Qantas and safety investigator the ATSB have disagreed over pilot performance monitoring procedures after an incident in which a Qantas 767 Cityflyer descended to 500 feet radio altitude with its wheels still up a mere 1500 metres north of Sydney Airport at the end of flight from Melbourne on October 26, 2009.

The ATSB finds that during the approach the captain’s monitoring of the performance of the first officer, who was the pilot at the controls, was ineffective and contributed to the 252-seat jet being “incorrectly configured”, which in lay terms, meant being flown into the final stages of a landing approach with the wheels up.

It also finds that “conflicting requirements and definitions in the operator’s publications [concerning 767operations] had the potential to diminish the importance of monitoring as an essential element in the safe operation of an aircraft”.

The safety investigator also highlights issues with the way Qantas procedures defined the heads down role of the pilot flying, in this case, the first officer, and heads up role of the captain, who was supposed to be effectively monitoring his junior.

In a forensic review of the particular flight, the ATSB also identifies changing flight conditions from instrumental to visual on the approach to Sydney Airport, and a late landing clearance from the Sydney tower as among other matters that distracted the flight crew from completing the normal landing procedure.

In dot points it says:

  • A number of distractions combined to narrow the crew’s attention, which in turn reduced the crew’s situational awareness.
  • The early application of the head free/head down standard operating procedure contributed to a loss of situational awareness by the flight crew.
  • The flight crew’s loss of situational awareness resulted in the crew not configuring the aircraft for landing.
  • The pilot not flying’s monitoring of the pilot flying’s handling of the aircraft was ineffective.

The ATSB says that the pilots had become aware of the situation they were in at about 580 feet radio altitude and initiated a go around immediately before the ground proximity warning system goes off at a radio altitude of 500 feet, after which the 767 begins to climb away from the inner western suburbs close to the end of the intended runway to return to for an uneventful wheels down landing.

In what it calls a minor safety issue the ATSB says “the conflicting requirements and definitions in the operator’s publications in relation to the pilot not flying role had the potential to diminish the importance of monitoring as an essential element in an aircraft’s safe operation”.

The ATSB notes this response from the airline.

Qantas Airlines has reviewed its current procedures and publications concerning monitoring as a result of this occurrence but has not currently deemed it necessary to make any changes at this stage. However, Flight Operations will continue to monitor this and make any necessary changes if required.

The  ATSB final report is a negotiated document, in that the language it uses is discussed with the party it is reporting on before the final draft is published.

In lay terms, Qantas has told the safety investigator to “sod off” and the ATSB in return does not say that it is “satisfied with the safety outcomes” a form of words that normally appear at the end of its final reports.