Incorrect configuration

On 31 March 2014, an Airbus A320 departed Auckland, New Zealand for a scheduled passenger flight to Gold Coast, Queensland. On departure from Auckland, the local barometric pressure (QNH) was 1025 hPa, and the crew had selected ‘STD’ for the standard atmospheric pressure of 1013 hPa on the altimeters during climb to flight levels.

During the cruise, about 15 minutes prior to commencing the descent for the Gold Coast, the crew obtained the automatic terminal information service (ATIS) for Gold Coast and the captain wrote the details onto the take-off and landing data (TOLD) card. The crew then conducted the approach briefing, including a review of this information, which was entered into the flight management guidance computer (FMGC) for the approach.

Approaching transition altitude, the ‘BARO REF’ warning flashed however the captain was communicating with ATC, hence the page in the FMGC with the QNH displayed was not selected. The first officer glanced at the TOLD card, and entered 1025 into the altimeter, possibly inadvertently interpreting either the cloud (025) or the temperature (25) as the QNH, instead of 1018.

The captain then completed the communication with ATC and commenced the transition check by stating ‘transition’. At this time the captain omitted to select the FMGC onto the flight plan page to display the QNH that had been entered. The first officer stated ‘set QNH 1025’ and the captain entered that into the second altimeter and the first officer entered the same value into the standby altimeter and a cross check confirmed that all three altimeters matched.

Passing about 1,000 ft AMSL, as the first officer completed the turn onto final, he observed the T-VASIS indicating a ‘fly-up’ profile. The RADALT callout of 500 ft sounded and the first officer realised that the approach path was incorrect. When at about 159 ft above ground level, the enhanced ground proximity warning system (EGPWS) ‘TERRAIN’ warning sounded, and the first officer commenced the missed approach. The captain first officer checked the QNH on the TOLD card and realised an incorrect QNH had been set.

This incident highlights the impact distractions can have on aircraft operations, particularly during a critical phase of flight.

Aviation Short Investigations Bulletin - Issue 31

On 5 March 2014 at about 1044 Eastern Standard Time, an ATR 72 aircraft, registered VH-FVI (FVI), was about 25 NM southeast of Moranbah, Queensland on descent to the airport.

The captain of FVI broadcast on the common traffic advisory frequency (CTAF), advising that the aircraft was inbound and planned to conduct a non-directional beacon (NDB) approach, with an estimated arrival time of 1049 overhead the airport. At about 1047, the captain broadcast when 10 NM SE tracking NW to conduct an NDB A approach. At 1049, the captain broadcast tracking outbound in the approach and that they “should be turning straight in for a landing runway 16”.

At about 1050, following the report of a suspected birdstrike by the aircraft just landed, the aerodrome reporting officer (ARO) on duty was in the airport terminal when asked by airport ground staff to conduct a runway inspection. At about 1052 the ARO broadcast on the CTAF advising that the vehicle was preparing to enter the runway for a runway inspection. The ARO then conducted a thorough lookout for aircraft approaching and on the runway with no aircraft sighted. He then broadcast a call entering the runway and commenced driving north along the runway. When at the northern threshold, the vehicle turned and drove south along the runway.

The crew of FVI did not hear either broadcast from the ARO. At about 1055, when at about 20 ft above ground level (AGL), the captain looked up out of the cockpit along the runway and sighted the safety vehicle on the white runway aiming point markings near the far end of the runway. The captain immediately broadcast “car vacate”. The ARO immediately drove the vehicle off the runway and once clear, broadcast that the safety vehicle had now vacated all runways.

This incident highlights the importance of radio communications and the benefits of alerted see-and-avoid practices.

Aviation Short Investigations Bulletin - Issue 31

On 31 October 2013, a flight instructor and student pilot were conducting flying training in a Beech A36 (Bonanza) aircraft, registered VH-YEN, at Camden Airport, New South Wales. The purpose of the flight was to enable the student to obtain an aircraft design feature, retractable undercarriage (landing gear) endorsement.

After completing about 45 minutes upper air training in the local training area, they obtained a clearance from ATC for a straight in approach to runway 06 at Camden.

During the approach, the student completed the pre-landing checks, which included extending the landing gear and selecting flap. At about 1445 EDT the aircraft touched down about 50-100 m past the runway threshold and about 2m left of the centreline. The instructor advised the student to re-align the aircraft with the runway centreline. The instructor focussed his attention outside the cockpit watching the re-alignment.

At about the same time, the student became concerned about the length of runway remaining and quickly moved to retract the flaps and prepare the aircraft for take-off. The student had completed all his recent training in a Cessna 182 type aircraft which has the flap control to the right of the power quadrant. This led to him inadvertently manipulating the landing gear lever. The instructor attempted to recover the aircraft, but it veered right, and the nose dug into the grass verge alongside the runway.

As a result of the occurrence, the aircraft operator has advised the ATSB that the company have changed their procedure for retractable design type endorsements. From now, instructors undertaking this type of endorsement training with students are required to conduct a full stop landing on the first approach.

Aviation Short Investigation Bulletin Issue - 27

On 13 September 2013, the flight instructor and student pilot of a Robinson R22 helicopter, registered VH-ONT, were preparing for a dual training flight from Armidale, New South Wales.

Prior to take-off, the instructor explained the purpose of the fuel mixture control guard, the use of the carburettor heat, and took the student through the start-up checklist.

At about 1515 Eastern Standard Time, the helicopter departed, with the instructor operating the controls. During the climb, at about 300 ft above ground level (AGL), the instructor handed control of the helicopter over to the student. When maintaining 1,200 ft AGL, the instructor discussed with the student on how to enter a descent. After confirming that they would reduce the engine power, the instructor asked the student to pull the carburettor heat on.

The instructor looked outside to check for traffic and the engine then stopped. The instructor immediately initiated an autorotation and lowered the collective. He observed that the fuel mixture control was in the idle cut-off position. The student had removed the fuel mixture control guard, inadvertently pulled the fuel mixture control instead of the carburettor heat control and then replaced the guard. The instructor asked the student to push the fuel mixture control back in and he broadcast a ‘MAYDAY’ call.

The instructor selected a paddock and focused on the autorotation. Prior to the landing flare, the low rotor revolutions per minute (RRPM) horn sounded. The helicopter landed and ran on the ground on its skids, before rolling onto its side due to the slope of the paddock. Both occupants sustained minor injuries and the helicopter was substantially damaged.

This accident highlights the benefit of pilots positively identifying the control to be manipulated, prior to performing the action.

Aviation Short Investigation Bulletin - Issue 24

On 24 July 2013, an Airbus Industrie A320 aircraft, registered VH-FNP (FNP) was being operated on a scheduled passenger flight from Perth to Newman, Western Australia.

Prior to reaching the top-of –descent point, the crew conducted a full approach briefing. This included the decision to use Flap Full for the visual approach.

Newman had a lot of aircraft movements both into and out of the airport that day. The pilot in command (pilot monitoring) focussed on maintaining separation for FNP, while the first officer (pilot flying) maintained the aircraft on the approach.

The crew reported the aircraft was on the correct glidepath and at the correct approach speed. This is confirmed by the flight data recorder (FDR) information.

By 500 ft above ground level (AGL) the landing gear had been extended and Flap 3 selected. As the visual approach had been programmed into the flight management guidance system, the crew expected to receive the automatically generated 500 ft AGL call.

At about 231 ft radio height the crew received a ground proximity warning system (GPWS) warning “TOO LOW FLAP”. Full flap was selected at about 185 ft and the aircraft landed shortly after.

Virgin Australia Regional Airlines (VARA) have initiated two safety actions in regard to the requirement to maintain track during go-around procedures and further training for the crew.

A United States Navy/National Aeronautics and Space Administration research report Cockpit Interruptions and Distractions: A Line Observation Study targets some of the actions that pilots take, when forced to make decisions, outside their well-practiced sequences.

Aviation Short Investigation Bulletin - Issue 26

What happened

At about 1440 Eastern Daylight-saving Time on 22 January 2013, the pilot of a Cessna U206F amphibious aircraft, registered VH-UBI, was conducting a seaplane joy flight from Corio Bay, Victoria with two passengers on board. During the flight the pilot refuelled the aircraft at Barwon Heads Airport, necessitating the use of the landing wheels. On the return trip the pilot detoured for local sightseeing before heading back to Corio Bay for a water landing. On touchdown, the aircraft pitched over and came to rest inverted. The pilot assisted the two passengers to evacuate the aircraft before rescue vessels arrived. All three occupants sustained minor injuries. The aircraft was substantially damaged.

What the ATSB found

The ATSB found that the pilot was distracted during the departure from Barwon Heads and as a result did not retract the landing wheels during the after-take-off checks. The investigation also determined that on returning to Corio Bay, the pilot shortened the approach due to perceived time pressure and did not complete the normal downwind and short final checks. In not completing those checks, the pilot reduced the likelihood of identifying that the landing wheels were still extended. Such events where individuals forget to carry out an action due to distractions are not uncommon and are described as skill-based lapses.

Safety message

This accident is a reminder for pilots and operators that human error can occur at any time, and highlights the importance of managing operational pressures and avoiding distractions. The need to follow procedures and complete checklists diligently is also reinforced. Effective application of threat and error, and distraction management principles can reduce risk.

The operator’s requirement for passengers to wear life jackets throughout the flight enhanced the survivability of the passengers.

On 21 August 2012, at about 1430 Eastern Standard Time, an Aero Commander 500S registered VH-YJS (YJS) departed Charleville Airport, Queensland for Brisbane Airport via, Roma, Dalby and Toowoomba on a freight only charter flight under the IFR. The pilot was the only person on board.

During the landing roll the landing gear was inadvertently retracted and the lower fuselage contacted the runway.  The pilot exited the aircraft without injury however the lower fuselage of the aircraft was damaged. 

A manual safe pin was incorporated as a design feature to prevent inadvertent retraction of the landing gear. However operation of the gear lever and safe pin together had become an automatic response by the pilot and the effectiveness of the safe pin as a countermeasure reduced. Pilots are reminded to positively identify any control lever before actioning. 

Aviation Short Investigation Bulletin – Issue 14

What happened

On 6 February 2012, the flight crew of an Airbus A320-232, registered VH-JQX, commenced take-off from runway 16R at Sydney Airport, New South Wales. The flight crew consisted of a training captain and a captain under training, who was occupying the left seat and conducting the duties of the captain.

During the take-off, one of the thrust levers was inadvertently moved forward of the required detent, which resulted in a thrust setting reversion to manual mode. The training captain identified the issue and initially made the required standard calls to the captain under training to indicate the issue with the thrust lever.

The training captain then made a call to indicate that the take-off should continue, with maximum thrust selected, and the captain under training began rotating the aircraft below the required rotation speed. At about that time the training captain increased the thrust levers to the maximum thrust setting. After noting the aircraft’s airspeed was below the required rotation speed, the captain under training discontinued the rotation until a suitable airspeed was achieved prior to commencing the climb.

What the ATSB found

The ATSB found that the captain under training misunderstood the command from the training captain, which led to the early rotation. The training captain recognised the thrust lever asymmetry situation, however the captain under training did not, and this resulted in a miscommunication that was not resolved effectively between the crew.

In addition, the captain under training was transitioning from another aircraft type to the A320 and the manual thrust mode on the A320 was consistent with his experience of a normal take-off on the previous aircraft type. This created a level of confusion for the captain under training and made it more difficult for him to recognise the thrust lever asymmetry situation. A situation where one thrust lever is in the detent and the other is not, is indicated to the crew on the flight mode annunciator panel and is only displayed above 100 ft.

What has been done as a result

Jetstar have advised that they have incorporated a module into simulator training for all pilots covering incorrect thrust settings at take-off. They have also released a communication to pilots on the responsibilities of the pilot in command during operational events.

Safety message

This incident highlights the importance of good flight crew communication to ensure a shared understanding of the aircraft’s system status.

On 28 July 2011, a Jetstar Airways, Airbus A320-232 aircraft, registered VH-VQA, departed Newcastle, New South Wales on a scheduled passenger service to Melbourne, Victoria. The First Officer (FO) was designated as the pilot flying.

While on approach to runway 34 at Melbourne, at about 245 ft (radio altitude), the Captain realised that the landing checklist had not been completed. At the same time, the crew received a 'TOO LOW FLAP' aural and visual warning from the aircraft's enhanced ground proximity warning system (EGPWS). The Captain identified that the aircraft was not in the landing configuration, immediately called for a go-around which the FO initiated. Prior to establishing a positive rate of climb, the crew received a second 'TOO LOW FLAP' warning.

The operator conducted an investigation and determined that the following factors had contributed to the incident: incomplete approach brief, loss of situation awareness, improper coaching techniques and cognitive overload. As a result, the operator intends to:

• provide the Captain and FO with a remedial training and coaching program
• conduct a review of their command upgrade training to ensure it focuses on the development of a positive cockpit authority gradient, and the command of flight capabilities
• incorporate this incident into the command upgrade training course as a case study
• conduct a review of their recurrent human factors training.

On 16 May 2011, while in the cruise, on a scheduled passenger flight from Changi Airport, Singapore, to Melbourne, Australia. The crew of the Qantas Airways, Airbus A380-842 (A380) aircraft, registered VH-OQI (OQI), noticed a significant discrepancy between the aircraft's fuel state and the fuel predictions. The crew monitored the fuel over the flight and determined that 3.8 Tonne of excess fuel had been used over a 6-hour period.

The excess fuel usage could not be explained.  Due to the potential for delays at Melbourne, the crew opted to divert to Adelaide Airport, where an uneventful landing was made.

Subsequent examination of the aircraft found no evidence of fuel leaks. Engine ground runs confirmed normal fuel flow to all engines. The flight data recorder was analysed by the Australian Transport Safety Bureau, which confirmed fuel flow during the flight was in accordance with the commanded thrust.

Subsequent investigation by the manufacturer and operator identified that for a period of about 4 hours during the flight, the speed brake lever (SBL) was set away from its stowed position of -5° to the +3.6°position. As a result, the aircraft spoilers were deflected into the airstream increasing drag and consequently fuel burn. The crew were not alerted to this as warnings are only displayed to the crew at or above the +5° SBL position.

As a result of the incident, Airbus plans to reduce the alerting position of the speed brake lever angle from +5° to +2.4°.

Airbus have also updated the standard operating procedures (SOP) to highlight that spoiler extension may occur without a crew alert.