Is air safety being served?
Opinion Editorial – Paul Phelan,
Two years and two months ago, a Jetstar Airbus A320 jet laden with unsuspecting passengers was flown to within just four seconds of crashing onto Melbourne’s runway 27 at 165 knots (305 km/hr).
Hopefully we’re describing this entire near-miss in language that’s understandable both to the aviation industry and to its customers, the growing numbers of people who expect aviation to deliver a safe and reliable air transport service that everybody can trust.
The crew of the early morning flight from Christchurch to Melbourne on July 21 2007 had made an instrument approach to Melbourne Airport because the airport was shrouded in fog. Following the published approach procedure to Runway 27 the crew had crew descended to 200 feet above the ground, the minimum “decision height” that is specified for that procedure. At that point if the crew cannot sight the runway they must abandon the approach and initiate a “go-around,” also known in the industry as a ‘missed approach.’
In that situation, a crew would normally advance the power levers to the “takeoff/go-around” (TOGA) position, re-configure the flaps and slats for climb, and after ensuring a positive climb is established, select “gear up” (undercarriage retracted).
Instead, selected information recovered from the digital flight data recorder (DFDR) and published by the Australian Transport Safety Bureau (ATSB) in its preliminary report, shows that the aircraft continued its descent until it reached a height of just 43 feet above the runway, having accelerated to about 165 knots (305 km/hr). At that point the crew reversed the descent, initiated the missed approach procedure, unsuccessfully attempted another ILS (instrument landing system) approach, conducted another missed approach from 200 feet above ground, and diverted to Avalon.
Long before the ATSB’s preliminary report had been published, almost all Australian airline pilots had become aware of the event, made their own enquiries, formed largely accurate conclusions on the causes of the near-accident, and stored the information for future use.
However the ATSB says it was unaware at that time of information that identified the event as an extremely serious one.
The ATSB says it received advice of the event from the company on July 26 2007, which:
“….indicated that the automated systems on board the aircraft did not function correctly, however the crew took manual control and the aircraft performed correctly once they did. On the basis of the information contained in the incident report, the ATSB did not assess that the circumstances met the criteria for a reportable matter under the Transport Safety Investigation Act 2003.”
On August 2, according to the ATSB, Jetstar began its investigation into the incident by examining data that recorded the activation of the enhanced ground proximity warning system (EGPWS) during the first missed approach. However, says the ATSB:
“This additional information was not provided to the ATSB at that time.”
Why not?
It is made clear in the ATSB’s preliminary report, published on October 30 of the same year, that the Bureau only recognised the seriousness of the incident after an electronic media report was published on September 10 2007. The ATSB says it then contacted the operator who provided additional information, which the Bureau assessed as being “of sufficient seriousness to warrant the immediate initiation of an investigation.”
ATSB’s preliminary report said the investigation was continuing and would examine:
- Flight crew [aircraft type] endorsement training
- Flight crew transition and check to line training
- Aircraft operating procedures
- Provision of information to flight crews
- Company reporting procedures
- Aircraft system operation and maintenance.
A few obvious dot points certainly; however it’s almost impossible to imagine how such an examination could take up two years of ATSB’s time without reaching some conclusions that would benefit global air safety – especially when all the data is tabulated, fully available, and quite explicit.
Of the several aspects of these events that disturb industry identities with whom we’ve discussed it, the most concerning is the quality of the information provided to ATSB which caused it to believe the matter was simply a systems failure that resulted in a flawed missed approach that was safely recovered by the crew. Most believe that unless that information had been deliberately deceptive, both ATSB and CASA would have become in involved much earlier, and would have been better informed and more effective.
Another surprise is the mild reaction of both government organisations to the void of information that almost succeeded in diverting any investigation at all. This is in stark contrast to the response of the regulator to similar events, just one of many examples being an incident in which a Yanda Airlines pilot attempted a takeoff with fully-aft elevator trim. The event was further dramatised when the pilot asked her passenger to help hold the nose down by pushing on the elevator control, when all she needed to do was operate the electric trim switch on the control yoke.
CASA media relations person Peter Gibson trumpeted the news that the passengers had been “seconds from death,” and although he didn’t say how many seconds it was probably more than four.
Within days of that event and before the matter had even been fully investigated, CASA was there with all guns blazing. Two days later Assistant Director Terrence Farquharson wrote to the operator saying that “CASA is satisfied that the immediate suspension of your AOC (air operator certificate) was justified based on the serious threat to air safety as a consequence of inadequacy of your training and checking system.”
Despite that outburst, the ATSB (eventually) briefly reported:
The possibility of a mis-set trim was explored and cannot be excluded. The pilot stated that all the appropriate checks before takeoff were carried out. The before-takeoff checks included setting the trim.
A checklist can be viewed in human factors terms as an additional interface between the human and the machine. That interface controls the method and sequence of the aircraft’s configuration. Regardless of the type or method used, the disciplined use of cockpit checklists by pilots is an essential element in flight safety. Distractions and interruptions can break the checklist process and may result in a checklist error or omission. This may be critical in single-pilot operations where the checklist is often the last line of defence against configuration errors. Having ensured that the appropriate training and checking has been carried out, an operator’s safety management is dependent on the degree of discipline and professionalism applied to each phase of the operation by the pilot. (our emphasis)
In that context it’s worth noting that Qantas’ worst-ever near miss, just like the Jetstar, Qantas and Yanda events, was a simple error of judgment or procedure by a pilot. But (notwithstanding Mr Farquharson’s dictum) nobody is suggesting there is any validity in laying human error at the feet of the airline’s training and checking system. And nobody (except possibly CASA) is suggesting that a single human error is reasonable cause for shutting down any airline, large or small.
The purpose of conducting air accident and incident investigations according to ICAO Annex 13 is made clear in every one of its reports:
The object of a safety investigation is to enhance safety. To reduce safety-related risk, ATSB investigations determine and communicate the safety factors related to the transport safety matter being investigated.
It is not the object of an investigation to determine blame or liability. However, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner.
ATSB Deputy Director Julian Walsh assured us four months ago that the report was being circulated to directly interested parties and its publication was expected before the end of June.
We’re left wondering which influence – politics, public service pressures or delaying tactics by interested parties – is now delaying the publication of this report, because further delay is not in the interests of advancing air safety.
And as a footnote, we are aware of at least two recent high-altitude “jet upset” events with another Australian carrier.
Are ATSB and CASA similarly aware? Or are they waiting for the media to break that story too?
Fair enough Paul, and somewhat concerning .. but let’s not forget that a DH (ILS is a precision approach) is different to a minimum … The question RVR remains of course but it’s hardly cause to claim “within just four seconds of crashing” as you do. You are being an alarmist shill!
As a former Boeing 747 training and check captain I believe this is the worst cover up in the history of Australian aviation. Any other airline would have had its Air Operator Certificate suspended immediately – but being a Qantas airline Jetstar were able to exert influence far and beyond what is healthy for aviation safety.
The ONLY difference between a serious incident and an accident is in the result – that is CASA’s own definition of a serious incident. In this case less than four seconds was the difference between over 170 passengers and crew being killed in a fireball at Melbourne Airport – and that event, by the narrowest of margins, not happening. Unless such events are treated as having actually occurred, and investigated as such, the possibility of such a similar event occurring in the future from lessons not learned remains. Rigorous application of that principle is what has made aviation as safe as it is today. It is also CASA and ATSB policy.
If the passengers and crew HAD perished would a Royal Commission have been called? No – as this would not be the correct protocol. However, if a similar accident had occurred in the meantime and it transpired that this serious incident had been covered up with no lessons learned – then a Royal Commission would be fully justified.
It really is that serious, and the public have a right to know.
I was on the flight. I noticed the power spool up and then the runway sighted and thought it was quite close below us. A fleeting glance. Then the fog obscured it again. The rest was handled well. First thought was it was a bugger that the go around was initiated and had to be continued when the runway appeared. Never felt threatened but if it was as close as the data says then let’s get it out in the open. No cover-ups should be allowed. Why has this taken so long to come out?