Jetstar incident reminds of value of the media

Late last week the ATSB handed down a report into the bungled missed approach incident involving a Jetstar flight at Melbourne Airport on 21 July 2007.

In that incident the aircraft descended to 38 feet above the runway while the crew mishandled the go-round.

The report says in part that:

A subsequent examination of the aircraft’s automated systems indicated that there were no system faults or anomalies that may have contributed to the event…

Neither the PIC’s nor the copilot’s training or experience, when coupled with the unexpected distractions and workload during the event, enabled them to quickly diagnose the situation during the early part of the first missed approach. For a period of approximately 48 seconds, they were uncertain as to what the automated flight control system of the aircraft was doing, or why…

Evidence from a range of studies worldwide indicates that shortcomings in flight crew training associated with the operation of aircraft automated flight control systems is of ongoing concern. Accidents and incidents where the flight crew have a poor understanding of the operation of the automated systems continue to occur…

Two major points of interest to emerge from the enquiry:

Firstly, ATSB recommends that, “As the aviation industry is increasingly using third party training providers to provide training for aircraft operators, it is becoming increasingly important that proposed requirements under CASR Part 142 (ie third party training organisations that provide training, either independently to individuals or in concert with aircraft operators, must be responsible for the training they provide) be introduced as a priority”.

Secondly, the report says that, “It was only when the ATSB was alerted by media reports of the potentially serious nature of the occurrence that sufficient information become available from the aircraft operator on which the ATSB could determine the need for a formal investigation under the TSI Act”.

The first report of this incident was in Aviation Business HEADLINES. Yet another reminder of the value of responsible media as a backup when established processes fail.