Jetstar plane 'came within 38 feet of hitting ground'

"Investigators found Jetstar had changed the standard flying procedures without conducting a risk assessment into what effect the changes might have". And the changes were risky indeed. Worse: Jetstar covered the near-crash up! It was only media questions that got the matter into the light of day! Amazing arrogance and negligence

Distracted pilots of a Jetstar plane carrying 138 passengers came within 38 feet of hitting the ground during an aborted landing attempt in heavy fog at Melbourne Airport, Australia's transport safety watchdog has found. In its final report on the 2007 incident released today, the Australian Transport Safety Bureau said the New Zealand-to-Melbourne flight was in its last stages of landing with its wheels down when the pilots decided to abort the landing because of low visibility.

The pilots intended to ascend and reattempt the landing but that's when it all went wrong. A number of factors including pilot error; problems with the flight computers and controls; the distraction of unexpected alarms; and untested changes of pilots' standard procedures saw the plane come close to the ground before aborting, the report said.

The drama unfolded rapidly after the pilot in command incorrectly initiated procedures to handle aborted landings (so-called "go-arounds") by not properly moving the the thrust levers to the "take-off/go-around" position, ATSB investigators found. "That led to crew confusion, which was compounded by alerts and warnings that distracted them; the end result was a higher-than-normal and unexpected workload, and the crew being unaware of the aircraft's current flight mode," the report said.

As a consequence, the flight computers did not switch to the ascent mode and the other air crew did not know what programmed mode the plane was in. The autopilot was still trying to land the plane.

Jetstar's change-of-pilot procedures meant the pilots were distracted from realising the plane wasn't climbing because they had to tick off other items first, the report found. The plane continued to descend to 11.5 metres, setting off a number of alarms. The pilots frantically tried to comprehend a barrage of alarms sounding in the cockpit warning the ground was fast approaching. The pilot in command switched off the autopilot and wrestled the plane back into the sky. It failed to land on a second attempt and was sent by air traffic control to land at Avalon without further incident.

The drama occurred on a Jetstar flight JQ156 from Christchurch to Melbourne on July 21, 2007. Investigators found Jetstar had changed the standard flying procedures without conducting a risk assessment into what effect the changes might have. Jetstar also failed to meet incident-reporting requirements of its safety systems or of the Transport Safety Investigation Act, including not notifying the authorities that the plane's ground-warning alert had sounded and tardy reporting of the incident.

Because Jetstar did not report a ground alert had been triggered, the safety bureau initially decided there was no need to investigate. An internal Jetstar investigation found the ground-warning alarm had been triggered, but still the company did not report this to the bureau as required. A bureau investigation was launched months later only after inquiries from the media into the incident.

As a result of the investigation, Jetstar has changed its go-around procedure to reflect what the aircraft manufacturer, Airbus, recommends. Jetstar has changed it aborted-landing procedures and is reviewing its flight procedures and incident-reporting requirements, the investigators say.

The Australian and International Pilots Association said Jetstar had some questions to answer. "The pilots concerned reported the event however Jetstar management has chosen not to report it to CASA [Civil Aviation Safety Authority] or the ATSB," said the association's president Captain Barry Jackson. "This event was only made known to the ATSB by media speculation, not an ideal way to find out. The obvious question now is what other events have not been reported?"

He said it appeared Jetstar had not followed its own operation's manual over safety reporting. "There seems to be some inconsistencies throughout the Qantas Group and this is not acceptable. Jetstar, Qantas and Qantaslink are all part of the Qantas Group and the same reporting procedures should be in place," Captain Jackson said.

Jetstar yesterday issued a short statement saying it was "pleased" the safety bureau was now satisfied with the company's actions, and that the lessons learned from the incident had been implemented by the airline and aircraft manufacturer.

SOURCE