Aviation safety investigations & reports

Incorrect configuration during an approach involving Airbus A320, VH-VNR, 28 km north of Sydney Airport, NSW, on 16 October 2019

Investigation number:
AO-2019-059
Status: Discontinued

Discontinuation notice

Discontinuation notice

Section 21 (2) of the Transport Safety Investigation Act 2003 (TSI Act) empowers the ATSB to discontinue an investigation into a transport safety matter at any time. Section 21 (3) of the TSI Act requires the ATSB to publish a statement setting out the reasons for discontinuing an investigation. The statement is published as a report in accordance with section 25 of the TSI Act, capturing information from the investigation up to the time of discontinuance.

Overview of the investigation

During an approach to Sydney Airport’s runway 16L on 16 October 2019, VH-VNR, a Tiger Airways A320, was at a speed in excess of that required for that particular phase of the approach. The pilot in command (PIC), performing the pilot monitoring (PM) role, instructed the pilot flying (PF)[1] to correct the speed and configure the aircraft for landing, however, the required corrections did not occur. As a result, the PIC took control of the aircraft, extended the speed brake to reduce the airspeed and configured the aircraft for landing.

During that configuration, at an altitude of about 1,300 ft, the speed brake was extended while the aircraft was in the landing configuration. This resulted in an EGPWS SPEED[2] alert. The configuration was corrected and the approach was stable by 1,000 ft. The PIC returned control of the aircraft to the PF, and the aircraft completed a stable approach and a safe landing.

On 22 October 2019, the ATSB commenced an investigation into the occurrence. As part of its investigation, the ATSB:

  • interviewed the flight crew
  • examined digital flight data and flight crew training records
  • analysed fatigue related data
  • reviewed the operator’s policy and procedural requirements and the recent occurrence data.

The ATSB determined that the two flight crew system operated as designed, detecting the incorrect approach conditions and correcting those conditions in sufficient time to enable a stable approach. A human factors review of the flight crew’s conduct and a fatigue assessment and examination of the flight crew’s training and the operator’s response to the occurrence, did not identify any factors that justified further investigation.

ATSB comment

Based on a review of the available evidence, the ATSB considered it was unlikely that further investigation would identify any systemic safety issues. Consequently, the ATSB has discontinued this investigation.

The evidence collected during this investigation remains available to be used in future investigations or safety studies. The ATSB will also monitor for any similar occurrences that may indicate a need to undertake a further safety investigation.

Finally, the ATSB briefed Tiger Airways about some of its observations and potential learnings. However, it considered that broader communication of this information would not be of significant benefit to other parties.

__________

  1. Pilot Flying (PF) and Pilot Monitoring (PM): procedurally assigned roles with specifically assigned duties at specific stages of a flight. The PF does most of the flying, except in defined circumstances; such as planning for descent, approach and landing. The PM carries out support duties and monitors the PF’s actions and the aircraft’s flight path.
  2. Enhanced Ground Proximity Warning System.
General details
Date: 16 October 2019   Investigation status: Discontinued  
Time: 3:05 UTC   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): 28 km N, Sydney Airport    
State: New South Wales   Occurrence type: Unstable approach  
Release date: 06 May 2020   Occurrence category: Incident  
Report status: Discontinued   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Airbus  
Aircraft model A320-232  
Aircraft registration VH-VNR  
Serial number 5900  
Operator Tiger Airways  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Nil  
Departure point Brisbane, Queensland  
Destination Sydney, New South Wales  
Last update 06 May 2020