[Peetwo]

TICK TOCK goes the Miniscule clock??

Running along the ever more critical theme - i.e. Closing the safety loop - there was released from the ATSB today

Aircraft loading events involving VH-VWT, Airbus A321, Melbourne Airport, Vic. on 29 October 2015 and VH-VQG, Airbus A320, Brisbane Airport, Qld on 19 October 2015

 
Investigation number: AO-2015-139
Investigation status: Active
 

• Summary
  

Summary
On 29 October 2015, an Airbus A321, registered VH-VWT and operated by Jetstar Airways (Jetstar), was scheduled to conduct a passenger flight from Melbourne, Victoria, to Perth, Western Australia. During the take-off roll, the pilot flying noticed that the aircraft was nose-heavy and required an almost full aft control input to raise the aircraft’s nose. Once airborne, the flight crew requested the cabin crew to confirm the passenger numbers and seating locations. The flight crew re-entered the updated information into the flight management computer and identified that the aircraft was outside the aircraft’s loading limits for take-off and landing. Passengers were relocated within the aircraft cabin to return the aircraft to within allowable limits for the remainder of the flight and landing.
Ten days earlier, an Airbus A320, registered VH-VQG and being operated by Jetstar, was being prepared for a scheduled passenger flight from Brisbane, Queensland, to Melbourne. During the passenger boarding process, the flight crew were advised of a discrepancy at the passenger check-in, and that 12 passengers were still to board the aircraft. A short time later, the flight crew were advised that the issue had been resolved, and they were given final passenger numbers.

During the flight to Melbourne, the flight crew requested the cabin crew to confirm the total number of passengers on board the aircraft. The passenger count in the cabin suggested that the aircraft departed Brisbane with 16 more passengers than advised, and the aircraft was about 1,328 kg heavier than the take-off weight used to calculate the take-off and landing data for the flight. The crew recalculated the aircraft’s landing data prior to the descent into Melbourne.

The ATSB has commenced an investigation into these two aircraft loading events, which will include:

• interviews with the flight and ground operations crews
  
• a review of the Jetstar internal procedures regarding aircraft loading
  
• a review of preventative- and recovery-type risk controls for aircraft loading.
  

_________________

The information contained in this web update is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this web update. As such, no analysis or findings are included in this update. 



 

Which was diligently caught and reported on, with updates, by Ben Sandilands...

Two serious Jetstar incidents under ATSB investigation

Ben Sandilands | Dec 04, 2015 8:27AM |


A Jetstar A321, a jet so badly loaded at Melbourne in October it struggled to get airborne

After an unexplained delay two incidents involving Jetstar domestic flights in October are being investigated by the ATSB, with one of them placing a jet equipped with more than 215 seats in grave danger.

On 19 October a Jetstar A32o left Brisbane for Melbourne with 16 more passengers on board than advised, meaning the aircraft was about 1,328 kg heavier than the take-off weight used to calculate the take-off and landing data for the flight.

On 29 October a Jetstar A321 was found to be so nose heavy during the take off roll from Melbourne bound for Perth that it required an almost full aft control input to raise the aircraft’s noses and become airborne.

It is understood that Jetstar promptly reported both incidents to the ATSB.

The flight had been dispatched with incorrect load information in its flight management computer which placed the jet outside its loading limits for take-off and landing.

This was an incident that could have ended in a fireball killing hundreds of people. It is almost inconceivable that an Australian airline, under the diligent oversight of its safety regulator CASA, could place so many people at risk through such a fundamental failure of basic operational procedures.

Both incidents are grounds for an urgent inquiry into the fitness of Jetstar to continue to hold an air operator certificate, and the appointment of an independent audit into the capacity of CASA to discharge its obligations to maintain air safety standards in this country.

Tiger Airways was grounded by CASA in 2011 for busting the minimum safe altitude over houses in Leopold near Geelong (as well as ignoring repeated safety warnings from the regulator).

The risks Tiger posed to air safety in Australia were however manifestly less than those evidenced in these and earlier serious incidents involving Jetstar. For an Australian licensed carrier to be dispatching jets before knowing how many passengers were on board, thus invalidating critical performance calculations on a flight by flight basis is one very serious matter.

But the discovery mid take off that a jet, an A321, was so dangerously loaded that it was almost uncontrollable, is a warning to the Australian government, and its dysfunctional safety regulator, as well as to anyone thinking of flying Jetstar, that there is something profoundly wrong in the management and operating culture of this airline.

You couldn’t make up worse scenarios for the operations of a scheduled mainline airline than those that played out in these incidents.

It is important also to get an explanation as to why their notification to the ATSB seems to have taken so long. Integrity in the reporting of safety incidents is a critical element in airline safety in the developed world.

The ATSB notifications of these incidents are about as blunt as any in recent years and can be read in full here.

Jetstar responds:
A spokesperson for Jetstar says “We’re investigating these events and working closely with the ATSB to assist with its inquiries.

“Since these incidents took place in October, we have put additional measures in place to check our flights have been loaded correctly and that aircraft weight and balance is properly accounted for.

“We’ve had no flights operate with this type of error since we introduced these measures.”

CASA responds:
CASA has begun its own investigation into the two Jetstar passenger loading incidents.
This investigation is looking at the root causes of the passenger loading errors, relevant systems and processes and Jetstar’s subsequent actions.

CASA’s investigation is running parallel to the investigation being conducted by the Australian Transport Safety Bureau and focusses on regulatory compliance and ongoing safety of flight.

The travelling public can be assured CASA will take all appropriate actions to ensure Jetstar has robust and appropriate systems and processes in place to ensure passenger loading mistakes are not made.

CASA is oversighting the changes Jetstar have made in relation to passenger loading and aircraft weight and balance following the October incidents.

From ABC World Today program:

Jetstar investigated by aviation safety and regulatory authorities over passenger loading issues


Will Ockenden reported this story on Friday, December 4, 2015 12:20:01
About JW Player 6.11.4923 (Ads edition)
 

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Transcript available shortly.

KIM LANDERS: Budget airline Jetstar is facing investigations from two aviation safety and regulatory bodies after making serious mistakes about the number of passengers on flights.


In one October flight, passengers were asked to move after takeoff to rebalance the plane.

In another flight that month, the plane ended up with more passengers than expected, making it too heavy.

While both flights landed safely, aviation commentators and experts say it could have resulted in disaster.

Will Ockenden reports.

WILL OCKENDEN: It was supposed to be a routine flight on the 19th October from Brisbane to Melbourne. But at some point, it dawned upon the Jetstar flight and cabin crew that something was wrong.

After a head count of passengers, it was discovered that 16 more people were on the plane than was thought at take-off, meaning it was 1,300kg heavier than expected.

BEN SANDILANDS: These are really serious investigations.

WILL OCKENDEN: That's Ben Sandilands, an aviation writer and commentator for the crikey.com.au blog, Plane Talking.

He says the other incident, 10 days later on the 29th October, was far more serious.

BEN SANDILANDS: A Jetstar flight to Perth actually really struggled to take off from Melbourne airport at all. It was very nose heavy, clearly had gone too far down the runway to stop and that could have been a very serious incident.

WILL OCKENDEN: The Australian Transport Safety Bureau says it's investigating both incidents to find out how the so-called "aircraft loading event" occurred.

It's classified the incidents as "serious".

Ben Sandilands agrees.

BEN SANDILANDS: They moved people around on the flight so that they could land in the proper configuration in Perth. On the other incident, which was a Brisbane to Melbourne flight, they were out by more than, well, almost two tonnes in the weights and balances on the aircraft and so they had to adjust their landing calculations for Melbourne.

WILL OCKENDEN: They're supposed to do this before they take off. Is there any indication why those checks weren't done?

BEN SANDILANDS: None whatsoever. What is extraordinary and I've been talking to a number of pilots this morning who just cannot believe that something that is fundamental to a small tier country airline service could be messed up so badly by a scheduled airline.

It is beyond belief that an airline in Australia would push back and begin a flight without actually knowing how many people were really on board and indeed the other elements of the calculations as to where they were seated.

That's fundamental. That is the sort of stuff that airlines stopped making a mess of back in the 1950s and 1940s.

WILL OCKENDEN: The Australian Transport Safety Bureau (ATSB) isn't the only one looking into this matter.

The aviation regulator, that's the Civil Aviation Safety Authority, or CASA has taken the unusual step of running its own investigation in parallel to the ATSB.

Peter Gibson is from CASA.

PETER GIBSON: We, of course, as the regulator, as the safety regulator need to look at immediate safety issues, be satisfied that they've been dealt with, that the causal factors have been understood by the airline and that the airline has taken the appropriate actions.

So that's why you've got two parallel investigations.

WILL OCKENDEN: What could be the outcome of a CASA investigation?

PETER GIBSON: Well, we're making sure most importantly that Jetstar is putting in place changes that will ensure these sorts of mistakes aren't made again.

WILL OCKENDEN: Both the aviation regulator and the safety investigator say they are scrutinising Jetstar systems.

Professor Jason Middleton from the School of Aviation at the University of New South Wales says if there's a systemic failure it needs to be fixed.

JASON MIDDLETON: It is a, potentially, a major safety problem because even if the discrepancy is small, the safety problem is, in itself that incident is not a problem, but the system which has allowed there to be an error, if systems are allowed to sort of stay in an error prone fashion then that potentially opens the door to a much bigger problem.

WILL OCKENDEN: A spokesman for Jetstar says the airline is working closely with the ATSB.

The spokesman says since the incidents in October, the airline has already made changes to properly account for the correct loading of passengers and to ensure the aircraft's weight is correct.

KIM LANDERS: Will Ockenden reporting.

Wake up Jeff...err Wazza - sheesh


MTF..P2

P666 - No surprise with this incident. Ever since LCC operations started here in Australia - VA, JQ and TT, there have been myriads of load, weight, out of trim issues reported to CAsA. Many more than in the day of the duopoly of QF and AN. CAsA slapped together a minimal inefficient ground ops team in 2009 from memory, but not enough has been done. I've said for years that it wouldn't surprise me that if one day we have a narrow body accident caused by a load control mistake, 4 tonne ULD not locked down or a general bugger up such as unreported GSE contact with an airframe or a cargo door not properly closed.


The fact that the crew of this flight allegedly had to pull the stick back fully on rotation and knew that she was way out of trim is serious shit. One day it won't get off the ground.



Meanwhile CAsA are too busy pinging pilots for having their caps on crooked, or they are too busy heading to Montreal for 5 star rorts.



TICK TOCK indeed Miniscule