Those familiar with basic aviation law are stunned by the continued evasion by the ATSB, CASA and the Qantas Group of full disclosure of a critical issue in the botched Jetstar go-around at Melbourne Airport on July 21, 2007, which is included in the terms of reference in the Senate inquiry into pilot training and airline safety.
In its final report into that incident the ATSB says:
The aircraft operator had changed the standard operating procedure for a go-around and, as a result, the crew were not prompted to confirm the aircraft’s flight mode status until a number of other procedure items had been completed. As a result of the aircraft not initially climbing, and the crew being distracted by an increased workload and unexpected alerts and warnings, those items were not completed. The operator had not conducted a risk analysis of the change to the procedure and did not satisfy the incident reporting requirements of its safety management system (SMS) or of the Transport Safety Investigation Act 2003.
As a result of this occurrence, the aircraft operator changed its go-around procedure to reflect that of the aircraft manufacturer, and its SMS to require a formal risk management process in support of any proposal to change an aircraft operating procedure.
Get Crikey FREE to your inbox every weekday morning with the Crikey Worm.
In fact Jetstar’s actions were a violation of the conditions of certification of the Airbus A320 for airline service in Australia that came into effect in 1998, a situation that could not possibly have been unknown to the Qantas subsidiary, or CASA or the ATSB.
Before 1998 Australia allowed unique flight manuals, and thus their incorporated standard operating procedures or SOPS, to be devised by its airlines and approved by the equivalent of CASA today.
But since then, the only approved flight manual, or AFM, for any type of airliner flown by an Australian carrier is the one published by the manufacturer and approved by the certification authority in the jurisdiction that applied to it. Boeings thus have AFMs which are approved by the US authority and adopted by convention by other aviation regulators, and Airbuses have AFMs approved by the European authorities.
If Jetstar wanted to change any of its SOPs in relation to its A320s it was under strict legal obligation to obtain the approval of both Airbus and its certification authority. A formal variation of the certification paperwork in Australia would then ensue.
No of these steps were taken by Jetstar. It made a change to the SOP applying to missed approaches by an A320 that meant the pilots were no longer required to immediately confirm the correct flight mode of the jet. That mode should have been to put the jet into its go around mode by engaging the TOGA or take-off and go-around engine power detent. In fact they selected a lower, inadequate and potentially dangerous setting.
But Jetstar had already instructed pilots not to immediately check the throttle setting in a go-around situation.
There is no conceivable rationale, nor legal basis, for the change Jetstar made. It was inherently inimical to the safety of flight. Jetstar made changes, without generating any paperwork that the ATSB could find, that were to imperil the 140 or so persons on board the A320 that descended in fog to within at least 38 feet of the ground at Tullamarine Airport, amid disorder in the cockpit, and a double enhanced ground proximity warning.
It is clear from the ATSB report that the two pilots didn’t understand why the jet was continuing to sink deeper into the fog and failing to respond as they had expected, because the thrust levers had actually been placed in the wrong detent. Their new procedure excluded an immediate check of the position of the throttle setting to determine if it had engaged the take off/go around power setting required by Airbus to fly away from the airport and variously make another attempt to land or divert to an alternative airport.
And as previously reported here and in Crikey, Jetstar withheld information about the generation of ground proximity warnings on that flight for 40 days after it became aware of them, and only provided it to the ATSB when ordered to do so, on September 11, 2007, in response to a report in Crikey and Aviation Business.
The withholding of information has continued in the Qantas/Jetstar, CASA and ATSB submissions which can be accessed here. The Qantas document only goes as far as to blame the pilots for not telling the airline that the ground proximity alerts had sounded, and thus on any fair reading, misleads the Senate through omission. CASA avoids discussing the situation at all, and the ATSB submission rather less concise about the situation that it was in its final inquiry report into the incident.
Qantas CEO Alan Joyce, who was the CEO of Jetstar at the time of the incident, is to appear before the Senate inquiry in February. No one is suggesting that Joyce was instrumental in the dangerous and inexplicable change made to the go-around procedure at Jetstar, but he is responsible for the conduct of the airline, then as its founding CEO, and now as the head of the group that owns it. He is responsible in the final analysis for the document that has been tendered on his behalf to the inquiry.
The Jetstar incident is relevant to the inquiry at a number of levels, including the actual engagement of airline managements in general with fulfilling their obligations to the maintenance of safety and flight standards. It is relevant to the rigor with which CASA enforces the purpose and intent of aviation regulations at the level of iconic and powerful airline brands. And, it draws attention to the candor with which the ATSB communicates with the public, at a time when the excellence of its investigations has been given world wide recognition because of its work on the Qantas QF32 A38o incident of November 4.
Perhaps before February some revised submissions from Qantas/Jetstar, CASA and the ATSB could be forthcoming, throwing light on Jetstar’s capacity to break the conditions for the operation of a jet airliner without even generating a single document, or causing any regulatory enforcement.
It is astonishing that CASA and the ATSB could not bring themselves to acknowledge that compliance with all aspects of the certification of an aircraft is a legal requirement, the more so when failure to obey that requirement put the lives of everyone on board that flight in mortal danger.