Aviation occurrence briefs

Incorrect configuration involving an Avro RJ100, near Adelaide Airport, SA, on 3 June 2019

Number:
AB-2019-021
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 3 June 2019, an Avro RJ100 departed for a commercial passenger flight from Port Augusta to Adelaide, South Australia. During approach into Adelaide, performance data and speeds were entered into the flight management system (FMS). The configuration selected for this particular approach was a flap 24 landing, due to the aircraft’s low landing weight. While conducting the approach, the crew observed that the speed was too low for a flap 24 approach and received an amber speed indication. The crew subsequently adjusted the speed setting.

After landing, the crew identified that incorrect data was entered into the FMS. Specifically, a flap 33 landing was selected, resulting in a lower approach speed. When entering the data into the FMS, standard operating procedures dictated that both crewmembers needed to crosscheck the performance data to ensure that it is correct prior to executing. In this instance, neither crew member crosschecked the data that was entered. The crew reported multiple contributing factors relating to this incident, including fatigue at the end of a long duty day, low arousal levels due to benign conditions and expectation bias as a flap 33 landing was used for all previous sectors that day.

Safety message

This incident highlights the importance of ensuring that the FMS is programmed correctly for all phases of flight, in particular critical phases, to reduce the risk of an aircraft approaching and landing with incorrect performance data. It also provides a reminder for crewmembers to monitor with each other during the flight to identify any potential decline in performance levels or alertness.

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: 03 June 2019   Investigation status: Completed  
Time: 1723 CST    
Location   (show map): Near Adelaide Airport,    
State: South Australia    
Release Date: 29 July 2019   Occurrence category: Incident  
Report status: Final    

Aircraft details

Aircraft details
Aircraft manufacturer British Aerospace PLC  
Aircraft model Avro 146-RJ100  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Nil  
Departure point Port Augusta, South Australia  
Destination Adelaide, South Australia  
Last update 31 July 2019