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On 12 October 2014, the flight crew operating a Qantas Airways B737 aircraft, registered VH‑XZI, were preparing for the approach and landing into Adelaide, South Australia. The captain was the pilot flying (PF) and the first officer was the pilot monitoring (PM).

The PM calculated the expected landing weight (LW) and after obtaining confirmation from the PF that his calculations were valid, he entered this figure into the aircraft gross weight (Gross WT) section of the approach reference page. However, a figure of 52 tonne (T) had been inadvertently entered instead of the predicted LW of 62 T. The flight management computer calculated the flap speed schedule and the landing reference speed (Vref), based on this lower weight.

At about 1,500 ft above mean sea level the captain disconnected the autopilot and hand flew the remainder of the approach and landing. During the approach, the PM made a verbal reference about the airspeed being ‘wrong’, however the PF reported he did not clearly hear what the PM had said, nor did he understand what message the PM was trying to convey. All the instrumentation presented to him looked normal, so he continued to focus on aircraft flight path management.

The PM reported he had advised the PF that the speed was wrong and had also announced the correct speed to be flown. When he noticed the PF advance the power (which was in response to the gusty conditions) he thought the PF had responded to his call. However the aircraft landed 7.5° nose pitch up; whereas normal was 3.5-3.75° nose pitch up. There were no injuries and no damage to the aircraft.

Action taken by Qantas

As a result of this incident, the new operating procedures will include an item requiring the PM to compare the landing weight entered into the Approach Reference page during descent preparation, with the load sheet estimated landing weight.

An ATSB research study titled Take-off performance calculated and entry errors: A global perspective is a research paper which focused on such incidents and accidents in the 20 years prior to 2009. A consistent aspect was the apparent inability of flight crew to perform ‘reasonableness checks’ to determine when parameters were inappropriate for the flight.


Aviation Short Investigations Bulletin - Issue 42

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General details
Date: 12 October 2014 Investigation status: Completed 
Time: 1545 CDT Investigation type: Occurrence Investigation 
Location   (show map):Adelaide Airport Occurrence type:Incorrect configuration 
State: South Australia Occurrence class: Operational 
Release date: 27 August 2015 Occurrence category: Incident 
Report status: Final Highest injury level: None 
 
Aircraft details
Aircraft manufacturer: The Boeing Company 
Aircraft model: 737-838 
Aircraft registration: VH-XZI 
Serial number: 39364 
Operator: Qantas 
Type of operation: Air Transport High Capacity 
Sector: Jet 
Damage to aircraft: Nil 
Departure point:Alice Springs, NT
Destination:Adelaide, SA
 
 
 
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Last update 18 April 2017