eastern Standard Time (

Last minute aircraft swap, final fourth sector of probably a long day, pushing Sydney curfew for departure, EFB stuffing up so manual calcs, and no doubt they’re probably on max hours for the month during September peak period going from early morning sign ons to late nights...

I could be wrong, but it’s probably safe to say it the crew were probably not at their best by that stage of their duty...

[Green.Dot]

Originally Posted by TimmyTee

Does it seem that Jetstar aircraft are somewhat over-represented in these types of stuff ups in this country?

Most overworked and tired pilots in the country perhaps? Until you have done 24 sectors in 6 days it’s hard to imagine how stuff like this happens. Then it makes sense

[Brakerider]

Originally Posted by TimmyTee

Does it seem that Jetstar aircraft are somewhat over-represented in these types of stuff ups in this country?

Couldn’t possibly be that they operate the most of the type in Aus, by far?

[wheels_down]

Originally Posted by Cessna Jockey

I could be wrong, but it’s probably safe to say it the crew were probably not at their best by that stage of their duty...

The ATSB normally include Fatigue in many investigations, and if crew did/did not feel any form of fatigue on the said shift. They normally also state the duty crew were flying, previous days etc..We don't know this but your point is very valid, the fact that Positive Climb/Gear Up was missed, but they thought they said it, reeks of Fatigue.

However there is nothing in there nor anything surrounding crew hours or total time.

If they did accept a fatigue issue in some form, I would expect the ATSB to include that in the report, not private discussions between itself and the operator on if they want this info put into a public final report. That sort of rubbish and cover up I would expect in some neighbouring countries. If they didn't acknowledge any form of Fatigue and were well rested, then they need to state this also. For the benefit of all.

[maggot]

Nah there’s a FRMS somewhere in the manuals therefore fatigue was not a factor

/sarc in case it wasn’t clear

[Cessna Jockey]

Originally Posted by wheels_down

The ATSB normally include Fatigue in many investigations, and if crew did/did not feel any form of fatigue on the said shift. They normally also state the duty crew were flying, previous days etc..We don't know this but your point is very valid, the fact that Positive Climb/Gear Up was missed, but they thought they said it, reeks of Fatigue.

However there is nothing in there nor anything surrounding crew hours or total time.

If they did accept a fatigue issue in some form, I would expect the ATSB to include that in the report, not private discussions between itself and the operator on if they want this info put into a public final report. That sort of rubbish and cover up I would expect in some neighbouring countries. If they didn't acknowledge any form of Fatigue and were well rested, then they need to state this also. For the benefit of all.

I see your point but whilst we pretend we operate within a “just culture”, the reality is the moment you admit you were fatigued, it comes back to bite you with “then why did you continue to operate”. The responsibility rests with the crew member to self assess, and if you chose to continue then the outcome will likely be just as harsh. Sometimes it’s easier to just fall on your sword and just admit you stuffed up.

The ADSB would have looked at their rosters and flight/duty hours from a legal standpoint, and no doubt they would be legal. But as we know, just because it’s legal doesn’t make it right. I’m currently on my fifth early in a row and I’m absolutely shagged - 3am call outs, as well as 4am and 5am alarms all week for 4 sector days. I’ll have just one day off before switching to lates.

How long have CASA delayed the new CAO48 for the benefit of the airlines? It’s astounding

[Stickshift3000]

Originally Posted by wheels_down

If they did accept a fatigue issue in some form, I would expect the ATSB to include that in the report, not private discussions between itself and the operator on if they want this info put into a public final report. That sort of rubbish and cover up I would expect in some neighbouring countries. If they didn't acknowledge any form of Fatigue and were well rested, then they need to state this also. For the benefit of all.

This. Why is everyone so damn sensitive to whom they MAY offend these days?

The best colleagues I’ve worked with and the best bosses I’ve worked for were those that told it as it was, regardless of consequence. I hold them in high regard.

[Sunfish]

Because offending someone is a career limiting move. Being “encouraged” to self report and actually self reporting are two different things. Management publicly encourages reporting and openness, but privately penalizes those that do.

How do I know this??

[Vref+5]

Why would the Qantas group want to confirm any kind of issues surrounding fatigue when they want to get Sunrise up and running? The ATSB have consulted with them before this report was released and QF have shut fatigue issues straight down

[TimmyTee]

I’m sure they have their tails somewhat between their legs (probably not now as it’s 1.5 years since incident, and fair enough too), but if both pilots believed they had, and reported fatigue, I’d fully support them if they came out publically questioned why this was completely ignored in the report.

The report paints an image of guys just lazily rocking up, time to burn, ready to go.
I highly doubt this is the fact, rather no doubt it was less than a min “planned” turn, with aircraft and cc swap, probably no airside access due expired cards, delayed full flight.
No mention of sign on time, sector lengths, sit around time between flights, access to sustenance, consecutive days or how the crew reported as feeling fatigue wise (which I’m sure was one of the first questions they were asked to ensure the FRMS system works/company arse-covers)
Ridiculous.

[The Baron]

Anyone that has been in this unfortunate position well knows the amount of insidious commercial pressure to continue when fatigued. I also wouldn't be surprised if the crew involved were based in Melbourne. Everybody should have realized by now that the standard airlines response to the "We were fatigued" statement will be "Why were you operating then?"
They treat you like you just signed on from a relaxing overnight in a fully sound proofed 5 star resort/hotel, not where crew get to stay.

[Sunfish]

It appears from reading between the lines in various accident reports and Pprune comments that the ATSB is no longer trusted as an unbiased investigator.

[Buttscratcher]

Sorry to move away from the 'Fatigue' thing, but why doesn't J* allow flex when using that table?
TOGA thrust on a low-ish TOW certainly would be one of the largest contributors to this event.
Seems odd to me that you can't flex.
Perhaps ATSB could have also recommended a 'normal' thrust flex procedure from these tables.

[Cessna Jockey]

Originally Posted by Buttscratcher

Sorry to move away from the 'Fatigue' thing, but why doesn't J* allow flex when using that table?
TOGA thrust on a low-ish TOW certainly would be one of the largest contributors to this event.
Seems odd to me that you can't flex.
Perhaps ATSB could have also recommended a 'normal' thrust flex procedure from these tables.

Its written into OM6 performance manual. Any other method than Flysmart, reduced thrust not permitted

[Ollie Onion]

They do not allow it, in fact the charts are only for Config 3, TOGA and packs off, so all directly contributed to making the miscalculation worse.

[Blueskymine]

You can see exactly how it happened.

She was very spritely during rotation and the speed was trending up to the bricks.

So to stop that, the PF brought the thrust back. The other guy thought WTF and during the chaos, the standard patter was missed. Then they just made some bad decisions (well reactions) during the subsequent events.

EBT is supposed to give good training for this type of event.

I speak from personal experience, but when things are happening, it can take great discipline to prioritise and aviate.

For instance who here has had a slat/flat jam during a go around, received the ecam when you called go round flaps and omitted positive rate, because you were distracted by the ecam? Who then didn’t call gear up because the other guy didn’t call positive rate? I’ll put my hand up.

I trust the crew learnt some great lessons after this event and hope that it’s shared amongst your pilot group.

[Lookleft]

I trust the crew learnt some great lessons after this event and hope that it’s shared amongst your pilot group.

The PIC retired.

This line is really where the problem started :

The operator’s procedures required the flight crew to verify the Flysmart software database version on their electronic flight bag (EFB), and update it if required prior to their first flight of the day. On this occasion, neither flight crew member updated their Flysmart software prior to their first flight of the day despite an updated version being available. I

Tony Kerns has plenty of good advice regarding cockpit discipline. It starts before you even get to the gate. The report also states that despite the incorrect database Flysmart would have come up with valid data so it would seem that the crew just assumed that the EFB was incorrect. Not really covered in the report was the crew were pushing curfew so they were rushing and the clear lesson is that is when mistakes are made.

Finally those speeds just should not have made sense for a 68t takeoff. Similar to the SQ 747 in AKL that tried to rotate at 127kts with a 397t takeoff. To go back to Tony Kerns, know your aircraft.

[wheels_down]

Originally Posted by Lookleft

Finally those speeds just should not have made sense for a 68t takeoff. Similar to the SQ 747 in AKL that tried to rotate at 127kts with a 397t takeoff. To go back to Tony Kerns, know your aircraft.

What about A321?

The 10pm Sydney to Melbourne is a A321. However it was downgraded obviously for some reason prior which explains the aircraft switch.