Aviation safety investigations & reports

Incorrect configuration involving Airbus A320, VH-VFX, Sydney Airport, NSW on 29 September 2018

Investigation number:
AO-2018-067
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

On 29 September 2018, a Jetstar Airways Airbus A320 aircraft, registered VH-VFK, was operating a scheduled passenger flight from Sydney, New South Wales to Melbourne, Victoria. While preparing for the flight and having difficulties with the electronic system used for calculating take-off performance figures, the flight crew reverted to the back-up procedure of manual calculations.

Shortly after take-off, the maximum flap extended speed was exceeded. As the aircraft climbed through 2,800 ft, the flight crew retracted the landing gear after realising it was still extended, resulting in a landing gear retraction overspeed.

What the ATSB found

In completing the manual calculations for take-off performance, the flight crew inadvertently calculated speeds that were higher than required for the actual aircraft weight and environmental conditions. The incorrect take-off speeds were not identified by independent verification and cross-checking.

During the first segment of the take-off climb period, at maximum engine power settings, the aircraft pitch rate was below the recommended 3° per second, resulting in a higher acceleration rate than anticipated. Due to the incorrect calculated speeds, the aircraft rotated with a margin of only 16 kt to the flap extended limit speed. Five seconds after rotation, the flap extended overspeed event occurred.

The aircraft did not rotate to the correct pitch attitude and the pilot monitoring did not alert the pilot flying of this. However, he called ‘speed, speed’ in an attempt to assist the pilot flying manage the airspeed, to which the pilot flying reduced the engine power in response, rather than increasing the aircraft pitch. The action of reducing the engine power was taken when the aircraft was below the safe altitude above ground.

The landing gear would normally be retracted by the flight crew as soon as the aircraft had a positive rate of climb. In this case, the crew did not retract the landing gear when required. Climbing through 2,800 ft, they identified that the landing gear was still extended while troubleshooting the source of a buffeting noise. They then immediately selected the gear to ‘UP’ without first checking the aircraft speed, resulting in a landing gear retraction overspeed event.

What's been done as a result

Jetstar Airways advised that they undertook several actions to prevent a similar occurrence in the future. A safety summary of the incident was distributed to the wider pilot community, focusing on the importance of having the latest Flysmart software database version on their Electronic Flight Bag. It also highlighted the importance of considering reasonability and accuracy checks, consulting company procedure manuals in the event of Electronic Flight Bag issues, and conducting a normal rotation followed by reference to the Speed Reference System.

Safety message

This incident highlights the importance of independent validation and cross-check by the flight crew, in particular for performance speeds and aircraft weight.

The Airbus magazine Safety First #18 reports on potential problems with using incorrect reference speeds. This highlights the design and operational considerations underlying recommendations that Airbus has issued to flight crews.

Download final report
[Download  PDF: 835KB]
 
 
Alternate: [Download  DOCX: 940KB]
 

The occurrence

Context

Safety analysis

Findings

Safety action

Submissions

General details
Date: 29 September 2018   Investigation status: Completed  
Time: 2237 EST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Sydney Airport   Investigation phase: Final report: Dissemination  
State: New South Wales   Occurrence type: Incorrect configuration  
Release date: 24 February 2020   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Airbus  
Aircraft model A320-232  
Aircraft registration VH-VFX  
Serial number 5871  
Operator Jetstar Airways  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Nil  
Departure point Sydney, New South Wales  
Destination Melbourne, Victoria  
Last update 24 February 2020