A fierce report about the conduct of pilot training at Jetstar and an incompetent and dangerously bungled double missed approach to Melbourne’s Tullamarine Airport on July 21, 2007 has been published this morning by the air safety investigator, the ATSB.

This report is the result of a persistent campaign by Crikey that year to force some accountability from Jetstar and CASA in relation to the incident.

Although Jetstar has since taken action that satisfies the ATSB, it begs the question why an inquiry into the fitness of the Qantas subsidiary to continue to hold an air operator certificate at the time was not launched by CASA, which is supposed to regulate the airline industry.

After the incident occurred Jetstar breached the reporting rules for safety incidents and on the basis of what it was told, the ATSB concludes that there was no requirement for an inquiry. It was not until September 11, when Crikey and Aviation Business both reported that the jet had come close to the ground and that the ground proximity warnings had been triggered that the then minister, Mark Vaile, CASA and the ATSB called for proper documentation of the incident.

It turned out to have been a near disaster which brought the Airbus A320 to within 38 feet of the ground during the first of two missed approaches and left two inappropriately trained pilots baffled, confused and annoyed by loud synthetic voice warnings while they tried to work out what to do next.

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The ATSB report finds fault with the Jetstar processes that were then in place for the endorsement of pilots unfamiliar with the Airbus fly-by-wire systems.

It finds that Jetstar, for reasons it was unable to ascertain, had changed the manufacturer’s recommended go-around procedures in a way that left the pilot and co-pilot unsure as to what was happening at a critical part of the procedure, other than being aware that their jet it was sinking toward the ground rather than climbing away from a runway they couldn’t see because of fog.

The captain of the jet set the incident in motion by failing to select the correct “detent” or throttle position after deciding to go around, leaving the engines delivering ‘flexible thrust’ rather than the expected maximum TOGA or take off/go around thrust setting.

The ATSB report documents the confusion and pressure in the cockpit, which left each pilot remembering only one of two sets of aural warnings, an unexpected pitch down in the nose of the jet at one stage and a degree of confusion unheard of in any previous report into a jet airliner incident in Australia ever.

cockpit confusion

It says that for 48 seconds neither pilot knew what the flight control system of the jet was doing or why. In the course of its inquiry the ATSB says it found evidence of other similar incidents of pilot confusion over the A320 in Jetstar service. The ATSB also details the failures of the airline to correctly report the incident, although it finds it did not set to do so deliberately.

Some of the archived Crikey reports aimed to forcing this incident into the open are here, here, here, here and here.