The preliminary report by the Australian Transport Safety Bureau into a double missed approach to Melbourne Airport in fog by a Jetstar A320 on 21 July points to a critical error that caused the jet to sink close to the ground instead of climbing away as intended.

The report needs to be read in full, not the one line summary. While the ATSB reports are non-judgmental and conducted solely with a view to learning from safety incidents and improving flight safety, it discloses some disconcerting details about the flight:

  • The pilot in command set the engine throttles at the wrong setting to conduct a go around;
  • With the engines incorrectly set the aircraft did not transition to the speed reference mode the pilots had anticipated and sank toward the ground instead of climbing away;
  • The jet was 43 feet above the ground before the wheels were retracted and the engine thrust had recovered sufficiently for the jet to climb as the pilots had originally intended.

It is clear from the preliminary report that Jetstar’s repeated claims that an automated system on the jet had failed were incorrect.

It is equally clear that Jetstar management was unaware of the seriousness of the situation the flight had been placed in until after 2 August when it began an internal investigation of the incident.

The ATSB notes that when the incident was first reported to it by Jetstar, on 26 July, the information provided led it to assess the incident as “not meeting the criteria of a reportable matter under the Transportation Safety Investigation Act.”

The safety investigator says that in response to media reports on 11 September of a potentially serious incident it contacted Jetstar which provided additional information.

The ATSB re-assessed it to be of sufficient seriousness to warrant the immediate initiation of an investigation.

The independent safety investigator says that its further inquiries into this Jetstar incident will focus on flight training standards, Jetstar’s incident reporting procedures, aircraft system operations and maintenance, provision of information to flight crews, and transition training (from other types of jets).

Crikey notes that these are all areas which are not only core responsibilities and obligations under Jetstar’s airline operator certificate, but the continuing responsibility the Civil Aviation Safety Authority under its oversight and enforcement obligations in law.

The subsequent and final report of the ATSB into this near thing at Tullamarine could prove to be seat-of-the-pants reading.

But more to the point, this process will greatly improve public safety.