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Jetstar twice broke safe altitudes landing in Queenstown

March 14, 2014 Aviation, Headline News No Comments Email Email

egtmedia59“Unsafe descent Airbus A320” is the terse headline on a statement by the Australian Transport Safety Bureau (ATSB) relating to its report on a Jetstar Airbus A320-232 which descended below minimum safe altitudes.

The ATSB considers the infraction serious enough to issue a bulletin reminding operators and flight crew “of the vital importance of continuous attention to active and armed auto-flight system modes”.

“This reminder comes after an incident which occurred on 16 July 2012 as an Airbus A320-232, operated by Jetstar Airways, was Queenstown Airportarriving at Queenstown International Airport, New Zealand,” the ATSB states.

The full report, which can be downloaded on the ATSB website www.atsb.gov.au, shows that the pilots twice took the 180-seat A320 below the safe minimum altitudes over two segments of the complex approach, as the jet was flying between mountain peaks. The pilots eventually recognised their error and climbed to a safe altitude before continuing the landing approach.

Queenstown, surrounded by snow-capped mountains, is considered a challenging airport at which to land. A video taken from the cockpit, showing an A320 landing there can be viewed by clicking here or below.  The plane’s registration number, visible on the control panel, looks like VH-VQS, an Australian-registered A320-232 flown by Jetstar Airways, according to planespotters.net

The ATSB report continues as follows:

The aircraft was conducting an instrument approach to runway 05 using the aircraft auto-flight system. The approach consisted of a series of progressively lower steps that signified the minimum safe altitude for each segment of the procedure.

The crew intended to select an auto-flight system mode during descent that would have ensured compliance with procedure minimum safe altitudes, but overlooked that selection. As a result, the aircraft continued descent in an unintended mode that did not prevent infringement of minimum safe altitudes.

The aircraft consequently descended beneath the minimum safe altitude of two segments of the approach procedure. Upon recognising the descent profile problem, the crew climbed the aircraft to intercept the correct path and continued the approach to land safely.

Although the aircraft was below the minimum safe altitude during two segments of the approach, a collision with terrain was never likely given the fine and clear in-flight conditions. No Ground Proximity Warning System alerts were generated during the incident.

The ATSB found that the crew were not strictly adhering to the operator’s sterile flight deck procedures, which restrict flight deck conversation during the safety-critical and high workload phases of flight to important operational matters. This probably allowed the crew to become distracted and not notice that descent was continuing in an unintended auto-flight system mode. Also, the operator’s procedures did not specifically draw the crew’s attention to unchanged auto-flight system modes during descent.

Following this occurrence, the operator included additional guidance material in its Flight Crew Training Manual regarding mode awareness. It also included a warning on its Queenstown approach charts.

It is important that crews continually monitor descent profiles in relation to approach procedure minimum safe altitudes, irrespective of any expectation that the descent is being appropriately managed by the auto-flight system. This occurrence also highlights the importance of robust auto-flight system management procedures.

The pilots also conducted a conversation about non-flying matters during the spectacular approach past mountain peaks.

Jetstar responded:

  • As part of our own review, Jetstar has included additional material in flight crew manuals further emphasising the importance of situational awareness for pilots.
  • Flying charts for Queenstown and the surrounding region have been amended to further emphasise the necessary requirements for approaches into the airport.
  • Jetstar takes anything that happens in its cockpits very seriously. The aircraft continued to fly a safe approach and landing in clear conditions on on the day of this event. 

Written by : Peter Needham

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