Aviation occurrence briefs

Incorrect flap configuration involving Fokker F28, near Kalgoorlie-Boulder, WA, on 1 August 2018

Number:
AB-2018-097
Status: Completed
Investigation completed

Brief

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.

What happened

On 1 August 2018 at 1530 Western Standard Time, the crew of a Fokker F28 aircraft was conducting a revenue passenger transport flight between Perth and Kalgoorlie, Western Australia. The flight crew comprised a captain and a first officer. The first officer was on his second day of training.

During approach, the captain briefed the first officer for a flap 25 configuration for the landing.

Later in the approach, the captain inadvertently called for the flaps to be extended to 42. The first officer questioned this call, and the captain confirmed the call for a flap 42 configuration. The first officer did not further question the captain’s call, and flap 42 was selected.

The captain reported that he was responding to other demands during this approach. There was a crosswind at 40 knots, and conditions were turbulent. The captain reported that during the approach he was focussed on monitoring the flight instruments.

The captain subsequently identified the incorrect flap configuration, and conducted a go-around. A second approach was conducted successfully.

Safety message

This incident highlights the importance of inter-crew communication. There was a breakdown of communication between the first officer and the captain. The flap configuration was not effectively communicated within the cockpit, resulting in an incorrect configuration being set. Although the first officer did query the captain’s initial instruction for a flap 42 configuration, he did not further challenge this call. Flight crews are reminded that active and effective communication, including clarification of unclear instructions, plays an important role in ensuring safe flight.

This incident also highlights the importance of managing operational pressures and distraction. During times of high workload, distraction can often lead to human error.

External pressures and distractions are sometimes unavoidable, however, there are effective ways to manage them, as discussed in the ATSB research report B2004/0324, ‘Dangerous distraction: An examination of accidents and incidents involving pilot distraction in Australia between 1997 and 2004’.

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.

General details
Date: 01 August 2018   Investigation status: Completed  
Time: 1530 WST    
Location   (show map): Near Kalgoorlie-Boulder    
State: Western Australia    
Release Date: 05 November 2018   Occurrence category: Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Fokker B.V.  
Aircraft model F28 MK 0100  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Nil  
Departure point Perth, WA  
Destination Kalgoorlie, WA  
Last update 12 December 2018