Jetstar A321 at Singapore on May 26th 2010, landing configuration warning

Last Update: April 19, 2012 / 13:31:34 GMT/Zulu time

Bookmark this article
Incident Facts

Date of incident
May 26, 2010

Airline
Jetstar Airways

Aircraft Registration
C-FWJI

Aircraft Type
Airbus A321

ICAO Type Designator
A321

The Australian Transportation Safely Board (ATSB) released their final report concluding:

Contributing safety factors

- The flight crew continued the approach despite not being able to satisfy the operatorÂ’s stabilised approach criteria prior to the stipulated 500 ft in visual meteorological conditions.

- A number of distractions during the approach degraded the crewÂ’s situation awareness and resulted in the crew not detecting the incorrect aircraft configuration.

- The captain did not appropriately monitor the aircraftÂ’s configuration or the actions of the first officer.

Other safety factors

- The lack of effective intra-crew communication accentuated their loss of situation awareness.

- The first officerÂ’s decision making was probably affected by fatigue.

The first officer (ATPL, 4,097 hours total, flying Airbus A320 family aircraft since May 2008) was pilot flying (PF) on approach to Singapore, the captain (ATPL, 13,431 hours total, A320/A330 family experience since 2005) was pilot monitoring (PNF). The aircraft was radar vectored for an ILS approach to runway 20R avoiding thunderstorm cells east and west of the aerodrome. The aircraft was subsequently cleared to descend to 2500 feet and intercept localizer runway 20R at a speed of 160 KIAS and flaps 2 extended. While intercepting the localizer the crew became visual with the runway and remained visual for the rest of the approach. The captain reported that he focussed to the outside of the aircraft in compliance with recommendations by the airline procedures, while procedural emphasis states continued monitoring of the aircraft performance and trajectory is essential.

After establishing the aircraft on the localizer the first officer disconnected the autopilot and continued manually, together with the autopilot disconnection a master warning continous chime and ECAM message "AUTO FLT A/P OFF" occurred, the first officer later reported he believed he did not push the Sidestick Takeover Button twice, neither pilot remembered the chime.

After intercepting the glideslope, descending between 2500 and 2000 feet, noises were heard in the cockpit indicating the arrival of text messages on the captain's mobile phone. The first officer requested the captain to set the go-around altitude of 5000 feet on the flight control unit but received no reply. He repeated the request using the "RAISE" method of bringing any divergence from the standard operating procedures to the attention of the relevant crew member, that had been approved by the operator. He still did not receive a reply and looked over to the captain seeing the captain pre-occupied with his mobile phone and set the go-around altitude himself. The captain stated in post flight interviews he was unlocking and shutting his mobile phone down and did not hear the first officer's communication.

The captain subsequently pointed out the autopilot disconnect message on the ECAM, the first officer requested the message to be cleared and stated later he found the intervention by the captain distracting.

When the GPWS announced "1000 feet" the first officer made a scan of the instruments. He stated in post flight interviews, that he felt something was not right but he couldn't pinpoint what it was. The captain stated he noticed at that point the landing gear was still up and the flaps at position 2. As he was not pilot flying he didn't focus on the stabilized approach criteria. Neither pilot initiated the landing checklist.

When the aircraft descended through 720 feet AGL (radar altimeter) a master warning and aural alert for landing gear configuration activated. The first officer noticed a red light at the landing gear lever and ECAM messages indicating the gear was not down and intended to go around, however the landing gear was selected down and descending through 503 feet AGL flaps were selected to position 3. The captain said in post flight interviews that he instinctively reached out and selected the gear down upon and flaps to position 3 upon hearing the configuration alarm. Neither captain nor first officer called out their intentions at that time.

Descending below 500 feet AGL the GPWS alerted "TOO LOW GEAR" as the gear was still in transit. 9 seconds after the alert the crew initiated a go-around, the pitch up rotation commenced at 392 feet AGL though both crew believed they had gone around at 800 feet AGL. During the pitch up rotation the captain's sidestick recorded a pitch down command for 4 seconds, after 2 seconds another pitch down was commanded on the captain's sidestick. The captain later said he was not aware of applying any side stick pressure.

The aircraft was cleared to climb to 3000 feet. The first officer commanded flaps 2, both captain and first officer thought the flaps were set to position 2, flight data recorder data however showed the flaps remained in configuration 3 until above 3000 feet. The aircraft subsequently positioned for a second ILS approach to runway 20R and landed without further incident.

Both crew believed in post flight interviews with the Duty Captain shortly after landing, that they were not tired and were not suffering from fatigue.

The ATSB observed a simulator training by the operator and subsequently annotated that descending between 2800 and 1000 feet there were 2 minutes of non-activity, during which no control manipulations or systems activation occurred. These two minutes could well be used to prepare for landing, e.g. select the landing gear down, select the flaps for landing configuration, arm the spoilers, select auto brakes, complete the landing checklist and check the flight parameters in order to ensure the aircraft was configured and stabilized for landing at 1000 feet AGL.

The ATSB stated with respect to monitoring of the flight progress: "The operatorÂ’s procedures required all crew members to be aware of the PFÂ’s intentions with respect to an approach and to ensure that any diversions from procedures, air traffic clearances or the intended flightpath were immediately drawn to the PFÂ’s attention. Also, as part of the operatorÂ’s stabilised approach criteria, the PNF was required to monitor the approach path, rate of descent and airspeed to ensure that they remained within specific tolerances during an approach. The PNF was required to immediately notify the PF of any excursions and both pilots were to monitor the approach."

The ATSB analysed that the aircraft was approaching in visual meteorological conditions requiring the aircraft to meet the stabilized approach criteria at 500 feet AGL, the aircraft however had not met these criteria, the go-around therefore was appropriate. A number of cockpit distractions combined with fatigue adversely affected the first officer. Under normal circumstances the captain would be expected to monitor and correct the situation.

The ATSB analysed further: "The lack of effective monitoring by the captain meant that the non-standard disconnection of the autopilot by the FO, and ‘AUTO FLT A/P OFF’ alert on the Electronic Centralised Aircraft Monitor (ECAM) remained undetected until later in the approach. Once visual with the runway, the captain’s focus external to the aircraft also adversely affected his monitoring role. The mobile phone messages acted to compound the captain’s distraction from the monitoring and support roles during the latter stages of the approach. That would likely explain the captain’s inaction when asked by the FO to set the missed approach altitude and the captain’s report that he did not hear the FO’s requests for that support. ... The receipt of the text messages on the captain’s phone, and the retrospective action by the captain to bring the autopilot disconnection ECAM to the FO’s attention, distracted the FO to the extent that the existing crew resource management effectively broke down."

A number of safety actions were taken by the operator as result of the incident.
Incident Facts

Date of incident
May 26, 2010

Airline
Jetstar Airways

Aircraft Registration
C-FWJI

Aircraft Type
Airbus A321

ICAO Type Designator
A321

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

You can read 2 more free articles without a subscription.

Subscribe now and continue reading without any limits!

Subscribe now
Are you a subscriber? Login
Subscribe

Read unlimited articles and receive our daily update briefing. Gain better insights into what is happening in commercial aviation safety.

Compare our plans

Send tip

Support AeroInside by sending a small tip amount.

Send tip

Related articles

Newest articles

Subscribe today

Are you researching aviation incidents? Get access to AeroInside Insights, unlimited read access and receive the daily newsletter.

Pick your plan and subscribe

Partner

Blockaviation logo

A new way to document and demonstrate airworthiness compliance and aircraft value. Find out more.

ELITE Logo

ELITE Simulation Solutions is a leading global provider of Flight Simulation Training Devices, IFR training software as well as flight controls and related services. Find out more.

Blue Altitude Logo

Your regulation partner, specialists in aviation safety and compliance; providing training, auditing, and consultancy services. Find out more.

AeroInside Blog
Popular aircraft
Airbus A320
Boeing 737-800
Boeing 737-800 MAX
Popular airlines
American Airlines
United
Delta
Air Canada
Lufthansa
British Airways