|
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. |
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. 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! |
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? |
More ticking more tocking
waren9
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. 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 |
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. |
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! |
Wasn't there a law passed a while back saying you had to have 1500hrs for a rhs? Did that go through yet?
|
Not quite the same, but seems to be similar circumstances with low time-on-type issues.
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. |
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 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. |
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. 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::ok:
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.:ugh: 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! |
Deleted. Thread was moved.
|
Don't get me started. QF has always got away with far to much with what used to be BASI and now CASA, I had no idea it had spread to the joey. :ugh:
|
This quote taken from one of Ben's reader comments is spot on (hope he doesn't mind if it is borrowed):
“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. “ This more than highlights, I think, the reasoning or 'Risk Management used in today's LCC! As gobbledock puts it "tick..tock". |
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 :sad:), 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.:eek: Two cents poorer, Icarus |
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. |
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. |
Don't blame the media, they didn't recruit and train the cadet.
The kid nearly killed everyone and was obviously not qualified to be there. Get over it! |
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 |
Ah. . . sorry mate, what did I say to disagree with you ? ? :ugh:
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 ? |
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:
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 |
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. |
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. :{:{:ugh::ugh: :sad: ps, i include myself in the collective "your". |
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................. |
Not a pilot, but a question starting from this quote:
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. |
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.
|
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? |
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. |
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!:hmm: It can be done quicker but to put cadets straight into a A320?:rolleyes::ugh::ugh::ugh: [esp with some Captains:ooh:] |
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... |
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. |
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.
|
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. :ugh: |
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.:hmm: |
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? |
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 := |
-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? |
My understanding was that 'Boganair' was a reference to the crew, not passengers. For Bogans in the back- surely Tiger holds the title. Certainly how they are perceived in Asia.
|
| All times are GMT. The time now is 10:57. |
Copyright © 2024 MH Sub I, LLC dba Internet Brands. All rights reserved. Use of this site indicates your consent to the Terms of Use.