Aviation safety investigations & reports

Airspeed management event involving a Fokker F28-0100, VH-UQN Rockhampton Airport, Queensland, on 10 November 2019

Investigation number:
AO-2019-063
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

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What happened

On 10 November 2019, a Fokker F28 Mk0100 (F100) aircraft, registered VH-UQN, was on final approach at night to runway 33 at Rockhampton Airport, Queensland. The aircraft was slightly high on the approach profile when smoke haze from nearby bushfires reduced the visibility on approach, obscuring the vertical approach lighting.

At about 400 ft above ground level, the aircraft encountered moderate turbulence affecting the aircraft’s approach profile. At about 300 ft, the airspeed reduced below the minimum approach speed and the pilot flying encountered increased resistance in the thrust levers while trying to recover airspeed. After a short period, the pilot forced the thrust levers to the desired setting. The aircraft’s engines responded, airspeed increased accordingly, and the aircraft landed safely.

What the ATSB found

The ATSB found that, when on final approach, the flight crew encountered reduced visibility and moderate turbulence from a bushfire, which added uncertainty and the late identification of a high approach profile. While attempting to regain the correct profile, the airspeed reduced below the minimum allowable speed, activating the automatic flight envelope protection or alpha mode before the aircraft started to accelerate. The flight crew were unaware of the alpha mode activation.

The operator’s initial type qualification training for the F100 aircraft and cyclic training did not adequately prepare the operator’s pilots to identify and respond to alpha mode activations during critical phases of flight. The ATSB further identified that the aircraft’s rate of descent exceeded the operator’s stabilised approach criteria for a short period during the approach; however, it was also identified that there was no permissible exceedance criteria in the stabilised approach criteria for transient exceedances.

There was an 8-day delay in reporting the incident to the ATSB. It was identified that the operator’s recently-installed internal safety reporting system provided warnings that adequately reflected the urgency of reporting, but contained a visual display peculiarity that subtlety concealed reportable matters, resulting in the report being unprocessed for 6 days.

The ATSB also identified that the acting safety systems manager was unable to effectively conduct the role due to limited experience in the role, increased workload, and remote working conditions during this time. This, along with other key changes, limited the operator’s capacity to provide effective safety assurance.

What has been done as a result

The operator issued an operations notice to pilots, which included guidance on the dangers of low thrust and low airspeed situations during performance decreasing conditions. The notice also provided greater guidance about the activation of alpha mode within its fleet. The operator updated its cyclic simulator training to include alpha mode activation scenarios and developed alternative procedures for pilots when encountering alpha mode activations.

Further, the operator proactively implemented an update to its safety reporting system that highlighted reportable matters by removing lesser priority indicators. It further introduced a statistical reporting tool to monitor the above system enhancement to ensure ATSB reporting obligations were measured and appropriately reported. In addition, it finalised the internal safety manual and standard operating procedures, developed a position handover checklist, and reviewed its company policy manual to detail the formal delegation of duties relating to key safety post holder positions.

Safety message

Flight crew awareness of automatic flight protections and their subsequent effect is paramount to the safe operation of passenger transport flights. Effective initial and cyclic training, and assessments in these systems, is important to ensure that pilots respond appropriately to these situations during critical phases of flight.

Operators are reminded that effective change management is an essential part of any safety management system. Changes to key safety management systems, key post holder positions, and the procedures and processes that support systems and personnel, need to be carefully managed in order to operate a robust and effective safety management system.

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[Download  PDF: 1005KB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Glossary

Sources and submissions

ATSB

Summary

The ATSB is investigating an operational event involving a Fokker 100, registered VH-UQN, at Rockhampton, Queensland, on 10 November 2019.

Passing 300 ft on final approach, the aircraft encountered moderate turbulence which resulted in a loss of airspeed. While attempting to arrest the loss of speed, the speed fell below the minimum approach speed. The aircraft landed safely.

As part of the investigation, the ATSB will interview directly involved parties and obtain other relevant information, including technical logs and recorded data.

A report will be released at the end of the investigation. Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant stakeholders so appropriate and timely safety action can be taken.

Safety Issues

Go to AO-2019-063-SI-01 - Go to AO-2019-063-SI-02 - Go to AO-2019-063-SI-03 -

Safety management reporting system

The operator’s safety management reporting system did not enable the effective prioritisation of submitted safety reports.

Safety issue details
Issue number: AO-2019-063-SI-01
Status: Closed – Adequately addressed

Flight crew training

The operator’s training for the Fokker F28-Mk0100 did not prepare pilots for alpha mode activation during critical phases of flight.

Safety issue details
Issue number: AO-2019-063-SI-02
Status: Closed – Adequately addressed

Organisational change

Changes in the operator's key safety post holder positions, safety reporting systems and internal processes reduced effective safety assurance.

Safety issue details
Issue number: AO-2019-063-SI-03
Status: Closed – Adequately addressed
General details
Date: 10 November 2019   Investigation status: Completed  
Time: 1958 EST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): 2 km south-east of Rockhampton Airport   Investigation phase: Final report: Dissemination  
State: Queensland   Occurrence type: Powerplant/propulsion - Other  
Release date: 07 June 2022   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Fokker B.V.  
Aircraft model F28MK0100  
Aircraft registration VH-UQN  
Serial number 11361  
Operator Alliance Airlines PTY Limited  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Nil  
Departure point Brisbane Airport, Queensland  
Destination Rockhampton Airport, Queensland  
Last update 07 June 2022