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A321, vicinity Singapore, 2010
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|On 27 May 2010 an Airbus A321-200 being operated by Australian operator JetStar on a passenger flight from Darwin to Singapore continued an initial approach at destination in day VMC with the aircraft inappropriately configured before a late go around was commenced which was also flown in a configuration contrary to prescribed SOPs. A subsequent second approach proceeded to an uneventful landing. There were no unusual or sudden manoeuvres during the event and no injuries to the occupants.|
|Actual or Potential
|Human Factors, Loss of Control|
|Type of Flight||Public Transport (Passenger)|
|Origin||Darwin International Airport|
|Actual Destination||Singapore Changi Airport|
|Take off Commenced||Yes|
|Flight Phase||Missed Approach|
|Location - Airport|
|Airport||Singapore Changi Airport|
|Tag(s)||Inadequate Aircraft Operator Procedures|
|Tag(s)||Flight Management Error,|
Temporary Control Loss,
Incorrect Aircraft Configuration
|Damage or injury||No|
|Causal Factor Group(s)|
On 27 May 2010 an Airbus A321-200 being operated by Australian operator JetStar on a passenger flight from Darwin to Singapore continued an initial approach at destination in day Visual Meteorological Conditions (VMC) with the aircraft inappropriately configured before a late go around was commenced which was also flown in a configuration contrary to prescribed SOPs. A subsequent second approach proceeded to an uneventful landing. There were no unusual or sudden manoeuvres during the event and no injuries to the occupants.
An Investigation was carried out by the Australian Transport Safety Bureau (ATSB) and recorded flight data was available. It was established that the First Officer had been PF for the sector. As the Instrument Landing System (ILS) LLZ for runway 20R was intercepted as instructed from a radar heading, the PF advised visual with the runway and this condition was retained thereafter. Once on the ILS LLZ, the AP had been disconnected using a method which activated the Master Warning. Shortly afterwards, the aircraft commander became distracted by message tones on his mobile phone and his action to unlock it and switch it off. The PF had to set his own Missed Approach stop altitude on the FCU and at the automated 1000 feet aal Rad Alt callout, neither pilot appeared to be aware that configuration for landing had not been achieved. The Investigation found that in the two minutes which elapsed whilst the aircraft descended (at a normal speed) from 2800 feet to 1000 feet, the following routine actions had not been completed:
- selecting the landing gear down
- selecting the flaps to ‘Config 3’ and then ‘full’
- arming the ground spoilers
- selecting auto brake
- completing the landing checklist
- checking the flight parameters.
This inaction was attributed to a combination of the commanders distraction and failure to monitor, the First Officer’s failure to monitor, which was considered may have been partly due to fatigue after poor pre flight rest and collectively poor Crew Resource Management.
The approach had been continued below 1000 feet aal with no change to configuration and so at 750 feet agl, the Master Warning activated because the landing gear was not down activated. This prompted the commander to select both landing gear down and Config (flaps) 3. However. The gear was still in transit as the aircraft passed 500 feet agl and so Terrain Avoidance and Warning System (TAWS) Mode 4 was annunciated.
Nine seconds later, without any effective intercommunication in the flight deck, the PF initiated a go around during which a minimum height of 392 feet agl was reached. During the initial pitch up, forward movement not subsequently recollected by the commander was recorded for the left hand side stick and this ‘dual control’ was again recorded between 1220 and 1420 feet agl. Two significant initial actions for the go manual go around were not taken - the landing gear was not selected up until called by the PF at 1000 feet and config (flap) 2 was not selected until the aircraft reached 3000 feet. Despite these actions/inactions, the manually-flown missed approach vertical profile was normal until the AP was re-engaged passing 2600 feet. The final report made no specific comment on the non standard aspects of the go around.
The Investigation identified three ‘Contributing Safety Factors’ which were considered to have led to the event:
- The flight crew continued the approach despite not being able to satisfy the operator’s stabilised approach criteria prior to the stipulated 500 ft in visual meteorological conditions.
- A number of distractions during the approach degraded the crew’s situation awareness and resulted in the crew not detecting the incorrect aircraft configuration.
- The Captain did not appropriately monitor the aircraft’s configuration or the actions of the first officer.
Two other ‘Safety Factors’ were also identified:
- The lack of effective intra-crew communication accentuated their loss of situation awareness.
- The First Officer’s decision making was probably affected by fatigue.
The Final Report Aviation Occurrence Investigation AO-2010-035 was published on 19 April 2012. No formal Safety Recommendations were made as a result of the Investigation but Safety Action taken by aircraft operator JetStar in response to the event were noted. These Safety Actions included removing ambivalence from related SOPs and planning the development of improved non-technical pilot training.