The flying public should be uneasy over the decision of Australia’s independent air safety agency, the Australian Transport Safety Bureau (ATSB) not to investigate a breakdown of captain-copilot co-operation in the cockpit of a Jetstar A321 that had to make a go-around while approaching Cairns airport on November 3.
The junior and inexperienced-on-type pilot twice made a basic error in flap selection. It is contrary to the purpose and intent of Australian air safety regulations for anyone so unskilled that he or she can’t find their way around the controls of an airliner to be accepted as suitably trained to fly one full of passengers.
The purpose of the rules is to stop such a situation arising, not ignore it.
This tells us there has been a quality control failure in Jetstar’s pilot training, type endorsement and hiring processes, and an inexplicable lack of judgment on the part of the safety investigator.
A mistake is one thing, but systemic failure is another, and it was discovered in this case in an abnormal flight situation when the pilot workload was subject to sudden additional stress.
It is precisely the sort of incident that air safety agencies are set up to investigate, and was first described in detail in Crikey blog Plane Talking yesterday.
The go-around was an instance of what air safety authorities call a CRM or cockpit resource management failure.
CRM failures kill people when they go wrong. They are a major cause of air disasters. Yet the ATSB has argued that because Jetstar says no aural alerts were generated in the cockpit, and because it happened when the 220 or so passenger airliner was about 1900 feet above the ground with its wheels lowered, it needn’t investigate, a sophism that ignores the significance of CRM incidents.
That significance has not been lost on CASA, which says it is now continually monitoring new pilot training outcomes at Jetstar, which, according to its group CEO Bruce Buchanan, prefers young, inexperienced pilots anyhow, a view that led to some fascinating exchanges before the Nick Xenophon-inspired Senate committee hearings into pilot training and airline safety earlier this year.
It is true that not all go-arounds require investigation. But those where a co-pilot fails to recognise the correct lever twice in quick succession in a jet full of people demands attention.
More to the point, the ATSB on Monday released a damning but cleverly muted report into a similar go-around by a Jetstar A320 approaching Melbourne Airport on July 28, also reported in detail here, which reveals different yet potentially deadly CRM failures on that flight.
In the July 28 stuff-up, the A320 was left in an unstable situation until it was 245 feet above the ground, and according to an internal Jetstar report, saw the captain overworked to distraction by a less-experienced co-pilot who was working on the assumption that the captain was performing functions critical to the landing for him, while the captain had no idea the person in the right-hand seat was under such an illusion.
For the ATSB to ignore one CRM related incident but inquire into another is inconsistent. Taking the two incidents into account, as it has, CASA has every reason to take action against Jetstar on the basis that there is a pattern of incidents that posed an inherent risk to public safety.
In a statement last night, CASA said the Jetstar incidents were not as serious or persistent as those that led to its grounding of Tiger Airways for five weeks in July and August.
They are nevertheless serious, and the implications of the ATSB not inquiring into a second Jetstar CRM related incident in three months ought to raise real concerns about the consistent and diligent public administration of air safety in this country.