The good news is that after being caught out the Malaysia flag carrier changed its procedures and instructed its pilots as to follow the published Australian requirements for approaching this particular airport in bad weather, without descending too steeply, or disregarding safe mininum altitudes, which are there to stop them hitting the mountain ridges of the Gold Coast hinterland.

Actually, the ATSB was a bit less blunt than the above, but this is a post about air safety breaches, written in plain english, and with a view to stopping practices that could scatter hundreds of dead across the landscape which the rules are there to keep jets from hitting.

On 4 May 2010 an AirAsiaX Airbus A330-300 with 258 passengers, nine cabin crew and two pilots made three missed approaches to a Gold Coast airport the pilots couldn’t see through the cloud and rain, after which they landed the jet at nearby Brisbane airport.

On 10 May 2010 a different AirAsiaX crew in the same A330 landed safety at the Gold Coast airport with 260 passengers and the same head crew for the cabin crew and pilots on board, after one non-compliant missed approach in similarly poor visibility.

These were pilots that fly single aisle A320s and twin aisle A330s in the same roster period. The jets are very similar in flight operations, but not identical, and not all Airbus users with such mixed fleets accept the premise that their pilots should mix ‘n match their duty time on the two models.

In its report the ATSB details all of the missed approaches in clinical detail.

This is an extract from the 4 May missed approaches, with emphasis added to show that at times the flights were above the required altitude, below the required altitude, and in breach of the published approach procedures.

When the aircraft was about 5 DME(9 km) from the Gold Coast Airport, and 2,500 ft above mean sea level (AMSL), the aircraft was above the recommended descent profile for that approach. With the selected flightpath angle (FPA) of -4.9°, the aircraft was descending at a rate of about 1,300 ft/min. The flight crew continued descent until the aircraft was about 1,000 ft at 1 DME (2 km). At that point, a landing was not possible and they initiated a missed approach.

The crew was radar vectored at 2,500 ft for a second VOR approach to runway 32. Subsequently, the crew was cleared to make a pilot intercept of the final approach track and to conduct the approach.

The crew used the autopilot in selected mode to fly the approach. At 11 DME (20 km) they commenced descent, selecting an FPA of ‑3°. At that point, the aircraft was below the recommended descent profile and was descending below the procedure’s segment minimum safe altitudes.

Approaching 7 DME (13 km), the flight crew reduced the FPA to achieve level flight at 1,300 ft. At about the same time, the aerodrome controller advised the crew to check their altitude and that the radar lowest safe altitude in that area was 1,500 ft. The controller cleared the crew for further descent in accordance with the runway 32 VOR procedure. The aircraft remained below the segment minimum safe altitude until reaching 5 DME (9 km). Soon after, the controller provided the crew with surface wind information and cleared the aircraft to land.

At about 4 DME (7 km) and 1,300 ft, the crew reselected an FPA of ‑3° to commence the final descent to 750 ft, which was the minimum descent altitude (MDA). The aircraft reached the MDA at 2 DME (4 km) but low cloud, rain and reduced visibility prevented the crew from landing and they commenced another missed approach.

The flight crew then conducted a runway 14 VOR approach. Again, due to weather, they were unable to land the aircraft and conducted a missed approach and diverted to Brisbane, Qld. The aircraft landed at Brisbane at 0823.

In its account of the 10 May missed approaches the ATSB says

The flight crew conducted a Runway 32 VOR approach but were unable to land due to reduced visibility in low cloud and rain. Following a missed approach, the crew conducted another Runway 32 VOR and landed.

For both approaches, the crew commenced descent from 2,500 ft at about 10 DME (19 km), which was below the recommended descent profile. During each of those approaches, when between 9 and 7 DME (17 and 13 km), the aircraft was below the procedure’s segment minimum safe altitude.

Both approaches were conducted in selected mode, with the vertical navigation of the aircraft initially conducted in ‘open descent’. In open descent, engine power reduces to flight idle and the aircraft descends at the FPA required to maintain the selected airspeed. The aircraft reached 1,500 ft by about 8 DME (15 km), recording a maximum FPA of ‑5.6° and a rate of descent of about 1,500 ft/min.

From 1,500 ft, the descent to the MDA was conducted using a selected FPA of ‑3°, in accordance with the published procedure.

 

Later in its analysis of these incidents, the  ATSB says of 4 May stuff up:

The descent from 2,500 ft to 1,300 ft at the selected flight path angle (FPA) of -3° was continuous and was conducted without apparent regard for the published segment minimum safe altitudes. That resulted in the aircraft operating below the segment minimum safe altitude prior to the aircraft reaching the final approach fix at 5 DME (9 km), with the effect that separation from terrain and other aircraft operating in non-controlled airspace was no longer assured.

It was not clear why the flight crew commenced descent prior to the aircraft intercepting the recommended profile for the approach. Being above the recommended flightpath on the first approach might have influenced the crew to descend earlier to avoid being similarly high during the second approach. Unfamiliarity with the conduct of non-precision approaches, and especially those that incorporated intermediate segment minimum safe altitudes, was another possibility.

It also says of the 29 May instances:

In both approaches on 29 May 2010, the crew initiated descent at about 10 DME (19 km) and before the aircraft had intercepted the recommended descent profile for the non‑precision approach. Those descents were conducted without apparent regard for the published segment minimum safe altitudes. As a result, separation from terrain and other aircraft operating in non-controlled airspace was no longer assured.

It was not clear why the flight crew commenced descent prior to the aircraft intercepting the recommended profile for the approach and descended below the segment minimum safe altitudes. However, unfamiliarity with the conduct of VOR approaches that included intermediate segment minimum safe altitudes was again a possibility.

One possibility that the ATSB doesn’t canvas is that the crew didn’t read the navigational notes or had no intention of paying any attention to them, preferring to press on regardless.

AirAsiaX did respond fully to these incidents with comprehensive safety actions.

• Action taken by the aircraft operator

In response to these occurrences, AirAsia X developed a simulator training session that specifically targeted the Gold Coast approaches and emphasised the preference for pilots to conduct managed approaches. All flight crews were required to complete this training prior to further operations into the Gold Coast.

In addition, AirAsia X:

• Issued a ‘flight operations circular’ advising that open descent mode should not be used when performing an instrument approach.
• Issued revised Gold Coast approach charts.
• Implemented additional training and checking of crews operating to the Gold Coast.
• Implemented a policy recommending a maximum of two approaches before diverting to an alternate airport.
• Reduced the incidence of mixed-fleet flying such that pilots only fly either the A320 or the A330/A340 during a roster period.
• Implemented an instructor standardisation and enhancement program.

During the press conference earlier this week at which AirAsiaX rival Scoot announced its plan to fly to the Gold Coast from June, Queensland Premier Anna Bligh confirmed that an ILS system to improve bad weather access to the airport would be installed there sometime this year.

This post in the Smarter Travel site’s Today in Travel blog deals with the dual fears of US sky warriors, of their banking system in general, and Citibank’s actions in particular in shopping them to the US tax authorities for their tax liability for American Airlines points it supposedly gave away as an incentive to open new accounts.

If US banks can turn a frequent flyer ‘gift’ into a tax liability in the hands of the recipients in order to gain new sucker baited clients, and turn it into an inflated tax deduction for their own benefit, while lumbering the recipients with a tax bill running into hundreds of dollars each, don’t ask whether this could happen in Australia, ask ‘when?’

The old tax free points protocols are under attack.

The second story of concern is the Etihad launch of an app that turns points into cash at the point of sale using your smart phone. Maybe we need a better adjective than ‘smart’ for apps like this, since Etihad has gone very quiet on the consequences, no doubt unintended, of turning loyalty in cash, because it effectively turns points into income that would have to be disclosed under Australian tax rules.

Yeah, sure, it can’t happen here. Once the ramifications of this are studied, make no mistake, it can happen here.

This reporter has on various occasions been told that Qantas selects those it entrusts with flying jets covered with its brands on the basis of impeccable high standards equal to those of the parent brand.

Let’s hope Qantas was kidding about that. I think Qantas selected Cobham because it was cheap, or alternatively, it did assess Cobham as being on the same level of excellence as the brand, and thus totally dropped the ball, which resulted in the jet covered in their branding getting into a situation where it might have been dropped into the red dirt of the gold fields.

This is why this ATSB report is of special importance. It shows how a Qantas contractor did things that Qantas passengers don’t expect from a Qantas jet.

The series of stick shaker incidents described in the report occurred to a Cobham flown Qantaslink branded Boeing 717 trying to land at Kalgoorlie on 13 October 2010 carrying 97 passengers, three cabin crew and two pilots.

The first two attempts to land were flown by the co-pilot. The third successful attempt was flown by the captain.  The co-pilot told the ATSB he later realised he may have been affected by personal stresses, but the report doesn’t elaborate on this and it is fair to say that given the contents of the report, this doesn’t seem to be material, and it isn’t mentioned in its list of factors in the incidents.

The crew had incorrectly entered a landing weight for the jet in its flight management system computer that was  9,415 kilogram less than its actual landing weight, resulting in the first two approaches, which were abandoned, being flown at too low a speed.

On each occasion the aircraft behaved as if it was experiencing turbulence and the stick shaker briefly activated, warning the pilots that airspeed was falling toward stalling speed.

However, the jet did not enter aerodynamic stall, but the pilots didn’t know what was really going on either.

In its restrained but appropriate prose, this is how the ATSB described the situation which gave passengers a total of three scenic if bumpy views of the approaches to Kalgoorlie.

The flight crew’s pre-landing preparations included the selection of an approach speed (Vapp) based on the flight management system (FMS) generated reference speed (Vref) of 116 kts and an additive to allow for local weather conditions. As the reported weather conditions were relatively benign, the flight crew accepted the FMS default approach speed of 121 kts (Vref+5 kts).

However, unbeknown to the flight crew, the required approach speed based on the aircraft’s weight was actually 135 kts. The effect was that the margin to the actual stall speed of 106 kts in straight and level flight was reduced from 29 kts to 15 kts. Similarly, the margin to stickshaker activation was reduced from 24 kts to just 10 kts. In addition, due to the predictive nature of the stall protection system, the margins were probably further reduced.

The slower-than-required approach speed led to a higher angle of attack and an increase in drag that had an adverse effect on the aircraft’s performance and flight control responsiveness. As a result, the engine power and pitch attitude required to maintain the desired flight profile were higher than usual and significant pitch oscillations were evident. Those pitch oscillations contributed to the difficulty experienced by the flight crew controlling the aircraft’s flightpath and maintaining a stabilised approach.

The flight crew was provided with an indication of the aircrafts proximity to the stickshaker activation speed by the relative positions of the pitch limit indicator (PLI) and the red checker column (Red zipper) on the primary flight display. Although the flight crew noted that the positions of the PLI and Red zipper were closer to stickshaker activation than was normal, they attributed those indications to the g-loading effects induced by turbulence. Those indications were symptomatic of an inappropriate approach speed and consistent with the degraded performance and controllability experienced by the flight crew.

Unfortunately the cockpit voice recorder was overwritten before the ATSB was able to recover the no doubt interesting and insightful conversations between the pilots. (It is quite surprising how often this happens in abnormal aircraft operations.)

This in part is what the ATSB says about the landing weight error, and the procedural failures that ensued.

At the time of the incident, the operator’s procedures did not include a validation check of the landing weight. As such, there was the potential for a pre-departure data entry error to adversely affect the accuracy of the landing data. The absence of an independent method for validating the accuracy of the FMS-generated landing weight, resulted in a lack of assurance that the approach and landing speeds were valid.

Although the operator did not have a validation check of the landing weight, there were procedures in place to ensure that the take-off weight (TOW) was correct. If the TOW was correct, the landing weight based on the same ZFW figures and fuel load was likely to also be correct. In this case, the procedural check of the TOW was not effective in detecting the two data entry errors.

The first data entry error occurred during the transfer of baggage compartment weights from the electronically transmitted load information sheet to the hand-held computer. There was a check prescribed of the load sheet for accurate figures, but the PIC did not detect the error. That data entry error created a deficit of 315 kg in the ZFW, which was not in itself a significant disparity and did not have an influence on the occurrence.

The second data entry error occurred during the transfer of the ZFW from the load sheet print-out to the FMS. Instead of selecting the ZFW figure from the load sheet, the PIC selected the aircraft operating weight (essentially an empty aircraft) and read it out for the copilot to enter into the FMS. The FMS then added the fuel load to the ZFW to generate the TOW. When the copilot called out the FMS TOW for the PIC to validate, the proper response of ‘RTOW checked’ was probably made, but the significant disparity between the TOW calculated by the FMS and the actual TOW on the load sheet was not detected.

As a result of the undetected data entry errors, the FMS-calculated TOW was 9,415 kg less than the aircraft’s actual TOW. Although that disparity had a significant effect on the required take-off speeds, due to aircraft design and the available runway length, the error went unnoticed at Perth and did not manifest as an operational problem until the approach into Kalgoorlie Airport.

The ATSB then turns its attention to how the pilots, which passenger may have assumed were Qantas pilots, handled the stick shaker events.

The flight crew reported that their response to the handling anomalies and first stickshaker were based on their assessment that they encountered turbulence while operating above 1,000 ft. Consequently, the turn and approach were continued. Eventually the approach became unstable and a go-around was completed.

On the second approach, the stickshaker occurred below 1,000 ft and with wings level. The flight crew reported that a missed approach was subsequently initiated because the approach was no longer stable.

However, the stall recovery procedure to be followed during an approach included applying maximum normal thrust, and rolling wings level. Furthermore, a stall recovery must then be followed by a mandatory go-around. Not following the prescribed stall recovery procedure increased the risk of the aircraft becoming aerodynamically stalled.

The flight crew’s training records indicated that they had not received stall recovery training since completing their initial type endorsements in 2008. The operator’s recurrent training programmes were designed to maintain and improve their pilot’s competencies and skills. However, there was no recurrent training that addressed recovery from a stall or stickshaker activation.

Although stickshaker and stall recovery training was completed as part of the flight crews’ initial endorsement, their ongoing competency was not assured.

These references to a lack of recurrent training at Cobham at the time of the incident, are deeply disturbing. At the end of the report (a full reading is urged) the ATSB notes the Cobham is in the process of putting in place responses to its findings.  Not has, but is. 

To a casual reader, who may have been under the impression that Qantas actually means Qantas, the ATSB report may cause discomfort. It also omits the usual courtesy of saying that the ATSB is satisfied with the safety outcomes.

The problem for Australian airline observers at this moment, and possibly for quite some time into the future, is that new models from Boeing or Airbus aren’t getting any head space in either the Qantas or Virgin Australia groups. To think that massive new fleet decisions are going to be taken in Australia in the immediate future is where the ‘dreaming’ is going on.

OK, there has to be a choice in Virgin Australia soon between the A320NEO or the 737MAX series, as otherwise it will find itself ending the decade with too many aging 737NGs that are no longer cutting edge fuel efficient compared to the later new technology options. But we can reasonably bet that the cost of such a choice with be as close to $0 for as long as possible, and that the jets will come from orders already placed or being negotiated with Airbus and Boeing by global leasing companies.

There is a very hard headed, and understandable, focus on cost reductions and if possible, reduced capital expenditures in the two airline groups, no matter what Boeing or Airbus have to offer by way of larger longer haul jets.

Which makes this latest analysis, in Aspire Aviation, a fascinating yet frustrating read.

By the time the 777-X options become reality, and the A350 gives us more clarity about what exactly going on in a program that looks more troubled by the day, Qantas and Virgin Australia will have been changed, possibly even broken apart and rationalised, by changes in their major shareholders, and the extreme stresses of global airline competition in a context where a strong Australian currency and ready access to our markets are continuing factors.

The Australian industry is undoubtedly under acute pressure. But despite everyone being in agreement about this, no-one can clearly see where it will end, as distinct from where the various players hope it will end.

Indeed we could take the view that some in Australian airline management don’t want to be around when these stresses work through the industry, but intend instead to have already made it through the exits with as much money as they can carry.

Which is another way of saying that the fleet decisions that count in the next 10-20 years will not be made by the current Australian managements, but their successors, who may not necessarily be Australian, or be in Australia.

The previous AD, issued on 20 January, only extended to the 20 A380s that had performed the most flights.

EASA has also called for the inspections to use equipment that will detect cracks that have not become visible to the naked eye, while the original directive required only visual inspections.

A spokesperson for EASA said that cracks had been found inside the wings of almost all of the first, and most flown, of the 20 A380s to be checked. As a consequence it was decided to immediately inspect the entire fleet of operational A380s, and replace those brackets found to have cracks.

There are 4000 such brackets inside the entire wing  of an A380, and the cracks that are of greater concern are the second type discovered, which tend to occur in the middle of the each half of the wing, near a fuel tank divider.

The replacement of any faulty brackets is expected to take about five days.  The EASA spokesperson said factors in the cracks occurring related to the use of a less flexible grade of aluminium in some of the brackets, as well as stress unintentionally built into them during the manufacturing process.

As reported when the first AD was issued on 20 January, Airbus is proposing a two step remedy for these type 2 cracks as well as the more minor type 1 cracks, shown in diagrams and with an explanatory text in this bulletin from Doric Asset Finance.

In the first stage, cracked brackets will be replaced with new components. In the second stage a permanent fix will involve the use of a different grade of aluminium and a revised manufacturing process to avoid locking in unintended additional stress.

Airbus repeated its previous guidance that none of the cracking found in the wings posed any safety of flight concerns for a considerable period of time.  However it was considered desirable to remove the risk of long term loss of structural strength at an early stage of the service life of the giant jet, rather than later.

Before today’s new AD was issued, Qantas had found and was repairing cracks in two of its A380s. It found type 1 cracks in its first A380–which had been severely damaged in November 2010 by the disintegration of one of its Rolls-Royce engines as it was climbing away from Singapore at the start of a flight to Sydney–during its subsequent extensive repair and reconstruction at Changi Airport.

That jet is due back in service next month.  More recently Qantas also found minor cracks in another A380 when it was undergoing a routine inspection following an encounter with severe air turbulence, but said these were, like those on the jet damaged near Singapore in 2010, the result of the manufacturing process and not caused by in-flight stresses.

This second A380 will return to service in about a week’s time, sooner than the jet being rebuilt at Singapore.

So who is the real beneficiary of the government’s decision to impose body-scanning technology on international passengers?

Step forward L-3 Communications, a key member of the US defence establishment and one with links to some of the worst scandals of the past decade.

The company will reap $28 million dollars from the government’s obsession with security theatre that has no demonstrated security benefits, through its provision of body scanners.

L-3 began as an orphan company after a Lockheed merger saw several business units sold off to two former Loral executives funded by Lehman Brothers, which still has a big stake in the company and a board seat. Since then, L-3 has grown into one of the top 10 US defence contractors. The company earned nearly a billion dollars in profit in 2010, from revenues of more than $15 billion.

Along the way, it has been involved in some of the US’ biggest defence and procurement scandals. In the late 1990s, the company’s lobbyist Linda Daschle helped the company get a Federal Aviation Authority contract to supply airport baggage scanners courtesy of legislation passed by her husband, Senate Majority Leader Tom Daschle. The scanners were later revealed to be faulty, but the FAA was obliged by Daschle’s legislation to continue to purchase them.

The company later acquired defence contractor Titan, which has been implicated in several procurement scandals. Titan provided “interpreters” at the US Army’s Abu Ghraib prison in Iraq, and the company was sued by a victims of US torture and abuse there, until the US Supreme Court finally dismissed the case in 2011. In 2010, a division of the company was suspended from providing any services to the US government after it was found using US government networks to spy on competitors. There have also been several lesser procurement scandals typical of the US defence industry.

But even as the US looks to cut back defence spending, with flow-on effects for big suppliers such as L-3, the fertile field of security theatre has opened up as a revenue source — there’s little or no political will to cut war-on-terror funding. By 2010, the company had provided nearly $US40 million worth of body scanners following the “underwear bomber”, having massively ramped up its lobbying effort. Not unhelpful is the fact that several US congressional representatives have big L-3 shareholdings, including former 2004 Democrat presidential candidate John Kerry.

Here, the company (with headquarters in Canberra) is represented by two lobbyist outfits. Its specialised night vision and targeting division is represented by defence specialist lobbyists Owen International while its maritime defence equipment arm L-3 Nautronix is represented by CMAX, headed by Tara and Christian Taubenschlag; the latter was Joel Fitzgibbon’s press adviser.

Typical of such companies, L-3’s board has extensive links with the US defence establishment, including a former chairman of the Joint Chiefs of Staff. Here, former Air Vice-Marshal Alan Titheridge is vice-president.

In 2011, L-3 and its various divisions scored more than $31 million dollars from Australian taxpayers, nearly all of it via direct tenders where there’s no competition. Its operations extend across military and communications hardware, from aircraft to detection and communications equipment to business services. Defence spending may be getting tighter, but security theatre is boom industry here and overseas.

Its first short haul international services will begin in 2013, and the franchise, owned by Japan Airlines, Qantas and Mitsubishi, expects to operate 24 A320s within ‘several years’.

The early utility of the domestic network for travellers using Jetstar flights between Japan and Australia is made clear in the graphic below.

Jetstar Japan’s like-for-like competitors will be two low cost carriers being launched in the near future by All Nippon Airways, one called Peach, and the other a joint venture with Air Asia.

Peach is launching its services with three A320s based at Osaka’s Kansai airport next month, serving a network which doesn’t directly compete with Jetstar Japan’s early city pairs.

Jetstar has not been able to provide any insights at this stage other than to say it is co-operating with the agency and is also conducting its own internal inquiry, but although the wording of the ATSB notification is brief it is interesting.

It is described as a pre-flight planning incident, but it also says:

During the takeoff run, the crew set the incorrect takeoff thrust setting.

The notification doesn’t say how fast the jet was going when the error was detected, or whether it took off before the error was detected, or whether it abandoned the take off attempt before the jet rotated.

So, an error was made pre-flight. And then that error went undetected until the jet was at least rolling, and perhaps not until after a somewhat leisurely takeoff occurred. The ATSB’s brief description of the incident begs the question as to what the crew selected at the start of the takeoff roll if the incorrect data was then entered after it had begun.

Whatever happened, it is serious enough for the ATSB to inquire, and given that it didn’t inquire into an incident on 3 November when a junior pilot twice incorrectly set flap on a Jetstar A320 approaching Cairns, this must have been a pretty awesome stuff up.

The quality of the training being given to Jetstar junior pilots by private contractors, but for which the senior management and board of Jetstar and Qantas are personally liable in Australian law, is at issue in incidents like this.

However incidents involving the incorrect entering of data into flight computers, even errors in calculating takeoff performance requirements in airliners without such computers, have occurred many times to many airlines, and some of them have caused disasters.

This inquiry is one to watch, as is the continued vigilance that CASA says it has put in place in relation to flight standards and training at Jetstar.

In hi-res on your computer, this looks like a polished opal. Cut from NASA file

Out in space there are no borders, and no signs or sounds of human conflicts, or the clash of ideas. There is just the blue marble that is planet earth, our vast yet finite home.

NASA has released its latest ‘blue marble’ images from the new Suomi polar orbiting satellite, which is building on earlier spacecraft that have been measuring how the earth re-radiates energy, how cloud cover works to both deflect in bound solar radiation and retard outbound re-radiation, and provide other data useful for studying short to longer term changes in the planetary environment.

A sliver of the far south, cut from a NASA blue marble Suomi image

These are not the most detailed blue marble images ever assembled by NASA, but the files can exceed 17MB in size, and the slivers of these images, made in January, have enough definition to reveal cities, and a great deal of topographical detail, even through what look likes small breaks in the cloud banks.  You can bring them up, and block out all of the other clutter on your desk top, just for a moment, before getting back to work.

This is a feeble resolution copy of a full earth blue marble image compiled from Suomi’s near earth orbital passes on 23 January.  The full file would crash our server.

Make some surprising discoveries taking slivers out of this

Until Scoot has real pix of its planes we may as well use an AirAsiaX photo

Singapore Airlines’ new long haul widebody low cost carrier Scoot seems to be aiming its second destination choice, the Gold Coast, more at Air AsiaX than anyone else.

It will certainly stress test the Malaysia carrier’s flights to Kuala Lumpur.

Not that anyone on the Gold Coast will be the least concerned about being the epicentre of some classic Malaysia-Singapore rivalries.

No schedule or fare details have been released yet for the five times weekly service, nor the daily service which Scoot has already announced to Sydney as its inaugural offering from this July.

Scoot will have a fleet of four refurbished, freshly crammed ex Singapore Airlines 777-200ERs which will offer two classes of seating this year.  The announced frequencies to Sydney and the Gold Coast take up half of that capacity, and the next cities to be announced for its Singapore home base are expected to be in Asia, although in this industry, anything is possible.