Incorrect configuration

What happened

On the 5 August 2018 at about 1545 Western Standard Time, a Boeing 717-200 operating between Perth and Broome, Western Australia, departed from runway 21 at Perth Airport.

Following a normal departure, Air Traffic Control (ATC) advised that the Standard Terminal Arrival Route (STAR)^[1] speed and altitude restrictions were cancelled. The aircraft captain (AC) briefed the first officer that the crew would maintain normal programmed departure speeds. Shortly thereafter, the AC was alerted to a low-speed warning on the primary flight display (PFD). The AC stated that as slat retraction had not been called for, the AC initially thought that the crew were experiencing an unreliable airspeed event. The AC checked the thrust and altitude parameters and identified they were within expected limits. As the airspeed was increasing at a normal rate, and there was no stick shaker or under-speed protection engagement, the AC elected to leave the autopilot engaged and monitor the situation. The AC then identified that the slats had been retracted prior to the AC calling for that action. As all flight parameters appeared normal, the crew continued the flight to Broome. Subsequent discussions identified that the first officer misinterpreted the AC’s instructions to maintain normal departure speeds and prematurely retracted the slats.

Safety action

As a result of this occurrence, the aircraft operator has advised the ATSB that they have issued an Operational Safety Alert, reminding flight crews of the importance of positively identifying and confirming actions prior to selection and taking the time to ensure tasks are done correctly.

Safety message

This incident highlights the importance of inter-crew communication to preventing, trapping and mitigating error. Flight crews should ensure they use procedures such as cross check, or identify and confirm to support effective communications and develop a shared understanding of the aircraft state.

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.

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1. STARs are procedural methods to control the flow of traffic within the vicinity of an aerodrome. Flight crews are to comply with published speeds and altitudes unless they are specifically cancelled or amended by ATC

What happened

On 11 September 2018 at approximately 1400 Eastern Standard Time, a Mooney Aircraft Corp, M20C, was on final approach into Bankstown, New South Wales, after completing a private flight.

The pilot of the M20C has lowered the aircraft’s undercarriage whilst on the downwind leg of the circuit in preparation for landing. The pilot reported not feeling confident about the 1,500 ft circuit height they were established in and raised the undercarriage to conduct a go-around^[1].

ATC observed the landing gear being raised and instructed the pilot to conduct a go-around prior to the pilot being able to communicate their intentions.

The flight proceeded without further incident.

Safety message

If a pilot is not completely satisfied that all the requirements are in place for a safe landing, performing a go-around is a way to ensure safety is not compromised.

The ATSB news article, Have an early decision point for an early and proper go-around has more information about the importance of performing an early go-around when a safe landing is in doubt.

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.

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1. A go-around is a safe, standard aircraft manoeuvre, which simply discontinues an approach to landing.

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.

What happened

On the morning of 15 May 2018, the crew of a SAAB 340A were conducting a cargo flight from Rockhampton, Queensland (Qld) to Mackay, Qld. At approximately 0545 Eastern Standard Time, the aircraft was on descent into Mackay passing 10,000 ft.

During descent, the left engine surged from 50 per cent torque to over 70 per cent with an increase in interstage turbine temperature^[1]. The crew retarded the power lever and all other indications appeared normal. The aircraft levelled off at 5,000 ft and failure management was carried out. The crew subsequently conducted a normal approach and landing.

Following the incident, the crew were interviewed and an analysis of the flight data recordings occurred. Engineers were notified of the incident and conducted inspections. No faults were found with the engine or controls. It was determined that the constant torque on take-off (CTOT) was inadvertently not de-selected during the climb phase of the flight, resulting in the abnormal engine surge.

Safety action

As a result of this occurrence, the operator has advised the ATSB that they have taken the following safety actions:

Refresher training was provided to the crew specific to the use and operation of the CTOT system.

The crew conducted a competency-based training refresher course on operations failure management.

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.

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1. The interstage turbine temperature (ITT) is the temperature of the exhaust gasses between the high pressure and low-pressure turbines.

What happened

On 15 May 2018, at about 1500 Western Standard Time (WST), a Fokker F100 was on a scheduled passenger flight from Perth, Western Australia (WA) to Kununurra, WA. The flight crew was comprised of the captain and the first officer (FO).

Passing through 10,000 ft on descent, the crew received a “LG Not Down”, triple chime alert. The flight crew identified that that the Radio Altimeter 1 (RA1) was erroneously indicating ‘zero feet’, which triggered the gear unsafe alert. The flight crew discussed the situation and decided to configure the aircraft for landing early, with the view to extend the gear as soon as practicable, in order to silence the triple chime alert.

Shortly after, the crew observed the autopilot disconnect and a ‘STAB TRIM 1 and 2’ fault alert. The captain took over flying the aircraft manually, commenced speed reductions and called for ‘Flaps 8’. Immediately following, RA1 appeared to return to normal operation and all alerts ceased.

Descending through 7,000 ft, RA1 returned to a reading of ‘zero feet’. The flight crew observed all of the previous alerts, in addition to a “TOO LOW GEAR” GPWS alert. The crew reviewed the situation and agreed to continue with the plan to configure the aircraft early for landing. The remainder of the approach and landing were conducted without further incident.

Once on the ground, the captain contacted Maintenance Watch and the Manager Flight Technical for guidance. In preparation for the return flight to Perth that afternoon, the team made the decision to dispatch the aircraft under the Minimum Equipment List (MEL).

At about 1630 WST, after a lengthy turnaround, the flight crew began the performance calculations for take-off on runway 12. The take-off flap position of ‘Flaps 15’ was correctly identified and circled on the Take-Off and Landing Data (TOLD) Card, to highlight the infrequently used setting.

After start, the flight crew became aware of an inbound aircraft on long final. The flight crew initiated a radio call to the crew on board the approaching aircraft to confirm their intended surface movements. As the departing aircraft approached the runway, the other aircraft made a radio transmission expressing confusion regarding the use of the taxiways. The confusion was resolved and the captain of the departing aircraft began the pre-take off sequences.

Distracted by the earlier confusion and eager to depart, the captain called for ‘Flaps 8’, the more commonly used take-off configuration. The captain then glanced at the TOLD card to cross check the numbers and continued with the take-off.

The aircraft’s speed had climbed above 100 kts before the FO and captain identified the incorrect flap setting. The captain called continue and the take-off was completed without further incident.

Safety message

This incident highlights the importance of managing operational pressures and distraction. The traffic on the taxiway, the events of the previous flight and the extended turnaround time had distracted the crew from completing the pre-flight sequences in a conscious manner. During times of high workload, distraction and perceived time pressures 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.