Jetstar pilots forgot to lower the landing gear

[keithr]

From the SMH

Confused Jetstar pilots forgot to lower the wheels and had to abort a
landing in Singapore just 150 metres above the ground, after the captain
became distracted by his mobile phone, an investigation has found.

The Australian Transport Safety Bureau report on the May 27, 2010
incident on Flight JQ57, from Darwin to Singapore, reconstructed a scene
of cockpit chaos.

The captain, of more than 13,000 hours flying experience, was distracted
by incoming text messages on his phone, while the first officer, of more
than 4000 hours experience, was probably fatigued, the report said.
Advertisement: Story continues below

The pair had lost their "situational awareness", leading to poor
decision-making and hampered communications, investigators found.

The problems aboard JQ57 began when the co-pilot, the first officer,
switched off the autopilot on the 220-seat Airbus A320 to make
preparations to land.

Somewhere between 2500 feet and 2000 feet, the captain's mobile phone
started beeping with incoming text messages, and the captain twice did
not respond to the co-pilot's requests.

The co-pilot looked over and saw the captain "preoccupied with his
mobile phone", investigators said. The captain told investigators he was
trying to unlock the phone to turn it off, after having forgotten to do
so before take-off.

At 1000 feet, the co-pilot scanned the instruments and felt "something
was not quite right" but could not spot what it was.

At this stage the captain still did not realise the landing gear had not
been lowered, and neither pilot went through their landing checklist.

At 720 feet, a cockpit alert flashed and sounded to warn that the wheels
still hadn't been lowered.

At 650 feet, the captain moved the undercarriage lever "instinctively"
but then a "too low" ground-warning alarm sounded as the plane sunk
through 500 feet, indicating the landing gear was not fully extended and
locked.

The co-pilot was confused by the captain's action in lowering the
wheels, as he was getting ready to do quite the opposite — to abort the
landing and re-ascend to the skies, investigators said.

Neither spoke to each other about their intentions.

At 392 feet, the crew aborted the landing and powered up the thrust.

At this time the pilots had lost track of their altitude, thinking they
were much higher, at about 800 feet.

A further piloting error occurred, with the wrong flap setting during
the ascent.

When the mistakes were recreated in a simulator, investigators
determined there were two minutes of descent, from 2800 feet to 1000
feet, where the pilots failed to take any necessary actions, including
putting the wheels down.

Jetstar said it had incorporated the the lessons learned from the
incident in its pilot training.

"Pilot distraction meant all the landing checklist items weren't
completed before the aircraft passed an altitude of 500 feet, at which
point a go-around was required under our operating procedures," said
Jetstar's Chief Pilot, Captain Mark Rindfleish.

"The combination of factors on JQ57 has provided new learnings and the
opportunity to add to these safeguards, which we take very seriously.”

Changes introduced included completing landing checklists before 1000
feet and a reminder to pilots to ensure their mobile phones are switched
off before take-off, he said.

[Rob]

On 20/04/2012 7:40 AM, keithr wrote:
> From the SMH
>
> Confused Jetstar pilots forgot to lower the wheels and had to abort a
> landing in Singapore just 150 metres above the ground, after the captain
> became distracted by his mobile phone, an investigation has found.
>
> The Australian Transport Safety Bureau report on the May 27, 2010
> incident on Flight JQ57, from Darwin to Singapore, reconstructed a scene
> of cockpit chaos.
>
> The captain, of more than 13,000 hours flying experience, was distracted
> by incoming text messages on his phone, while the first officer, of more
> than 4000 hours experience, was probably fatigued, the report said.
> Advertisement: Story continues below
>

You would think that the crew should be more aware of mobile phones and
there regulations aboard aircraft.

Wonder if the captain gets a kick in the bum.

[Petzl]

On Fri, 20 Apr 2012 12:54:44 +1000, Rob <mesa...@google.com> wrote:

>>
>> The captain, of more than 13,000 hours flying experience, was distracted
>> by incoming text messages on his phone, while the first officer, of more
>> than 4000 hours experience, was probably fatigued, the report said.
>> Advertisement: Story continues below
>>
>
>You would think that the crew should be more aware of mobile phones and
>there regulations aboard aircraft.
>
>Wonder if the captain gets a kick in the bum.
>

Wonder why there are no on/off buttons on Mobile phones?
You have to hold a button down for some mystical time before they are
switched off. Not the first time people have tried to turn them off
and it starts playing tunes after?
--
Petzl

[keithr]

On 20/04/2012 12:54 PM, Rob wrote:
> On 20/04/2012 7:40 AM, keithr wrote:
>> From the SMH
>>
>> Confused Jetstar pilots forgot to lower the wheels and had to abort a
>> landing in Singapore just 150 metres above the ground, after the captain
>> became distracted by his mobile phone, an investigation has found.
>>
>> The Australian Transport Safety Bureau report on the May 27, 2010
>> incident on Flight JQ57, from Darwin to Singapore, reconstructed a scene
>> of cockpit chaos.
>>
>> The captain, of more than 13,000 hours flying experience, was distracted
>> by incoming text messages on his phone, while the first officer, of more
>> than 4000 hours experience, was probably fatigued, the report said.
>> Advertisement: Story continues below
>>
>
> You would think that the crew should be more aware of mobile phones and
> there regulations aboard aircraft.
>
> Wonder if the captain gets a kick in the bum.

I believe that Jetstar have amended their SOPs

[Rob]

Mine would be off most of the time.

[Rob]

Lets watch another video!

[AA]

On 20/04/2012 12:54 PM, Rob wrote:

Captain resigned.

[Tudor5]

On Apr 21, 7:19 am, AA <sirronnalaREM...@yahoo.com.au> wrote:
> On 20/04/2012 12:54 PM, Rob wrote:
>
>
>
>
>
>
>
> > On 20/04/2012 7:40 AM, keithr wrote:
> >> From the SMH
>
> >> Confused Jetstar pilots forgot to lower the wheels and had to abort a
> >> landing in Singapore just 150 metres above the ground, after the captain
> >> became distracted by his mobile phone, an investigation has found.

Snip
>
> Captain resigned.

Really !
I wonder if it was jump before push ?

What the press and many folks may miss in this
is the root cause .

I am profoundly disturbed at a few companies policy and attitude to
fatigue management within the industry .
The Phone matter is not in dispute - bloody slack & silly reading
the report .

However, in my book not exactly a sacking offence
Certainly some re programming required on the chaps attitude . But
Many pilots have gone on to be safer & wiser after a "scare"
SOP's I hope now have a check list "confirm Mobile phones etc "are
OFF and secured .

Turning back to fatigue management . The issue is (IMO) not yet
properly understood or addressed by the bean counters
within the industry . Including the Ag and EMS folk As well as GA
( think resources industry drivers)

Aviation Medical folk really need to drive the dangers home to
Government and the industry .

Steps down off soap box -back to lurking

[Sylvia Else]

On 20/04/2012 12:54 PM, Rob wrote:

> On 20/04/2012 7:40 AM, keithr wrote:
>> From the SMH
>>
>> Confused Jetstar pilots forgot to lower the wheels and had to abort a
>> landing in Singapore just 150 metres above the ground, after the captain
>> became distracted by his mobile phone, an investigation has found.
>>
>> The Australian Transport Safety Bureau report on the May 27, 2010
>> incident on Flight JQ57, from Darwin to Singapore, reconstructed a scene
>> of cockpit chaos.
>>
>> The captain, of more than 13,000 hours flying experience, was distracted
>> by incoming text messages on his phone, while the first officer, of more
>> than 4000 hours experience, was probably fatigued, the report said.
>> Advertisement: Story continues below
>>
>
> You would think that the crew should be more aware of mobile phones and
> there regulations aboard aircraft.
>

If pilots could reasonably be expected to just remember to do everything
that needed to be done when operating an aircraft, there'd be no need
for checklists.

From the ATSB report, it appears that it was unusual for the captain to
have had his mobile phone turned on prior to takeoff. It is thus easy to
understand how he'd forget to turn it off in the absence of a specific
prompt. Passengers have the advantage of being told by the cabin crew,
but presumably those announcements are not audible in the cockpit.

One may question the captain's judgement regarding the decision to
attempt to turn the phone off during the descent, rather than just
ignoring it, but it may even have been a reasonable response if the
phone were sufficiently distracting.

It would not surprise me at all if this were not the first case of
cockpit crew discovering during the descent that they've left their
phones on. It's probably just the first where that combined with other
factors to lead to a loss of situational awareness.

Sylvia.

[D Walford]

The phone being on isn't really that much of an issue, the issue is that
the captain decided to attend to the phone during such a critical time,
if he can't workout how to turn off a phone that any 5yr old could work
out in a micro second you have to wonder if he has the technical ability
to be flying the plane in the first place.
I hope he was severely dealt with.


Daryl

[Nick O'Tyme at]

"D Walford" <dwal...@internode.on.net> wrote in message
news:4f920ee6$0$11122$c3e...@news.astraweb.com...

The noise of the phone could have been enough of a distraction at such a
critical time that it warranted being turned off.

Under a high technical workload, the 10-15 seconds or so may have been
enough to fluster the captain. On my phone you have to hold the on / off
button for several seconds, then have to wait to see the closing down screen
before you are sure it has turned off.

I doubt his ability is in question. He wouldn't have been where he was if he
didn't have the ability. His judgment is in question but 20/20 hindsight is
always wonderful and is used extensively by management.

Critics need to place themselves in similar situations before they say what
should be done. We are all human. Something many people seem to forget when
casting stones at other people.

Can any of you really say you have never made a mistake.

[D Walford]

Of course we all make mistakes but most of us don't make them when the
lives of so many people are put at risk.
Once he was aware that the phone was what was the cause of the
distraction he should have just ignored it, getting caught just touching
a mobile phone whilst driving a car earns you a significant penalty and
the risks of doing that are much less than being distracted whilst
landing a large aircraft.
I don't think its a hanging offence but surely a significant penalty
needs to be applied?



Daryl

[Paul Saccani]

On Sat, 21 Apr 2012 11:35:24 +1000, D Walford
<dwal...@internode.on.net> wrote:

>The phone being on isn't really that much of an issue, the issue is that
>the captain decided to attend to the phone during such a critical time,
>if he can't workout how to turn off a phone that any 5yr old could work
>out in a micro second you have to wonder if he has the technical ability
>to be flying the plane in the first place.
>I hope he was severely dealt with.

As many mobiles can both turn themselves on and off - EG, Nokia 3300
classic, I find the reference to a five year old uncalled for. They
can also say that they are shuting down, appear to shut down, but not
shut down.
Cheers,

Paul Saccani,
Perth,
Western Australia

[D Walford]

On 21/04/2012 2:42 PM, Paul Saccani wrote:
> On Sat, 21 Apr 2012 11:35:24 +1000, D Walford
> <dwal...@internode.on.net> wrote:
>
>> The phone being on isn't really that much of an issue, the issue is that
>> the captain decided to attend to the phone during such a critical time,
>> if he can't workout how to turn off a phone that any 5yr old could work
>> out in a micro second you have to wonder if he has the technical ability
>> to be flying the plane in the first place.
>> I hope he was severely dealt with.
>
> As many mobiles can both turn themselves on and off - EG, Nokia 3300
> classic, I find the reference to a five year old uncalled for.

I should have said 2yr old, phones just aren't that complicated, a
friends 2yr old grandson can operate his fathers iphone.

They
> can also say that they are shuting down, appear to shut down, but not
> shut down.

Which isn't relevant, he was distracted at a critical time by a simple
to use device that could have easily been ignored, doing so whilst
driving a car could cause you to loose your license so what penalty did
the pilot receive if any?


Daryl

[Nick O'Tyme at]

"D Walford" <dwal...@internode.on.net> wrote in message

news:4f92453b$0$29975$c3e8da3$5496...@news.astraweb.com...

Perhaps the message tone sounded like a tone generated by one of the a/c
systems. Who knows.

And in the heat of the moment, people can do all kind of things which when
looked at later, even the perpetrator says "what the hell was I thinking". I
know, I've been there.

You shouldn't judge until you know all the facts and I doubt if any one in
this group knows all the facts.

[D Walford]

What I find interesting is everyone's willingness to defend the pilot
yet most are very quick to condemn car drivers who commit a similar
offence which is unlikely to have consequences anywhere near as
catastrophic.


Daryl

[Nick O'Tyme at]

"D Walford" <dwal...@internode.on.net> wrote in message

news:4f92635f$0$1667$c3e8da3$7649...@news.astraweb.com...

I try not to condemn anyone because I too am human.

[Cees Binkhorst]

I notice that nobody raises the silence between the pilots, whereas they
should have been talking about their actions and observations.

Regards / Cees

[Clocky]

Everybody seems to be concentrating on the mobile phone message sounds which
could have been ignored during such an important stage of flight (in fact
it's almost a red herring it's that silly) when the whole story seems to be
pointing to a comedy of errors to the point of incompetence.

[Rob]

lets put it another way why are people compelled to answer phones, why
do we rush to answer phones, why do we take notice of any ring peep or
buzzer?

Just a question on aircraft mode on the mobile phone what does it do??

[Brad]

It is supposed to turn off the radio functions in the phone.

[D Walford]

Disconnects the phone from the network, in flight mode you can't make or
receive calls or connect to the internet via the phone system.


Daryl

[Paul Saccani]

On Sat, 21 Apr 2012 17:35:49 +1000, D Walford
<dwal...@internode.on.net> wrote:

>> Perhaps the message tone sounded like a tone generated by one of the a/c
>> systems. Who knows.
>>
>> And in the heat of the moment, people can do all kind of things which
>> when looked at later, even the perpetrator says "what the hell was I
>> thinking". I know, I've been there.
>>
>> You shouldn't judge until you know all the facts and I doubt if any one
>> in this group knows all the facts.
>>
>>
>What I find interesting is everyone's willingness to defend the pilot

You clearly have a lot to learn about human factors.

You will see many people here wanting to find out what the facts are
before making a judgement, and you will find those same people will
criticise those who don't have access to the facts and are quick to
rush to judgement, whilst compartively very inexperienced.

That you interpret criticism of your remarks as a defence of "the
pilot" is all down to you.

When you have more experience, you may change your views and be much
less hasty to judge, and more aware of the fact that a human being has
limitiations, just as a piece of metal does.

You would then focus on constructing an effective defence against a
similar incident, instead of finding someone to blame and leaving the
situation to be repeated.

There does seem to be a strong inverse co-relation between
aeronautical experience and willingness to condemn aircrew wtih
cursory evaluations.

>yet most are very quick to condemn car drivers who commit a similar
>offence which is unlikely to have consequences anywhere near as
>catastrophic.

What a load of bull - find me these people that condemn car drivers
for turning their mobile phone off. Find me legislation that says
that you can not turn a mobile phone off when driving a car.

[Paul Saccani]

On Sun, 22 Apr 2012 09:52:14 +1000, Rob <mesa...@google.com> wrote:

>lets put it another way why are people compelled to answer phones, why
>do we rush to answer phones, why do we take notice of any ring peep or
>buzzer?

Such sounds are often used in transport catagory aircraft as the sole
warning of quite a few dangerous conditions.

They can be quite distracting, especially if identical to tones
generated by the aircraft systems.

>Just a question on aircraft mode on the mobile phone what does it do??

It shuts down the transceiver used on the mobile network. Usually
bluetooth transceivers are left active.

[Paul Saccani]

On Sun, 22 Apr 2012 07:41:41 +0800, "Clocky" <not...@happen.com>
wrote:

>Everybody seems to be concentrating on the mobile phone message sounds which
>could have been ignored during such an important stage of flight (in fact
>it's almost a red herring it's that silly)

Have you considered the possibility that ignoring tones which might be
used by the aircraft systems to warn of dangers is not actually such a
smart idea?

There are ring tones and message tones which are identical to aircraft
system annunciations, eg

"whoop-whoop", "whoop-whoop pull up", "whoop-whoop terrain terrain
pull up", "Be-Bop Be-Bop Windshear Windshear"

See, for instance,
http://www.hark.com/clips/ksxmyycrsr-whoop-whoop-pull-up

and go down the page for quite a long list of systems tones and
annuciations used as tones on phones.

Or
http://www.phonezoo.com/ringtone/33243608/whoop-whoop-pull-up-crj-900.htm

Or
http://www.atcbox.com/modules.php?name=html-ringtones


There are also a number of standard tones which are identical to
system tones.

Vibrate alerts can also be mistaken for system tones, such as
overspeed warnings, or even for a "stick shake".

But hey, lets just ignore it all and carry on - what could possibly go
wrong.....

>when the whole story seems to be
>pointing to a comedy of errors to the point of incompetence.

Humans have limitations - it is well to remember this.

I would like to think that if I was in that situation, I would have
simply done a go around, sorted out the issue and made a new
approach, rather than try to carry on after being distracted. And
then reported the issue.

But as I am a human, it is not a given.

[Paul Saccani]

On Sat, 21 Apr 2012 15:27:13 +1000, D Walford

<dwal...@internode.on.net> wrote:

>On 21/04/2012 2:42 PM, Paul Saccani wrote:
>> On Sat, 21 Apr 2012 11:35:24 +1000, D Walford
>> <dwal...@internode.on.net> wrote:
>>
>>> The phone being on isn't really that much of an issue, the issue is that
>>> the captain decided to attend to the phone during such a critical time,
>>> if he can't workout how to turn off a phone that any 5yr old could work
>>> out in a micro second you have to wonder if he has the technical ability
>>> to be flying the plane in the first place.
>>> I hope he was severely dealt with.
>>
>> As many mobiles can both turn themselves on and off - EG, Nokia 3300
>> classic, I find the reference to a five year old uncalled for.
>
>I should have said 2yr old, phones just aren't that complicated, a
>friends 2yr old grandson can operate his fathers iphone.

Well, no, you shouldn't say that, because if you did, it would
indicate that you failed to learn anything. It would also indicate
that you are not able to think logicially.

I find it interesting indeed that you think that a 2 year old can
knowingly turn an iphone off (as opposed to "soft-off), and know the
difference between a soft-off and a power off.

> They
>> can also say that they are shuting down, appear to shut down, but not
>> shut down.
>
>Which isn't relevant,

Oh, so you reckon that a phone that says it is shuting down, appears
to shut down but does not shut down is not relevent to shutting a
phone down.

You have a rather peculier notion of relevency.

> he was distracted at a critical time by a simple
>to use device that could have easily been ignored,
> doing so whilst
>driving a car could cause you to loose your license so what penalty did
>the pilot receive if any?

Again, an irrational and illogical comment. You have no reason to
believe that it could be easily ignored, you don't know what it was
doing - you simply choose to assume that it is so. Nor is what you
can or can not do in cars relevent in the slightest.

Again, an indication of your peculiar notion of relevancy.

But not to worry, that's just a normal human factor.

[Rob]

The first wasn't related to any industry but a general question as to
why people respond to a phone, why do they have the compulsion to answer it.

[keithr]

Would it not seem a bit stupid for a pilot to use those ringtones,
especially if they don't bother to turn the phone off in flight.

[Nick O'Tyme at]

"Rob" <mesa...@google.com> wrote in message
news:jn016i$5uq$1...@dont-email.me...

Phones are a communications device. When they ring it usually means someone
wants to communicate with you. Answering is what you are supposed to do.

[D Walford]

Nothing to do with anyone's "aeronautical experience", assuming the
media report is correct (and that is never a given) then the fact that
he allowed himself to become distracted at such a critical time is
reasonable cause to question his competence.

>
>> yet most are very quick to condemn car drivers who commit a similar
>> offence which is unlikely to have consequences anywhere near as
>> catastrophic.
>
> What a load of bull - find me these people that condemn car drivers
> for turning their mobile phone off.

I suppose TV or radio journalists don't really qualify as people, you
don't have to listen all that often to hear it.
Jon Faine on ABC radio in Melb is particularly condemning as its one of
his pet subjects.

Find me legislation that says
> that you can not turn a mobile phone off when driving a car.
>

In all Australian States just touching a mobile phone whilst driving
(including whilst stationery) will earn you a fine plus loss of points,
you don't have to be making a call so attempting to either turn the
phone off or on whilst driving is an offence.
http://www.vicroads.vic.gov.au/Home/SafetyAndRules/SafetyIssues/MobilePhonesAndDriving.htm



Daryl

[D Walford]

On 22/04/2012 1:41 PM, Paul Saccani wrote:
> On Sat, 21 Apr 2012 15:27:13 +1000, D Walford
> <dwal...@internode.on.net> wrote:
>
>> On 21/04/2012 2:42 PM, Paul Saccani wrote:
>>> On Sat, 21 Apr 2012 11:35:24 +1000, D Walford
>>> <dwal...@internode.on.net> wrote:
>>>
>>>> The phone being on isn't really that much of an issue, the issue is that
>>>> the captain decided to attend to the phone during such a critical time,
>>>> if he can't workout how to turn off a phone that any 5yr old could work
>>>> out in a micro second you have to wonder if he has the technical ability
>>>> to be flying the plane in the first place.
>>>> I hope he was severely dealt with.
>>>
>>> As many mobiles can both turn themselves on and off - EG, Nokia 3300
>>> classic, I find the reference to a five year old uncalled for.
>>
>> I should have said 2yr old, phones just aren't that complicated, a
>> friends 2yr old grandson can operate his fathers iphone.
>
> Well, no, you shouldn't say that, because if you did, it would
> indicate that you failed to learn anything. It would also indicate
> that you are not able to think logicially.
>
> I find it interesting indeed that you think that a 2 year old can
> knowingly turn an iphone off (as opposed to "soft-off), and know the
> difference between a soft-off and a power off.

I don't need to "think" a 2yr old can turn an iphone on and off because
I have have seen him do it, not only that after he turned it on he found
his favourite game and started playing it, I didn't believe myself until
I saw him do it.
Just to stay slightly on topic the little boys father is a LAME:-)

Daryl

[Paul Saccani]

On Sun, 22 Apr 2012 17:18:47 +1000, D Walford
<dwal...@internode.on.net> wrote:

>> There does seem to be a strong inverse co-relation between
>> aeronautical experience and willingness to condemn aircrew wtih
>> cursory evaluations.
>
>Nothing to do with anyone's "aeronautical experience", assuming the
>media report is correct (and that is never a given) then the fact that
>he allowed himself to become distracted at such a critical time is
>reasonable cause to question his competence.

QED.

>>> yet most are very quick to condemn car drivers who commit a similar
>>> offence which is unlikely to have consequences anywhere near as
>>> catastrophic.
>>
>> What a load of bull - find me these people that condemn car drivers
>> for turning their mobile phone off.
>
>I suppose TV or radio journalists don't really qualify as people, you
>don't have to listen all that often to hear it.

Are they defending pilots?

>Jon Faine on ABC radio in Melb is particularly condemning as its one of
>his pet subjects.

So, you assert that they condemn people for turning their mobile
phones off. I doubt that this is factual. But not being a Victorian,
I am not in a position to know what these fellows are saying.

> Find me legislation that says
>> that you can not turn a mobile phone off when driving a car.
>>
>In all Australian States just touching a mobile phone whilst driving
>(including whilst stationery) will earn you a fine plus loss of points,

No it won't.

>you don't have to be making a call so attempting to either turn the
>phone off or on whilst driving is an offence.
>http://www.vicroads.vic.gov.au/Home/SafetyAndRules/SafetyIssues/MobilePhonesAndDriving.htm

First off, that is not a law.

Secondly, it contains errors of fact in relation to what the laws
actually are.

Now, in Victoria, section 300(c) of the road safety rules defines
turning a mobile phone off as using a mobile phone - so far so good
for your case, but this is not a uniform rule across the states, which
is why your claim fails. In WA, you are expresselly allowed to touch
*and* use a mobile phone under some defined circumstances, for
instance.

Then, in the same rules, section 300(a) provides an exeception,
allowing a driver to hold a mobile phone. (which kind of needs you to
touch it)

Proving my case - You are wrong to state that "In all Australian

States just touching a mobile phone whilst driving (including whilst

stationery) will earn you a fine plus loss of points", because that is
not the case in Victoria, which is an Australian state, as it happens.

I trust you do not interpret these remarks as hostile to you, becauset
hat is certainlly not their intent.

[Paul Saccani]

On Sun, 22 Apr 2012 17:25:34 +1000, D Walford

Knowingly turn off - as opposed to soft off. Seeing him do it and
having him knowingly do so are different things.

Turning it off and then turning it on in order to play a game does not
suggest an abilty to operate the phone. And are you confusing soft
off with power off?

[Tim McQueen]

>> The first wasn't related to any industry but a general question as to
>> why people respond to a phone, why do they have the compulsion to
>> answer it.
>
> Phones are a communications device. When they ring it usually means
> someone wants to communicate with you. Answering is what you are
> supposed to do.

Yes, but at your convenience, not necessarily the callers.

When you hear an unanswered ringing phone just say to yourself 'thank
goodness the telephone wasn't invented by Alexander Graham SIREN!'

--
Cheers,

Tim

[D Walford]

No.
The phone was powered off, his father must have shown him how to do it,
its quite amazing how quickly and easily very small children learn.


Daryl

[D Walford]

You are welcome to test that in Vic., please be prepared to either pay a
fine or spend a lot of time and money defending the case in court
because there is no doubt you will be fined if caught.
BTW I don't agree with the rule but that's the way it seems to be
interpreted by the Police and most of the population.

> I trust you do not interpret these remarks as hostile to you, becauset
> hat is certainlly not their intent.
>

OK.


Daryl

[D Walford]

On 23/04/2012 4:00 PM, Tim McQueen wrote:
>
>>> The first wasn't related to any industry but a general question as to
>>> why people respond to a phone, why do they have the compulsion to
>>> answer it.
>>
>> Phones are a communications device. When they ring it usually means
>> someone wants to communicate with you. Answering is what you are
>> supposed to do.
>
> Yes, but at your convenience, not necessarily the callers.

Seems many people are hard wired to answer when another person wants to
communicate with them.
I've noticed people who spend a lot of time on the phone are able to
ignore their phones possibly because its the only way they can get any
work done but many people including me who don't receive many calls feel
compelled to answer immediately.

>
> When you hear an unanswered ringing phone just say to yourself 'thank
> goodness the telephone wasn't invented by Alexander Graham SIREN!'
>

LOL.


Daryl

[Rob]

On 23/04/2012 4:00 PM, Tim McQueen wrote:
>

I say - if its important they will ring back.

[Paul Saccani]

Logically, there is no reason for me to test it at all. It is up to
you to prove your point, once an objection is lodged, and all the more
so when that objection is backed by specific reference to legislation.

So, again, I caution you that you are not thinking rationally.

[David Lesher]

Further, the phone making noise easily can disrupt your
processing of the Jetstar's alerts.

ISTM the bigger issue is the flying pilot's fatigue & failure to
declare a go-round far sooner. If something feels wonky, declare
a missed approach & try again
--
A host is a host from coast to coast.................wb8foz@nrk.com
& no one will talk to a host that's close........[v].(301) 56-LINUX
Unless the host (that isn't close).........................pob 1433
is busy, hung or dead....................................20915-1433

[Paul Saccani]

On Sun, 22 Apr 2012 15:08:32 +1000, keithr <kei...@nowhere.com.au>
wrote:

>> There are also a number of standard tones which are identical to
>> system tones.
>>
>> Vibrate alerts can also be mistaken for system tones, such as
>> overspeed warnings, or even for a "stick shake".
>
>
>Would it not seem a bit stupid for a pilot to use those ringtones,
>especially if they don't bother to turn the phone off in flight.

It may very well seem that way, but that is a human performance
limitation, is it not? The fact is, many pilots find them amusing and
a conversation starter - and we aren't talking about "bother to turn
the phone off", we are tallking about either doing so unsuccessfully,
or forgeting to do so

I certainly concede that it doesn't sound like a choice that you would
want to explain to the coroner.

However, no such situation exists with the vibrate alert functions,
which are an innocent choice.

And, as always, we find the case where a number of small factors can
add up to a big problem if they all happen at the same time.

I don't think "just ignore the phone" is the right stategy, unless you
have a strong safety reason to land "right now". The appoach should
be aborted, the phone turned off, composure regained, and the before
landing checklist done again.

Human performance limitations have to be accepted, rather than simply
ignored as the "just ignore it" people would have it. Maybe this
situation should be included in the simulator from time to time,
rather than pretend it will never happen or simply blame someone if it
does. A developed procedure for what to do, so that thinking about it
at a high workload time would be helpful, though of course, there are
other higher risk scenarios queing for simulator time.

[Paul Saccani]

Again, how do you explain a competent operator turning the phone off
in order to play a game?

A competant operator would not turn the phone off and then on in order
to play a game, would they?

[veritas]

On 27/04/2012 2:52 PM, Paul Saccani wrote:
> On Mon, 23 Apr 2012 16:19:11 +1000, D Walford
> <dwal...@internode.on.net> wrote:
>
>>>> I don't need to "think" a 2yr old can turn an iphone on and off because
>>>> I have have seen him do it, not only that after he turned it on he found
>>>> his favourite game and started playing it, I didn't believe myself until
>>>> I saw him do it.
>>>
>>> Knowingly turn off - as opposed to soft off. Seeing him do it and
>>> having him knowingly do so are different things.
>>>
>>> Turning it off and then turning it on in order to play a game does not
>>> suggest an abilty to operate the phone. And are you confusing soft
>>> off with power off?
>>>
>> No.
>> The phone was powered off, his father must have shown him how to do it,
>> its quite amazing how quickly and easily very small children learn.

At the age of 3, one of my sons used to turn the 'poota' on (240v) at
the back of the set wait for the <C:/>, then type <DIR> then copy the
name of his favourite game (as spelled on the directory) and hit <ENT>.

The little turds can do it - for sure! Watching his older brothers
helped, I suspect.

[D Walford]

Very true, they learn at an amazing rate.


Daryl

[Tudor5]

Bugger it :(
Don't know what has happened to this forum .

Perhaps folks just do not read the ATSB before launching into
theories

So here it is in full

Abstract
At 1845 Singapore Time on 27 May 2010, an Airbus A321-231, registered
VH-VWW and operating as Jetstar flight JQ57, was undertaking a landing
at Singapore Changi International Airport. The aircraft was not in the
correct landing configuration by 500 ft height above the aerodrome
and, as required by the operator's procedures in the case of an
unstable approach, the crew carried out a missed approach.
The investigation identified several events on the flight deck during
the approach that distracted the crew to the point where their
situation awareness was lost, decision making was affected and
inter-crew communication degraded. In addition, it was established
that the first officer's performance was probably adversely affected
by fatigue.
The investigation did not identify any organisational or systemic
issues that might adversely impact the future safety of aviation
operations. However, following this occurrence, the aircraft operator
proactively reviewed its procedures and made a number of amendments to
its training regime and other enhancements to its operation.
FACTUAL INFORMATION
At 1422 Singapore Time1 on 27 May 2010, an Airbus A321-231 aircraft
(A320), registered VH-VWW and operating as Jetstar flight JQ57,
departed Darwin Airport, Northern Territory on a scheduled service to
Singapore Changi International Airport. The first officer (FO) was the
pilot flying (PF) and the captain was the pilot not flying (PNF) for
the sector.
The aircraft was at the top of descent for an Instrument Landing
System2 (ILS) approach at about 1840. Singapore Air Traffic Control
(ATC) issued an approach clearance to runway (RWY) 20R and radar
vectored3 the aircraft to the north to avoid thunderstorm activity to
the east and west of the airport.
ATC then issued a series of step-down descent clearances and
instructions to reduce the aircraft's speed in order to manage traffic
separation and arrivals at the airport. The FO requested the captain
to activate the approach phase before the FO selected 'managed speed'4
and progressively decelerated the aircraft to 160 kts and selected
Flap 2.
At this point, ATC instructed the flight crew to descend to 2,500 ft
above mean sea level (AMSL) and to turn onto a heading of 230° to
intercept the localizer (LLZ) for RWY 20R. The FO complied and the
aircraft was cleared for the approach. On intercept with the LLZ, the
FO reported 'becoming visual' to the captain and the crew commented on
the density of buildings and lights in residential Singapore. The
captain recalled that after becoming visual with the runway, they were
able to remain visual for the rest of the approach.
The captain reported going 'heads out' at that time and focussing
outside the aircraft. This is permitted and encouraged in the
operator's procedures; however, the procedure emphasises that constant
monitoring of the aircraft's performance and flightpath is essential.
Once established on the LLZ, the FO disconnected the autopilot (A/P).
The recorded data indicated that a master warning (MW) continuous
chime was activated for 6 seconds, coincident with the A/P
disconnection. An Electronic Centralised Aircraft Monitor (ECAM)5 AUTO
FLT A/P OFF message was activated and remained displayed on the Engine/
Warnings Display (E/WD) monitor. The FO stated that he believed the
ECAM message was activated by his not pushing the Sidestick Takeover
Push Button twice within 1.5 seconds.6 Neither pilot remembered the MW
continuous chime.
Somewhere between 2,500 ft and 2,000 ft in the descent, the crew heard
noises associated with incoming text messages on the captain's mobile
phone. The FO requested that a missed approach altitude of 5,000 ft be
set into the Flight Control Unit (FCU)7 and, after not getting a
response from the captain, repeated the request. The FO stated that he
attempted to use the 'RAISE'8 method from the operator's Operations
Manual to communicate with the captain.
The FO recalled that, after still not getting a response from the
captain, he looked over and, on seeing the captain preoccupied with
his mobile phone, set the missed approach altitude himself. The
captain stated that he was in the process of unlocking and turning off
his mobile phone at that time and did not hear the call for the missed
approach altitude to be set in the FCU.
Shortly after, the captain alerted the FO to the ECAM message 'AUTO
FLT A/P OFF'. The FO requested the captain to clear the ECAM message
and stated that he found the captain bringing it to his attention
distracting.
Both pilots stated that they heard the automated height call of 'one
thousand' that was generated by the Flight Warning Computer via the
radar altimeter (RADALT)9, and signified the aircraft's descent
through 1,000 ft. The FO indicated that at this point, it was his
usual practice to perform a visual scan of the cockpit
instrumentation. He further stated that he felt 'something was not
quite right' but could not identify what it was.
The captain reported that he did notice that the landing gear was
still up and that the flaps were at 'Config 2' (Flap Configuration 2).
He also stated that he was not maintaining a focus on the stable
approach criteria (see the subsequent section titled Stabilised
approach criteria) as he was the PNF. Neither crew member initiated
the landing checklist.
At 720 ft RADALT, a MW and associated continuous triple chime for
'Landing Gear Configuration' activated.10 The FO stated that, on
hearing that warning, he noted a red light in the landing gear lever
and an ECAM message 'LG not DN' displayed on the E/WD. In combination,
that signified that the landing gear had not been selected down.
At about 650 ft RADALT, or 4.5 seconds after the commencement of the
master warning chime, the landing gear was selected down. At 503 ft
RADALT, or about 7 seconds after the landing gear was selected down, a
'Config 3' selection was made by the crew. The captain stated that he
'instinctively' reached out and selected gear down and 'Config 3' upon
hearing the master warning.
The FO reported feeling 'confused' by the captain's action, as he was
preparing to conduct a go-around. Neither the captain nor the FO
communicated their intentions at that time.
At 1843.31, eleven seconds after the landing gear was selected down, a
'Too Low Gear' Enhanced Ground Proximity Warning System (EGPWS) alarm
sounded. That signified that the aircraft had descended below 500 ft
RADALT with the landing gear still not secured in the down position
(the landing gear was still in transit to the down position at that
time).
At 1843.40, the flight crew commenced a go-around. The FO made the
standard 'go around flap' call and selected Take Off/Go-Around power
on the thrust levers, initiating an automated go-round procedure. The
recorded data showed an initial pitch-up command, consistent with the
commencement of the go-around, at 392 ft. Both crew stated that they
were unaware of the minimum height reached before the aircraft
climbed, but believed that they initiated the go-around just below 800
ft RADALT.
The initial nose-up pitch coincided with about 4 seconds of forward
movement on the captain's side stick. Two seconds later, forward
movement of the captain's side stick was applied for a further
8 seconds. A radio transmission was made during that time.
The captain recalled resting his hand on the side stick during the
approach but does not recall applying any pressure to the side stick
or making any side stick inputs. The captain reported using the radio
transmit switch on the side stick to inform ATC that the aircraft was
going around. In response, ATC cleared the aircraft to maintain runway
heading and to climb to 3,000 ft.
The captain stated that he thought he had selected 'Config 2' at the
commencement of the go-around as per the 'go-around flap' command and
the FO recalled seeing 'Flap 2' selected on the flaps lever. The
recorded data showed that 'Config 3' remained selected until the
aircraft was above 3,000 ft.
At 1,000 ft, the FO called for 'gear up', which was set by the
captain. The FO engaged the autopilot at about 2,600 ft and, after a
series of left turns, the aircraft was established on a second ILS
approach for RWY 20R. A plot of the recorded data is at Appendix A.
The flight crew discussed the occurrence with the Duty Captain by
telephone at about 1930 that night. The Duty Captain attempted to
determine the crew's fitness for duty and whether they were happy to
continue their duty. The possibility of the crew being tired was
raised; however, based on the information provided by the crew, there
was no indication of their being fatigued. The crew resumed duty and
flew the next sector from Singapore to Darwin. The captain acted as
the PF and the FO as PNF for that sector.
Personnel information
Captain
The captain held an Air Transport Pilot (Aeroplane) Licence (ATPL(A))
and was type rated on the A320. He held a current medical certificate
and instrument rating and had about 13,431 hours total flying
experience.
The captain had flown the A320 since 2005 before moving to the A330 on
27 March 2007. In March 2008, the captain required additional training
before completing his line check. In September 2008, the captain
experienced difficulty in a simulator check flight and, after
discussions with the operator's management, decided to return to the
A320.
All of the captain's subsequent training had been completed to a
satisfactory standard.
First officer
The FO held an ATPL(A), was type rated on the A320 and held a current
medical certificate and instrument rating. He had 4,097 hours total
flying experience and had flown the A320 since May 2008.
Aircraft information
There was no evidence that the aircraft or its systems were a factor
in the occurrence.
Meteorological information
The Aerodrome Forecast (TAF) for the flight's arrival predicted a wind
from 170 °(T) at 8 kts, visibility greater than 10 km, Few11
cumulonimbus clouds with a base of 1,800 ft and Scattered cloud with a
base of 2,000 ft. Temporary deteriorations in the conditions were
forecast for not more than 1 hour with visibility reducing to 3,000 m,
scattered thunderstorms and rain with associated cloud base 1,500 ft,
and Broken cloud base 1,800 ft.
Both pilots stated that the weather had been good but that, on
commencing descent into Singapore, they were required to deviate from
the planned flightpath due to thunderstorm activity. Once clear of
that activity, they were able to proceed to the initial approach fix
and commence an ILS approach.
Weather was not considered to be a factor in the occurrence.
Tests and research
The occurrence flight was recreated by the operator's senior check and
training pilots in a simulator using the recorded flight data. That
simulation was observed by Australian Transport Safety Bureau (ATSB)
investigators.
During the simulation, the differences between the standard autopilot
disconnect and the non-standard disconnect applied in this instance
were examined. The ECAM messages and associated audio and visual
warnings were noted and found to align with the recorded data.
The simulator session also identified a period of about 2 minutes
between about 2,800 ft and 1,000 ft in the descent where no control
manipulations or systems activation was recorded. In contrast, during
that period, a number of tasks should have normally been completed in
preparation for landing, including:
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.
The completion of those items in the simulator ensured that the
aircraft was configured and stabilised by 1,000 ft.
Organisational and management information
Use of the autopilot and automation
The Airbus A320 is designed to be flown using the autopilot and the
aircraft's other automated systems. Aircraft manufacturers and
operators have developed a number of procedures and standard calls to
ensure that both pilots maintain awareness of their aircraft's mode
and flightpath.
In general terms, those procedures can be divided into two categories:
aircraft configuration, in this case the Approach and Landing
Configuration
approach procedures, which in this instance changed from an ILS to a
visual approach due to the PF calling 'visual procedures' on descent.
Prior to the approach phase, crews gather information on the most
appropriate approach. Normally an approach commences from 3,000 ft,
with the aircraft's speed reducing to the minimum clean speed12 before
intercepting the glideslope. From that point, the wing flaps are
extended progressively13 to the required landing setting and the
landing gear is selected down.
The operator's policy on the use of automation stipulates the
disengagement of an aircraft's automated systems only if the relevant
system's performance becomes inaccurate, unclear or inappropriate.14
There was no indication that the aircraft's systems were a factor in
the occurrence.
The Airbus A320 Flight Crew Operating Manual (FCOM) stated that the
autopilot disengaged advisory on the ECAM, and associated audio and
visual warnings, only appeared if the autopilot was disengaged by a
means other than by pressing the takeover push button on the side
stick. The recorded data showed that the autopilot was disconnected by
forward movement of the side stick.
ILS approach standard operating procedures
The standard calls and procedures for application during an ILS
approach are based on each crew member having specific tasks, either
as the PF or the PNF. According to the operator's Operations Manual,
the PF controls the aircraft through the flight controls or autopilot
and the PNF monitors the PF, actions items and assists with other
duties at specific times or when requested by the PF. Both pilots are
required to monitor the aircraft's progress and ensure the correct
aircraft configuration at each phase of flight. The PF is responsible
for initiating the landing checklist.
Stabilised approach criteria
The Flight Safety Foundation has been at the forefront in the
development of a series of stabilised approach criteria in response to
a number of hard landing, runway overrun or other approach and landing
accidents.15 Some of the contributing factors in those accidents and
incidents have included:
excessive speed
incorrect flaps configuration
a rushed approach resulting in crew overload or task shedding
high rates of descent which were not able to be corrected.
In essence, an approach is considered 'stabilised' if the aircraft is
on the correct lateral and vertical flightpath and is in the desired
landing configuration; all flight parameters such as airspeed, pitch
attitude, bank angle, and so on are in limits; and the landing
checklist has been completed. Not below heights for the attainment of
those criteria are set at 1,000 ft for an approach in instrument
meteorological conditions (IMC) and 500 ft when in visual
meteorological conditions (VMC).
If the pre-determined criteria were not satisfied at the stipulated
altitude, crews were required to carry out a missed approach.
The operator's Operations Manual 1 - Administration, section 6.4.11
titled Stable approach stated that:
The final landing flap selection shall normally be made prior to
reaching 1000 ft height above airport (HAA). All approaches should be
fully configured and stabilised by 1000 ft HAA in both IMC and VMC.
However the following limits below must be adhered to:
* In VMC, if the approach is not stable by 500 ft HAA, a go-around
must be initiated.
Portable electronic devices policy
The operator's policy on portable electronic devices was laid down in
Operations Manual 1 - Administration and required crew to follow the
same procedures as affected passengers. That was, devices such as
mobile phones were permitted for use in-flight once the seat belt sign
was extinguished after takeoff only if 'Flight Mode' (non-
transmitting) was selected prior to flight, and only until top of
descent.
The captain stated that after the crew finished their flight planning
duties in Darwin and proceeded to the aircraft, he received a phone
call from the airline's operations group informing him of a change in
the weather at Singapore and that he would need to take on more fuel.
The captain reported that he kept his phone turned on while in the
cockpit at Darwin in case operations needed to contact him again.
Prior to departure, he unintentionally omitted to turn the phone off
and, during the approach, a number of messages were received from a
Singapore mobile phone service provider.
Phone records showed that there were no texts sent or answered by the
captain during the approach. Inquiries with the captain's Australian
mobile phone service provider determined that messages sent to and
received by a phone from another network would not be recorded by the
other provider. Similarly, no record of those messages was kept by the
Australian provider. By the time the captain was interviewed as part
of this investigation, he had erased the messages from his phone.
The investigation was unable to obtain the exact timings of the mobile
phone messages.
Monitoring
The operator's procedures required all crew members to be aware of the
PF's intentions with respect to an approach and to ensure that any
diversions from procedures, air traffic clearances or the intended
flightpath were immediately drawn to the PF's attention.16 Also, as
part of the operator's stabilised approach criteria, the PNF was
required to monitor the approach path, rate of descent and airspeed to
ensure that they remained within specific tolerances during an
approach. The PNF was required to immediately notify the PF of any
excursions and both pilots were to monitor the approach.
Additional information
Fatigue management
Fatigue management was used by the operator to mitigate any crew
fatigue-related issues. In this case, the pilots had operated a flight
to Darwin, arriving at about 0030 Singapore Time that morning. Both
had spent their rest period in a hotel in Darwin, which was used by
the airline operator for crew accommodation. The crew had checked into
the hotel at 0100.
The captain stated that he felt well rested prior to commencing duty
that day but had been woken twice at about 0630 and 0830 by fire alarm
tests.
The FO reported going to sleep at about 0130 on the morning of the
occurrence and being woken by a phone call from housekeeping at about
0430. He had dozed until getting up at 0630 to go for a jog and did
not get any other sleep prior to crew sign on at 1315.
The FO stated that he did not feel tired or fatigued before the
flight. However, he reported feeling tired on descent into Singapore
and that he disengaged the autopilot during the approach in order to
hand-fly the aircraft and 'wake [him] up'. During the return flight to
Darwin, the FO had two periods of controlled rest.17
Both pilots reported having attended fatigue risk management training
and felt satisfied that they were able to judge their own level of
fatigue and fitness in respect of being able to perform their duties.
Both crew reported having adequate sleep in the 72 hours prior to the
commencement of their duty period.
The organisation's fatigue management system and the crew's rosters,
fatigue biomathematical model figures and sleep histories were
examined to assess the crew's level of fatigue. That examination
determined no issues in relation to crew fatigue prior to the
commencement of the duty period on 26 May 2010. However, following
commencement of this duty period, the FO's rest period between
operating the Darwin and Singapore sectors on 27 May 2010 was
interrupted, and the FO did not avail himself fully of the rest
opportunity.
Distraction and prospective memory
Situation Awareness is a human perceptual state in which information
is gained from the environment through a number of processes. These
processes are generally agreed to be the perception of environmental
elements, the comprehension of their meaning and the projection of the
consequences for their status of a change in a variable (such as time).
18
Prospective memory can be defined as the intention to perform an
action in the future, coupled with a delay between recognising the
need for that action and the opportunity for its performance.19 A
distinguishing feature of prospective memory is the need for an
individual to remember that they need to remember something.
ANALYSIS
Stable approach criteria
The incorrect aircraft configuration approaching 500 ft in visual
meteorological conditions meant that the operator's stable approach
criteria were not satisfied and that it was appropriate for the flight
crew to initiate a go-around. The 'Landing Gear Configuration' and
enhanced ground proximity warning system 'Too Low Gear' alerts
activated correctly to signal the circumstances of the aircraft.
The effects of a number of cockpit distractions combined with fatigue
to adversely affect the first officer's (FO) configuration of the
aircraft for the approach and landing. Normally, it could be expected
that the captain, as the pilot not flying (PNF), would have been
monitoring the situation and have intervened to correct the situation.
Monitoring
The lack of effective monitoring by the captain meant that the non-
standard disconnection of the autopilot by the FO, and 'AUTO FLT A/P
OFF' alert on the Electronic Centralised Aircraft Monitor (ECAM)
remained undetected until later in the approach. Once visual with the
runway, the captain's focus external to the aircraft also adversely
affected his monitoring role.
The mobile phone messages acted to compound the captain's distraction
from the monitoring and support roles during the latter stages of the
approach. That would likely explain the captain's inaction when asked
by the FO to set the missed approach altitude and the captain's report
that he did not hear the FO's requests for that support.
Distraction and prospective memory
Air traffic control's request to slow the aircraft earlier in the
approach than anticipated, the discussion by the crew of the Singapore
skyline, the receipt of the text messages and the late detection of
the autopilot-related ECAM alert distracted the crew. That distraction
degraded their situation awareness to the extent that they did not
identify the incorrect aircraft configuration. These actions, coupled
with a lack of effective monitoring by both crew and the FO's fatigue,
appear to have impacted their prospective memory. As a result, the
landing checklist and gear down procedure were intended but missed.
These omissions are an indication of a loss of stage-two situation
awareness: comprehension, and stage-three situation awareness:
projection. That would explain the crew not returning to the relevant
checklist and satisfactorily configuring the aircraft for the approach
and landing.
Fatigue and decision making
The FO's reported tiredness at the top of descent was probably due to
his disrupted sleep on the night before the flight. The lack of any
additional sleep prior to signing on for duty increased the risk of
fatigue, with the result that his decision making abilities would be
adversely affected and that any distraction might impact his normal
duties. That included his appropriately configuring the aircraft for
landing.
The FO's less than ideal interaction with the captain during the
approach, which would have been exacerbated by the FO's level of
fatigue, further degraded his situation awareness and decision making.
Rather than attempting to wake himself up by disengaging the autopilot
and manually flying the approach, the FO may have been better prepared
for the approach had he attempted to take a nap prior to signing on,
or availed himself of controlled rest during the flight to Singapore.
Despite the disruptions to his sleep, there appeared to be adequate
opportunity for the FO to take the rest he required to operate the
aircraft the next day. The organisational aspects of fatigue
management did not appear to materially contribute to the issue of
fatigue.
Crew resource management
The receipt of the text messages on the captain's phone, and the
retrospective action by the captain to bring the autopilot
disconnection ECAM to the FO's attention, distracted the FO to the
extent that the existing crew resource management effectively broke
down. That would explain the captain not setting the missed approach
altitude when asked by the FO; the FO, as the PF, not anticipating the
necessary changes in the aircraft's configuration; the omission by the
FO to initiate the landing checklist; and the non-standard
communication between both crew members.
The maintenance of effective crew resource management would have
increased the likelihood of the crew maintaining situation awareness
and completing the approach in accordance with the operator's standard
operating procedures. Had that been the case, it is highly unlikely
that the occurrence would have taken place.
FINDINGS
From the evidence available, the following findings are made with
respect to the incorrect aircraft configuration occurrence at
Singapore Changi International Airport on 27 May 2010 involving an
Airbus A321-231 aircraft, registered VH-VWW. They should not be read
as apportioning blame or liability to any particular organisation or
individual.
Contributing safety factors
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.
Other safety factors
The lack of effective intra-crew communication accentuated their loss
of situation awareness.
The first officer's decision making was probably affected by fatigue.
SAFETY ACTION
The Australian Transport Safety Bureau (ATSB) expects that all safety
issues identified by the investigation should be addressed by the
relevant organisation(s). In addressing those issues, the ATSB prefers
to encourage relevant organisation(s) to proactively initiate safety
action, rather than to issue formal safety recommendations or safety
advisory notices.
The investigation did not identify any organisational or systemic
issues that might adversely impact the future safety of aviation
operations. However, the following proactive safety action was
advised.
Jetstar
In response to this incident and its own investigation, Jetstar
advised that it has:
Reviewed its stable approach criteria and amended the relevant text in
its operations manual from 'should be fully configured by 1,000 ft
Height Above Airport (HAA)' to 'must be fully configured by 1,000 ft
HAA'.
Stipulated that landing checklists are to be completed by 1,000 ft
HAA.
Committed to a review of its stabilised approach reference landing
checklist.
Arranged to develop a crew resource management training video for
inclusion in its training program. The video will use this incident as
an example, emphasise crew complacency as a key threat, and examine
the precursors for any complacency within regular public transport
operations.
Committed to redesigning its training system to include a:
remedial process for poor non-technical performance,
system for ensuring that the non-technical aspects of flight crew
training are tailored on an individual basis.
Enacted quarterly reviews by the standards department of all pilots'
non-technical scores. Pilots with sub-standard scores will have peer
review and feedback sessions and remedial training will be conducted
as required on a case-by-case basis.
Arranged for the development of a human factors (HF) training video
that will be incorporated into the 2012 HF recurrent training program.
SOURCES AND SUBMISSIONS
Sources of information
The main sources of information during the investigation included:
the flight crew
the aircraft operator
the Bureau of Meteorology
Singapore Air Traffic Control.
Submissions
Under Part 4, Division 2 (Investigation Reports), Section 26 of the
Transport Safety Investigation Act 2003 (the Act), the Australian
Transport Safety Bureau (ATSB) may provide a draft report, on a
confidential basis, to any person whom the ATSB considers appropriate.
Section 26 (1) (a) of the Act allows a person receiving a draft report
to make submissions to the ATSB about the draft report.
A draft of this report was provided to the aircraft operator, the
flight crew, the Air Accident Investigation Branch of Singapore and
the Civil Aviation Safety Authority.
Submissions were received from the aircraft operator, the Air Accident
Investigation Branch of Singapore and the first officer. The
submissions were reviewed and where considered appropriate, the text
of the report was amended accordingly.
The Air Accident Investigation Branch of Singapore submission included
the following suggested change in Analysis section Distraction and
Prospective memory:
Remove 'Air traffic control's request to slow the aircraft earlier
than anticipated, the'.
As it could be interpreted as either that air traffic control should
have requested the slow down later, or it is a distraction from the
point of view of the crew alone during a period of high workload.
The ATSB did not consider that the section could be misconstrued and
this section of the report was not amended.