Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.
On the 5 August 2018 at about 1545 Western Standard Time, a Boeing 717-200 operating between Perth and Broome, Western Australia, departed from runway 21 at Perth Airport.
Following a normal departure, Air Traffic Control (ATC) advised that the Standard Terminal Arrival Route (STAR) speed and altitude restrictions were cancelled. The aircraft captain (AC) briefed the first officer that the crew would maintain normal programmed departure speeds. Shortly thereafter, the AC was alerted to a low speed warning on the primary flight display (PFD). The AC stated that as slat retraction had not been called for, the AC initially thought that the crew were experiencing an unreliable airspeed event. The AC checked the thrust and altitude parameters and identified they were within expected limits. As the airspeed was increasing at a normal rate, and there was no stick shaker or under-speed protection engagement, the AC elected to leave the autopilot engaged and monitor the situation. The AC then identified that the slats had been retracted prior to the AC calling for that action. As all flight parameters appeared normal, the crew continued the flight to Broome. Subsequent discussions identified that the first officer misinterpreted the AC’s instructions to maintain normal departure speeds and prematurely retracted the slats.
As a result of this occurrence, the aircraft operator has advised the ATSB that they have issued an Operational Safety Alert, reminding flight crews of the importance of positively identifying and confirming actions prior to selection and taking the time to ensure tasks are done correctly.
This incident highlights the importance of inter-crew communication to preventing, trapping and mitigating error. Flight crews should ensure they use procedures such as cross check, or identify and confirm to support effective communications and develop a shared understanding of the aircraft state.
About this report
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
|Date:||05 August 2018||Investigation status:||Completed|
|Release Date:||22 November 2018||Occurrence category:||Incident|
|Report status:||Final||Highest injury level:||None|
|Aircraft manufacturer||The Boeing Company|
|Type of operation||Air Transport High Capacity|
|Damage to aircraft||Nil|