Jetstar A320 at Sydney on Sep 29th 2018, wrong speeds, gear not retracted, flaps overspeed on departure

Last Update: February 24, 2020 / 18:22:58 GMT/Zulu time

Bookmark this article

Photo of Jetstar Airways VH-VFX, Airbus A320 — Jetstar Airways VH-VFX, Airbus A320 (Photo credit: Umedha Hettigoda / Flickr / License: CC by-sa)

Incident Facts

Date of incident
Sep 29, 2018

Classification
Report

Airline
Jetstar Airways

Flight number
JQ-529

Departure
Sydney, Australia

Destination
Melbourne, Australia

Aircraft Registration
VH-VFX

Aircraft Type
Airbus A320

ICAO Type Designator
A320

A Jetstar Airbus A320-200, registration VH-VFX performing flight JQ-529 from Sydney,NS to Melbourne,VI (Australia) with 174 passengers and 6 crew, was preparing for departure when the flight crew computed the takeoff data. However, both flight crew had not updated their electronic flight bags prior to the first flight of the day, the pilot monitoring had updated his EFB just prior to the occurrence flight, the pilot flying still had the old database. The pilot monitoring entered the data computed by his EFB into the FMS, the pilot flying subsequently verified the data and found discrepancies. While troubleshooting the discrepancies the crew discovered the EFB of the pilot flying had the old database on it, the pilot flying attempted to update his EFB, however, his EFB only showed the busy indication continuously and was effectively inoperative. The same happened to the spare EFB on board of the aircraft, which too had an old database on it and showed permanently "busy" after the update was started. The crew thus reverted to manually computing the takeoff performance data, the crew subsequently agreed that their V1 was 157 KIAS, Vr 161 KIAS and V2 164 KIAS. The aircraft subsequently departed Sydney's runway 16R, began rotation at 169 KIAS at 2.8 degrees/s, reached 11.6 degrees nose up about 6 seconds after becoming airborne, the airspeed increased through 189 KIAS above the maximum flap speed. The pilot monitoring had called "Speed! Speed!" to warn the pilot flying their speed was accelerating towards maximum flaps speed and omitted the call "positive climb". In response to the speed call the pilot flying reduced the thrust (rather than increasing the pitch) at 144 feet AGL while still below the thrust reduction height of 800 feet. The flaps were retracted from position 3 to position 1, the thrust lever was placed into the climb detent and the autopilot was engaged. The aircraft continued the climb and the flaps were subsequently retracted. The crew became aware of buffeting noises, discovered the APU was still supplying bleed air, thinking this was the source of the buffeting noises they turned the APU bleed air off according to standard operating procedures. The buffeting noises continued however. The flight crew subsequently realised the landing gear was still down, the pilot flying called "gear up" and the pilot monitoring selected the gear lever up without checking the speed. The aircraft was already flying at 250 KIAS with the maximum gear retraction speed being 220 KIAS. The flight crew discussed the occurrence, in the absence of any abnormal indication they continued the flight to Melbourne where the aircraft landed without further incident.

The ATSB released their final report releasing following findings:

- The flight crew did not follow standard operating procedures to verify and update Flysmart database during sign on for the day.

- When using manual calculations to obtain performance speeds, the flight crew made an error which was not detected by independent validation. This resulted in a calculated rotation speed based on an aircraft weight significantly heavier than the actual take-off weight.

- The rotation rate commanded by the pilot flying was too low to prevent a flap overspeed, given the incorrect performance speeds and use of maximum take-off thrust.

- In an attempt to manage the airspeed, the pilot flying reduced the thrust from the take-off setting, rather than increasing the pitch, but the aircraft was below the safe altitude above the ground to do so.

- The landing gear was not retracted at the normal phase of the take-off.When the flight crew identified that the landing gear was still extended, they retracted it immediately, even though the aircraft was above the maximum landing gear retraction speed.

The ATSB reported the captain was pilot flying, the first officer was pilot monitoring.

The ATSB analysed:

Electronic flight bag

The flight crew did not have the same database versions on their electronic flight bags (EFB). The standard operating procedures required the version to be checked at sign-on each day. Had this been completed the databases on the flight crew’s EFBs would have been the same and the current database. Although the operator reported that the discrepancy should not have made a difference to the performance results obtained for this flight, had both databases been up to date, it is more likely the crew would have considered the source of the discrepancy between the two EFBs was related to something else, such as a data entry, and resolved the discrepancy.

Manual calculations of performance speeds

Instead of using the one serviceable EFB, the crew reverted to the manual take-off charts to calculate the performance speeds, a procedure rarely practiced by the crew. When using the manual performance tables to derive take-off speeds, it was unlikely the flight crew completed the full procedure for the manual calculation. The instruction to move down the ‘wind column’ appears at the top of the second page of instructions. It was likely that this step, and subsequent steps, were overlooked, resulting in performance speeds for the maximum regulated take-off weight (RTOW) being used.

The ATSB could not establish whether both of the flight crew independently made the same calculation error or if the results were not independently validated by the pilot flying (PF). Either way, the error by the pilot monitoring (PM) was not detected by the PF.

Rotation and flap overspeed

The actual rotation speed of 169 kt was only 16 kt below the maximum flap extended speed (185 kt), 41 kt closer than the correct rotation speed would have been. The PF rotated the aircraft at a rate significantly below the recommended rate of 3°/s. This resulted in the aircraft attitude reaching 10.5° pitch-up, instead of 15°, 5 seconds after rotation when the maximum flap extended speed was exceeded. The pitch attitude reached 15°; 11 seconds after rotation.

It is likely that the SRS was indicating guidance to the PF to increase the pitch, which, had the PF followed, would have reduced the aircraft acceleration. According to the simulation conducted by Airbus, if a 3°/s pitch rate had been achieved, the flap overspeed would not have occurred.

The PM did not bring to the attention of the PF the incorrect pitch attitude at take-off. Had the PM called ‘pitch’ it may have prompted the PF to increase the pitch. Jetstar stated this call was not specifically published, like many calls a PM would need to make to identify an incorrect control input.

Thrust management

When the PM called ‘speed, speed’, the PF reduced the engine power in response, as opposed to increasing the aircraft pitch. The thrust reduction occurred below the thrust reduction altitude and therefore had the potential to affect safety of the flight.

Landing gear retraction overspeed event

The retraction of the landing gear was not performed when positive climb was achieved. While troubleshooting a buffeting sound, the PF found that the landing gear was still extended and called ‘gear up’. The PM immediately retracted the landing gear without checking the aircraft’s actual airspeed relative to the maximum landing gear retraction speed. This resulted in an overspeed event when the landing gear was retracted beyond the maximum landing retraction speed. The correct procedure was to reduce the aircraft’s speed below the maximum landing gear speed before retracting the landing gear. There is no aircraft warning associated with this event.