Jetstar A320 at Coolangatta on Mar 31st 2014, incorrect configuration for landing

Last Update: June 17, 2014 / 15:15:31 GMT/Zulu time

Bookmark this article

Incident Facts

Date of incident
Mar 31, 2014

Classification
Incident

Airline
Jetstar Airways

Flight number
JQ-216

Departure
Auckland, New Zealand

Destination
Coolangatta Goldcoast, Australia

Aircraft Registration
VH-VGT

Aircraft Type
Airbus A320

ICAO Type Designator
A320

Airport
Gold Coast Airport, Gold Coast

Airport ICAO Code
YBCG

A Jetstar Airbus A320-200, registration VH-VGT performing flight JQ-216 from Auckland (New Zealand) to Coolangatta Goldcoast,QL (Australia), was on approach to Coolangatta's runway 14 when the aircraft descended below approach profile prompting the crew to initiate a go around. The aircraft positioned for another approach to runway 14 and landed safely about 12 minutes after going around.

Australia's ATSB reported the crew had "inadvertently set an incorrect air pressure (QNH) on the Electronic Flight Instrument System Control Panel (EFIS), resulting in the aircraft being below the normal approach path." The ATSB rated the occurrence a serious incident and opened an investigation.

Radar data show, that the aircraft was below 600 feet measured to standard pressure (approximately 700 feet MSL measured to QNH) 3nm before the runway threshold on first approach before initiating the go-around. At that position a standard 3 degrees glidepath would require the aircraft to be at 950 feet AGL.

On Jun 17th 2014 the ATSB released their final bulletin releasing following safety message:

The ATSB SafetyWatch highlights the broad safety concerns that come out of our investigation findings and from the occurrence data reported to us by industry. One of the safety concerns is data errors, such as the wrong figure being used as well as data being entered incorrectly, not being updated, or being excluded,

In this incident, the incorrect data was entered and there was a subsequent omission to check the data. Risk controls including procedures, systems, reference materials, crew management practices and training were assessed as being adequate, however local conditions of time pressure and distraction may have contributed to the incident.
This incident highlights the impact distractions can have on aircraft operations, particularly during a critical phase of flight. Research conducted by the ATSB found that distractions were a normal part of everyday flying and pilots generally responded to distractions quickly and efficiently. It also revealed that 13 per cent of accidents and incidents associated with pilot distraction between January 1997 and September 2004 occurred during the approach phase of flight.

The crew was descending towards Gold Coast Airport, as usual enroute the altimeters had been selected to STD settings (QNH 1013). About 15 minutes prior to estimated landing the crew obtained ATIS, the captain - pilot monitoring - noted down: "cloud, which was ‘scattered’ (3-4 oktas4) at ‘025’ (2,500 ft); temperature 25 °C; and barometric pressure (QNH) 1018 hPa." The crew subsequently performed their approach briefing. The aircraft subsequently was cleared to descend to FL130 where the first officer briefly levelled off the aircraft before the aircraft received clearance to descend to 9000 feet QNH 1018. The captain acknowledged the clearance and compared the QNH with his notes and the FMGC settings. When the aircraft was descending through transition altitude the captain was again busy communicating with ATC.

Normally the pilot monitoring would initiate the transition checklist. The first officer pointed to the barometric reference switch in an attempt to alert the captain to begin the transition checklist. When the aircraft descended through 10,000 feet the BARO REF began flashing. As the captain did not respond and did not initiate the transition checklist, the first officer glanced at the takeoff and landing card/notes of the captain and entered 1025 into the altimeter, possibly interpreting either cloud or temperature as QNH.

The captain finished the communication with ATC and initiated the transition checklist, but omitted to call the FMGC page showing the entered QNH. The first officer stated QNH 1025, the captain entered that setting into the second altimeter, the first officer entered that setting into the stand by altimeter and all three altimeters were cross checked.

The crew subsequently performed a required navigation performance RNP approach. The radio altimeter callout 2500 feet occurred over the sea, the altimeters showed 2500 feet and thus did not alert the crew to an incorrect altimeter setting.

While descending through 1000 feet AGL the VASIs provided a fly up indication, the first officer asked the captain whether the profile looked wrong and the captain responded it may look different due to local terrain. The approach was continued, the gear was extended and the flaps set to 3. When the radio altimeter call out 500 feet occurred the first officer realized the profile was wrong. At 159 feet AGL the EGPWS activated calling "Terrain!" and the first officer initiated a go-around. The first officer checked the takeoff and landing card and realised the QNH was wrong.

The first officer noticed during the second approach that upon the radio altimeter call 2500 the altimeters showed 2340 feet MSL.

The ATSB summarized the crew statements: "The crew reported that in Australia, air traffic control provide the QNH for the arrival destination when providing the clearance through the transition altitude, which the crew read back and cross-check against the QNH entered in the FMGC. After setting the QNH, there are no further requirements for ATC to provide the QNH. In New Zealand, on first contact with approach, the crew are again given the QNH. This provides a cross check between the QNH that has been set in the altimeters with the actual QNH. The first officer commented that having set the altimeter prior to the standard ‘transition’ check, and not in conformance with standard procedure, he should have identified that as a potential threat and advised the captain. He also reported that reducing the aircraft speed approaching transition, may have reduced the workload at the time.
The captain commented that if he had prioritised setting the QNH over communicating with ATC approaching the transition altitude, he may then have checked the QNH in the FMGC and set the correct QNH."

Airbus advised that they have commenced a design review to conduct an automatic cross check of ADIRS and FMGC QNH settings. This cross check would have alerted the crew to the fact, that the QNH values entered into the altimeters and into the FMGC were different.

Metars:
YBCG 311000Z AUTO 19005KT 9999 // SCT017 SCT025 BKN030 22/20 Q1019
YBCG 310952Z AUTO 19005KT 9999 // SCT017 SCT023 BKN028 22/21 Q1019
YBCG 310930Z AUTO 21004KT 4600 // SCT023 BKN032 BKN043 22/21 Q1019
YBCG 310927Z AUTO 22004KT 6000 // SCT023 BKN032 BKN043 22/21 Q1019
YBCG 310900Z AUTO 19003KT 9999 // SCT016 BKN020 BKN026 22/21 Q1018
YBCG 310830Z AUTO 15004KT 9999 // SCT019 BKN033 OVC063 23/20 Q1018
YBCG 310829Z AUTO 15005KT 9999 // SCT019 BKN033 OVC063 23/20 Q1018
YBCG 310813Z AUTO 15008KT 6000 // SCT019 SCT027 BKN033 23/20 Q1018
YBCG 310800Z AUTO 17007KT 9999 // SCT019 SCT025 SCT031 24/21 Q1018
YBCG 310730Z AUTO 16007KT 9999 // SCT018 SCT026 BKN045 24/21 Q1018
YBCG 310700Z AUTO 16008KT 9999 // SCT020 SCT024 25/20 Q1018
YBCG 310630Z AUTO 16010KT 9999 // SCT022 BKN069 25/20 Q1018
YBCG 310600Z AUTO 16010KT 9999 // SCT025 SCT078 25/20 Q1017
YBCG 310530Z AUTO 13012KT 9999 // SCT023 SCT032 SCT072 26/20 Q1017
YBCG 310500Z AUTO 13012KT 9999 // SCT070 BKN110 27/20 Q1017
YBCG 310430Z AUTO 13012KT 9999 // OVC100 26/19 Q1018
YBCG 310400Z AUTO 14011KT 9999 // SCT074 OVC091 26/19 Q1018
YBCG 310330Z AUTO 14011KT 9999 // SCT029 OVC076 25/19 Q1018
YBCG 310300Z AUTO 13012KT 9999 // BKN072 OVC085 26/19 Q1018
YBCG 310230Z AUTO 15011KT 9999 // SCT025 BKN079 OVC105 26/19 Q1018