ScareAsia the normalised deficient airline of Australasia?
Via the ATSB website:
Quote:What happened
On the evening of 19 February 2016, an Airbus A320 aircraft, registered PK-AXY and operated by PT Indonesia AirAsia was on a scheduled passenger service from Denpasar, Indonesia to Perth, Australia. During cruise, the captain’s flight management and guidance computer (FMGC1) failed. Due to the failure, the flight crew elected to use the first officer’s duplicate systems. For the aircraft’s arrival in Perth there was moderate to severe turbulence forecast below 3,000 ft with reports of windshear. The crew commenced an instrument landing system (ILS) approach to runway 21.
During the approach, the flight crew made a number of flight mode changes and autopilot selections, normal for an ILS approach with all aircraft operating systems available. However, some of those flight modes and autopilot selections relied on data from the failed FMGC1 and the autothrust system commanded increased engine thrust. The crew did not expect this engine response and elected to conduct a go-around. With an increasing crosswind on runway 21, the crew accepted a change of runway, to conduct a non-precision instrument approach to runway 06.
With the time available, the first officer programmed the new approach into his FMGC and conducted the approach briefing. During this period, the captain hand flew the aircraft and manually controlled the thrust. During the approach to runway 06, the crew descended the aircraft earlier than normal, but believed that they were on the correct flight path profile.
While descending, both flight crew became concerned that they could not visually identify the runway, and focused their attention outside the aircraft. At about that time, the approach controller received a “below minimum safe altitude” warning for the aircraft. The controller alerted the crew of their low altitude and instructed them to conduct a go-around. The crew then conducted another approach to runway 06 and landed.
What the ATSB found
The ATSB identified that the flight crew were unsuccessful in resolving the failure of the FMGC and had a limited understanding of how the failure affected the aircraft’s automation during the ILS approach. This resulted in the unexpected increase in engine thrust, which prompted a go-around.
The flight crew had a significant increase in workload due to the unresolved system failures, the conduct of a go-around and subsequent runway change. This, combined with the crew’s unfamiliarity and preparation for the runway 06 instrument approach, meant they did not effectively manage the descent during that approach.
The flight crew’s focus of attention outside the aircraft distracted them during a critical stage of flight. The crew did not detect that they had descended the aircraft below the specified segment minimum safe altitude.
The flight crew commenced their descent for the second runway 06 instrument approach later than normal, initially necessitating an increased rate of descent and at 300 ft the engine thrust reduced briefly to idle.
Safety message
Handling of approach to land is one of the ATSB’s SafetyWatch priorities. Unexpected events during the approach and landing can substantially increase what is often a high workload period. Adherence to standard operating procedures and correctly monitoring the aircraft and approach parameters provides assurance that the instrument approach can be safely completed. A go-around should be immediately carried out if the approach becomes unstable or the landing runway cannot be identified from the minimum descent altitude or missed approach point.
https://www.atsb.gov.au/media/5773855/ao..._final.pdf
AAI & the implications of bureaucratic O&O - Part II
And from HVH:
ATSB Chief Commissioner Greg Hood said that the approach to land is one of the most critical phases of flight, and stressed the importance of flight crews understanding their aircraft systems and adhering to cockpit control, monitoring and communication procedures to ensure a stabilised approach during the approach and landing phases of flight.
“The approach and landing phases of flight are amongst the highest of workload for flight crews, and domestically and internationally where we see the highest accident rate” Mr Hood said. “It’s a complex operation at the best of times, but when something unexpected occurs such as a failure of an aircraft system in-flight, it can add substantially to flight crews’ workload. It is critical that flight crew fully understand their aircraft systems and how they will respond in a degraded mode, and adhere to cockpit protocols and procedures to ensure a stabilised approach resulting in a safe landing. In this case, there was considerable added complexity for the flight crew as a result of adverse weather, and an air traffic control change to a runway without a precision approach.”
“The ATSB urges all flight crew to ensure that they understand their aircraft systems, and how the aircraft will respond in a degraded mode, and to adhere to cockpit protocols and procedures to ensure a safe approach and landing. If there’s any doubt or confusion, or if the stable approach criteria is not being met, communicate it, and never hesitate to conduct a go-around.”
WTD? - HVH now a Guru on Airline CRM & Human factors
Also a summary from Annabel, via the Oz:
Perth airport told ‘distracted’ air crew to go around
An Air Asia A320 was sent around for a second go after approaching too low.
The Australian 12:00AM January 17, 2018
ANNABEL HEPWORTH
Aviation Editor Sydney
@HepworthAnnabel
Australia’s aviation safety investigator has urged flight crews and airlines to pay extra attention to the risks of runway approaches after it said an Indonesia AirAsia flight crew was “distracted” during a critical stage of a flight into Perth.
In its report into the “serious” incident in February 2016, where the Indonesia AirAsia Airbus A320 flew too low on approach to Perth, the Australian Transport Safety Bureau found the flight crew “did not detect that they had descended the aircraft below the specified segment minimum safe altitude”.
The radar at air traffic control showed a “minimum safe altitude warning” and the controller told the crew: “Go round, you are low, low altitude alert, go round.” The crew then did another approach to the runway and landed safely.
In a statement, ATSB chief commissioner Greg Hood urged all flight crew “to ensure that they understand their aircraft systems, and how the aircraft will respond in a degraded mode, and to adhere to cockpit protocols and procedures”.
According to the ATSB report, as the plane was cruising from Denpasar on the holiday island of Bali and was just over an hour from Perth, it became apparent the captain’s flight management and guidance computer had failed.
The crew decided to use the first officer’s duplicate systems and started an approach to Perth’s main runway, but relied on data from the failed computer.
The crew was “unsuccessful” in resolving the failure of the computer and had a “limited understanding” of how the failure affected the aircraft’s automation during the approach, the ATSB found.
This led to an unexpected increase in engine thrust, prompting a go-around.
After this, because of an increasing crosswind, the crew was told to change runway for a non-precision instrument approach. While descending, crew members were concerned they could not see the runway and focused their attention outside the plane. About then, the controller got the altitude warning.
The ATSB found the flight crew had a “significant increase” in workload because of the unresolved system failures, go-around and runway change. Combined with the crew’s “unfamiliarity and preparation” for the instrument approach to the different runway, this “meant they did not effectively manage the descent during that approach”.
AirAsia Indonesia said in a statement yesterday that it had taken action.
This included an internal investigation and briefing of all pilots on its findings and the ATSB findings, and reviewing recovery procedures. As well, there were additional classroom sessions on aircraft technical review and the incident had been incorporated as a subject of the “special orientation training” in the simulator syllabus.
“AirAsia Indonesia reiterates that strict maintenance schedules and robust management systems are in place to monitor and prevent similar incidents from reoccurring,” the statement said.
Q/ Have ScairAsia managed to capture CASA?
I guess in hindsight it was no worse than this other A320 approach incident...
Distracted Jetstar pilots forgot to deploy landing gear, ATSB finds
April 20, 2012 by
australianaviation.com.au
A file image of A321 VH-VWW. (Andy McWatters)
A Jetstar Airbus A321 was forced to abort landing in Singapore in 2010 after both the crew forgot to extend the landing gear in time, according to an ATSB report.
The report said the captain was distracted by his mobile phone during the aircraft’s descent while the first officer
was likely suffering from fatigue.
Jetstar said it had made several training changes as a result of the May 27 2010 episode, including requiring pilots to turn off their mobile phones as part of pre-flight checks. The airline also doubled to 1000ft the altitude at which pilots must finish their pre-landing checks.
Flight JQ57 landed safety on the second attempt, and Jetstar claims the incident had not posed a serious safety risk. Still, the ATSB narrative makes for some interesting reading.
According to the report, the first officer, who was the pilot flying the A321, VH-VWW, during the aborted landing, had gotten less than six hours sleep the night before in Darwin and began feeling tired as the flight approached Singapore around 6:30pm. The report said the first officer disengaged the autopilot during approach to Singapore’s Changi Airport “in order to hand-fly the aircraft and ‘wake [himself] up’.”
As the flight approached 2000ft, the crew heard a series of incoming text messages arrive on the captain’s mobile phone, which he’d forgotten to switch off. Around the same time, the first officer twice asked the captain to set a missed approach altitude into the flight control unit. Not receiving a response, he looked over to find the captain “preoccupied with his mobile phone” and set the missed approach altitude himself.
The captain told investigators that he was attempting to unlock and switch off his mobile phone at the time and did not hear the first officer’s requests.
As the flight descended below 1000ft the first officer reported feeling that “something was not quite right” but couldn’t identify what it was. The captain told investigators that he noticed the landing gear had not been lowered and that the flaps had not been set for landing but did not say anything.
At 720ft, a Master Warning and continuous triple chime alerted the pilots that the landing gear had not been extended. The captain told investigators that he “instinctively” lowered the landing gear and deployed the flaps after the warning chime went off, though the report said it took 4.5 seconds until the landing gear was selected down and more than 11 seconds before the flaps were selected. The first officer, meanwhile, reported that he was “confused” by the captain’s actions as he was preparing to conduct a go-around.
A few seconds later, another alarm went off warning that the aircraft had descended below 500ft with the landing gear still not secured in the down position, at which point the crew aborted the landing and commenced a go-around. Both pilots told investigators that they believed they had initiated the go-around at an altitude of just under 800ft, though the investigation found that it had in fact commenced at 392ft.
“The investigation identified several events on the flightdeck during the approach that distracted the crew to the point where their situation awareness was lost,” the ATSB concluded. “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.”
But the investigation did not identify any “organisational or systemic issues” and said the crew had been given adequate rest time prior to the flight.
..."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.”
But the investigation did not identify any “organisational or systemic issues” and said the crew had been given adequate rest time prior to the flight...
Q/ Wonder if fatigue was examined in the ScairAsia occurrence?
ANS/ Yes it was apparently - "...
The flight crew reported feeling alert during the approaches. The ATSB reviewed their flight and duty times and 72-hour history prior to the occurrence, and found no evidence that they were likely to be affected by fatigue at the time of the incident..."
Hmm...gotta wonder though about the veracity of that statement, especially after the systemic failures of CASA and the ATSB to properly attribute fatigue as a significant causal/contributing factor in the VH-NGA ditching?
MTF...P2