Jetstar A320 at Ballina on May 18th 2018, two go arounds and incorrect configurations

Last Update: December 10, 2019 / 14:41:22 GMT/Zulu time

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Incident Facts

Date of incident
May 18, 2018

Classification
Incident

Flight number
JQ-458

Aircraft Registration
VH-VQK

Aircraft Type
Airbus A320

ICAO Type Designator
A320

A Jetstar Airbus A320-200, registration VH-VQK performing flight JQ-458 from Sydney,NS to Ballina,NS (Australia), was on a left visual circuit to Ballina's runway 24 with the first officer flying, when on short final at about 500 feet AGL the crew decided to go around. An incorrect flap setting was used during the go around, the captain took control of the aircraft. During the second approach, now with the captain flying, the crew received a warning that the landing gear was not down, the landing gear had not been selected down, the captain initiated another go around. The aircraft landed safely on its third approach.

The ATSB reported the crew estimated their workload as being high including due to communication regarding other traffic. The occurrence was rated an incident and is being investigated.

On Dec 10th 2019 the ATSB released their final report concluding the probable causes of the incident were:

- During the first go-around, the flight crew did not fully complete the standard go-around procedure, resulting in the aircraft’s flaps remaining at Flaps 3 rather than Flaps 1 during the subsequent visual circuit at 1,500 ft.

- During the downwind leg following the first go-around, the flight crew did not select the landing gear DOWN, as they had commenced the configuration sequence for landing at the Flaps 3 setting.

- The flight crew did not identify that, because the aircraft had not climbed through 2,200 ft, the landing memo had not been reset and was not displayed.

- Following both go-arounds, the captain elected to conduct non-standard right circuits. This increased the potential for traffic conflicts with other aircraft, and flight crew workload managing such conflicts.

The ATSB reported the first officer (CPL, 1,600 hours total, 1,400 hours on type) was pilot flying, the captain (ATPL, 11,000 hours total, 3,000 hour on type) was pilot monitoring.

During the first approach the first officer disengaged the autopilot at about 2000 feet AGL and continued manually, the aircraft was above the vertical profile with a higher speed than normal, the captain prepared for a go around but wanted first to be established on final approach due to considerations of traffic around (a helicopter was performing right hand patterns at the aerodrome). During the turn to final the aircraft reached up to 1300 fpm of sink rate but still remained above profile. At the automated 500 feet call the captain stated "unstable approach" and instructed a go around. The aircraft climbed to 1500 feet, the circuit altitude, with flaps in position 3 and TOGA thrust. The first officer considered that the aircraft was still accelerating and they might not remain below flaps limits, thus reduced the thrust levers to idle, which also disconnected autothrust. The captain noticed that the pitch approached 10 degrees nose up with reducing speed and called immediately to place the thrust levers into the Climb Detent again and re-engage autothrust. The captain decided to perform a right hand pattern, considering the helicopter was also doing right hand patterns, the first officer offered to relinquish control to the captain, the captain took control of the aircraft. While on the turn to second final to runway 24 the captain noticed the flaps were still at position 3 and commanded full flaps, which the first officer selected. The landing checklist was completed while descending through 950 feet. At about 700 feet AGL a master warning "L/G GEAR NOT DOWN" was triggred, the landing gear was selected down at that point, two seconds after the gear was selected down the captain initiated a go around however. The aircraft performed another right hand pattern and safely landed on the third approach.

The ATSB analysed:

Conduct of the first go-around

Due to the unstable approach on the first attempt to land, the flight crew appropriately performed a go-around.

An all engines go-around is a very dynamic procedure with high accelerations created by the application of take-off/go-around (TOGA) thrust. When performed at a low aircraft weight with low altitude level off, such as a 1,500 ft circuit height, it can be a demanding manoeuvre. It requires flight crews to perform a significant number of actions in a short period of time with all of them related to important changes of attitude, thrust, flight path, landing gear and flap configuration and flight modes. The actions need to be performed in the correct order, with a high level of coordination between the crew.

The initial actions of the first go-around manoeuvre, up until reaching the thrust reduction altitude, were performed correctly. However, instead of retracting the flaps on schedule to Flaps 1, the first officer (FO) called for the approach mode to be activated first in an attempt to reduce the aircraft’s acceleration. Concerned about a potential flap overspeed, the FO then retarded the thrust levers past the climb detent to IDLE. This action de-activated the autothrust system and its protections, which limit thrust to help prevent overspeeds. With Flaps 3 still set and about 10° nose-up pitch attitude, the aircraft performance deteriorated, requiring intervention by the captain.

Visual circuit

In this incident, several distractions caused the flight crew to deviate from the operator’s normal visual circuit procedures at Ballina. The FO was anticipating a left circuit to be flown in accordance with the published procedure for runway 24. However, the captain commanded a non-standard right circuit for various reasons, which he had not previously advised the FO during the approach briefing or the subsequent approach.

As the aircraft was being turned onto downwind the flight crew were presented with further distractions including the handover of flying duties to the captain and then correcting the lateral flight path spacing in the circuit. The captain continued to manually fly the aircraft, which added to his workload. Accordingly, the captain elected to concentrate on flying the aircraft and have the FO conduct the required checklists and radio calls. As the captain prioritised tasks he chose to remain at Flaps 3, which was permissible and safe, but not the operator’s standard configuration for a visual circuit which was Flaps 1.

Landing configuration

Linking an aircraft’s normal procedures with an identifiable phase of flight is designed to assist a flight crew’s procedural recall. During most approaches, a flight crew will follow the same sequence for configuring flaps, landing gear and spoilers and conducting the landing checklist.

The operator’s sequence of configuring the aircraft for landing required the landing gear to be selected DOWN prior to the selection of Flaps 3. As the captain turned on to the final approach during the second approach, he scanned the flight instruments, observed Flaps 3 already set and instinctively commanded Flaps FULL, which was the normal sequence from Flaps 3. The FO selected Flaps FULL but then also turned his attention to monitoring the aircraft’s flight path. As such, neither of the flight crew were aware that the landing gear had not been selected DOWN.

Landing checklist

The flight crew flew the second visual circuit at about 1,500 ft. Therefore the Electronic Centralised Aircraft Monitor (ECAM) landing memo logic was not reset after the go-around. When the flight crew performed the landing checklist on the second approach, with the aircraft at about 950 ft, the landing memo would not have been displayed on the Engine/Warning Display.

The absence of the landing memo should have prompted the flight crew to perform the items of the landing checklist as a ‘read-and-do’ checklist. Had they read the required actions from the checklist, both the captain and FO would have been required to independently check and announce that the landing gear was down. This method should have effectively ‘trapped’ their error.

When the landing memo did appear at 800 ft, both of the flight crew were situationally focused on intercepting the final approach path and performing radio calls. Neither the captain nor the FO recalled seeing the landing memo appear on the E/WD; which would have had the landing gear item in blue text. Both the captain and FO were subsequently alerted to the incorrect configuration for landing by a master warning message triggered at about 700 ft.

It would be ideal if the aircraft’s systems were designed such that the landing memo became available during the 1,500 ft visual circuit. However, system design is often a matter of compromise and there is also a need to minimise unnecessary complexity. Airbus set a minimum height of 2,200 ft to prevent spurious display of the landing memo during take-off and to prevent display flickering during an approach.

The exact reasons why both crew did not notice the absence of the landing memo when completing the landing checklist are unclear. However, a combination of workload and expectancy are often involved in such errors (Wickens and McCarley, 2008).9 In this case, the flight crew probably expected the memo to be there, given that it is normally present at that phase of flight. In addition, the absence of something that should be present is often more difficult to detect than the presence of something that should not be there (for example, Thomas and Wickens, 2006).10
Overall, this occurrence reinforces the importance of using normal procedures, and minimising and managing the effects of workload during critical phases of flight.
Incident Facts

Date of incident
May 18, 2018

Classification
Incident

Flight number
JQ-458

Aircraft Registration
VH-VQK

Aircraft Type
Airbus A320

ICAO Type Designator
A320

This article is published under license from Avherald.com. © of text by Avherald.com.
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