The Before Start checklist did not distinguish between the various fuel pump selection options. The checklist just called for fuel quantity and Pumps ON.
On 27 November 2007, the Chief Pilot for the operator issued a Flight Standing Order that included the following: Effective immediately, the BEFORE START and BEFORE TAXI Procedures and Checklists have been revised as follows: 1. The Captain, in addition to the First Officer, is now required to respond to the “Fuel” challenge item in the BEFORE START Checklist and the “Anti-ice” challenge item in the BEFORE TAXI Checklist; 2. The Fuel checklist item also includes a procedural memory aid (which does not need to be verbalized) that states “Verify CENTRE TANK FUEL PUMPS (as required)….ON.”
On 15 June 2009, the operator advised the following: The [Operator] Flight Administration Manual (FAM) 21.2 (Adherence to Standard Operating Procedures) and 21.8 (Checklist Philosophy) clearly details the policy regarding adherence to Aircraft Operations Manual (FCOM) checklists. The standard checklist philosophy is articulated in the QRH [Quick Reference handbook], which forms part of the FCOM. This section (QRH CI.1.1) states that "Both pilots visually verify that each item is in the needed configuration or that the step is done." This fact is acknowledged as the relevant page appears as page 37 of the ATSB report. This policy ensures that Flight Crew are aware of the switch positions and is standard philosophy across all Boeing models. The suggestion of touching the respective switches is not standard Airbus or Boeing practice, nor part of their recommendations. We will discuss the matter directly with the OEM [original equipment manufacturer] but have no intention to adopt this procedure at this time. ATSB assessment of the operator’s response/action The ATSB notes the action proposed by the operator and will continue to monitor this safety issue | The operator's Flight Operations confirmed that they have discussed the suggested procedure with Boeing who advised that although interested, have no intention of adopting this procedure at this time. As a result, the operator confirms that their position has not changed [that is, they do not intend to introduce a requirement to touch switches during checklists]. | The ATSB ackowledges that the operator has followed-up this issue with Boeing and that Boeing is currently not interested in altering their checklist philosophy. In light of wanting to remain consistent with the current Boeing checklist philosophy, the ATSB understands that the operator is not willing to change their checklist practices at this time to introduce the touching of switch positions. This safety action has been closed.
During the checklist procedure, the copilot would call the check item and then the copilot would check it. There was no crosscheck required by the pilot in command.
Proactive industry safety action description
28/07/2009 - On 15 June 2009, the operator advised the following:In addition to the information provided in response to item 4.1.2, the Normal Checklist was amended to require that the Captain also respond to the "Fuel" challenge item contained in the BEFORE START checklist.
The "Fuel" item itself was also expanded to include an additional memory aid (not verbalised) that stated "...Verify CENTRE TANK FUEL PUMPS (as required)...ON."
ATSB assessment of response/action The action taken by the operator appears to adequately address the safety issue.
Action organisation
Qantas Airways
Safety action release date
28/07/2009
Safety action status
Closed
28/07/2009
Investigation complete date
28/07/2009
Safely action number
AO-2007-036-NSA-077
Risk category
Significant
Safety issue description
The checklist procedure did not require flight crew to touch the switches of the fuel pumps to ensure that they were aware of the position of the switches.
Proactive industry safety action description
28/07/2009- On 15 June 2009, the operator advised the following: The [Operator] Flight Administration Manual (FAM) 21.2 (Adherence to Standard Operating Procedures) and 21.8 (Checklist Philosophy) clearly details the policy regarding adherence to Aircraft Operations Manual (FCOM) checklists. The standard checklist philosophy is articulated in the QRH [Quick Reference handbook], which forms part of the FCOM. This section (QRH CI.1.1) states that "Both pilots visually verify that each item is in the needed configuration or that the step is done." This fact is acknowledged as the relevant page appears as page 37 of the ATSB report. This policy ensures that Flight Crew are aware of the switch positions and is standard philosophy across all Boeing models. The suggestion of touching the respective switches is not standard Airbus or Boeing practice, nor part of their recommendations. We will discuss the matter directly with the OEM [original equipment manufacturer] but have no intention to adopt this procedure at this time. ATSB assessment of the operator’s response/action The ATSB notes the action proposed by the operator and will continue to monitor this safety issue
30/08/2010 - The operator's Flight Operations confirmed that they have discussed the suggested procedure with Boeing who advised that although interested, have no intention of adopting this procedure at this time. As a result, the operator confirms that their position has not changed [that is, they do not intend to introduce a requirement to touch switches during checklists].
06/09/2010 - The ATSB ackowledges that the operator has followed-up this issue with Boeing and that Boeing is currently not interested in altering their checklist philosophy. In light of wanting to remain consistent with the current Boeing checklist philosophy, the ATSB understands that the operator is not willing to change their checklist practices at this time to introduce the touching of switch positions. This safety action has been closed.
Action organisation
Qantas Airways
Safety action release date
28/07/2009
Safety action status
Closed
6/09/2010
Investigation complete date
28/07/2009
Safely action number
AO-2007-036-NSA-105
Risk category
Significant
Safety issue description
The checklist procedure did not require flight crew to touch the switches of the fuel pumps to ensure that they were aware of the position of the switches.
Proactive industry safety action description
On 16 June 2009, CASA advised the following: CASA will follow up with the operator regarding their action on “4.1.2 Inadequate checklist procedures to verify position of switches” and “4.1.3 Absence of crosscheck in checklist".
24/09/2010 - CASA has followed up with the operator and is satisfied with the operator's responses provided in the final report in relation to: i) the inadequate checklist procedures to verify the position of switches; and ii) the absence of a check item crosscheck in the checklist. No further action will be taken by CASA.
28/09/2010 - The ATSB is satisfied that CASA has undertaken the safety action as intended and closed this safety action.
Action organisation
Civil Aviation Safety Authority
Safety action release date
28/07/2009
Safety action status
Closed
28/07/2009
Investigation complete date
28/07/2009
Investigation number
AO-2007-036
Safely action number
AO-2007-036-NSA-107
Risk category
Significant
Safety issue description
During the checklist procedure, the copilot would call the check item and then the copilot would check it. There was no crosscheck required by the pilot in command.
Proactive industry safety action description
On 16 June 2009, CASA advised the following: CASA will follow up with the operator regarding their action on “4.1.2 Inadequate checklist procedures to verify position of switches” and “4.1.3 Absence of crosscheck in checklist".
24/09/2010 - CASA has followed up with the operator and is satisfied with the operator's responses provided in the final report in relation to: i) the inadequate checklist procedures to verify the position of switches; and ii) the absence of a check item crosscheck in the checklist. No further action will be taken by CASA.
28/09/2010 - The ATSB is satisfied that CASA has undertaken the safety action as intended and closed this safety action.
Action organisation
Civil Aviation Safety Authority
Safety action release date
28/07/2009
Safety action status
Closed
28/07/2009
Investigation complete date
28/07/2009
Investigation: AO-2007-044: Go-around event Melbourne Airport, Victoria, 21 July 2007, VH-VQT, Airbus Industrie A320-232
Safely action number
AO-2007-044-NSA-073
Risk category
Significant
Safety issue description
The aircraft operator had changed the standard operating procedure for the go-around. The change resulted in the flight crew being unaware of the flight mode status of the aircraft during the first part of the first missed approach.
Proactive industry safety action description
The operator has advised that the standard operating procedure for a go-around has been modified in line with the procedure promulgated by the aircraft manufacturer.
ATSB assessment of action taken - The ATSB is satisfied that the action taken by the aircraft operator adequately addresses the safety issue.
Action organisation
Jetstar Airways
Safety action release date
1/03/2010
Safety action status
Closed
1/03/2010
Investigation complete date
5/03/2010
Safely action number
AO-2007-044-NSA-085
Risk category
Significant
Safety issue description
The aircraft operator did not conduct a risk analysis when changing the go-around procedure, nor did its safety management system require one to be conducted.
Proactive industry safety action description
The operator has introduced a change to the safety management system such that any change to an aircraft operating procedure requires the completion of a formal risk analysis prior to that change being implemented.
ATSB assessment of action taken - The ATSB is satisfied that the action taken by the aircraft operator adequately addresses the safety issue.
Action organisation
Jetstar Airways
Safety action release date
1/03/2010
Safety action status
Closed
1/03/2010
Investigation complete date
5/03/2010
Safely action number
AO-2007-044-NSA-087
Risk category
Minor
Safety issue description
Flight crew undergoing initial endorsement training with the third party training provider were not trained to the procedures and systems used by the operator.
Proactive industry safety action description
The operator has reported that it is conducting a review of existing flight training arrangements.
ATSB assessment of action taken - The ATSB is satisfied that the action proposed by the aircraft operator will adequately address the safety issue.
Action organisation
Jetstar Airways
Safety action release date
1/03/2010
Safety action status
Closed
1/03/2010
Investigation complete date
5/03/2010
Safely action number
AO-2007-044-NSA-088
Risk category
Minor
Safety issue description
The aircraft operator did not comply with accepted document change procedures when modifying the standard operating procedure for the go-around.
Proactive industry safety action description
The operator has implemented changes to its document control procedure to indicate when specific operator initiated changes to procedures are made.
ATSB assessment of response/action - The ATSB is satisfied that the action taken by the aircraft operator adequately addresses the safety issue.
Action organisation
Jetstar Airways
Safety action release date
1/03/2010
Safety action status
Closed
1/03/2010
Investigation complete date
5/03/2010
Safely action number
AO-2007-044-NSA-111
Risk category
Significant
Safety issue description
The aircraft operator had changed the standard operating procedure for the go-around. The change resulted in the flight crew being unaware of the flight mode status of the aircraft during the first part of the first missed approach.
Proactive industry safety action description
Although this safety issue arose out of a change that was made to the go-around procedure by the aircraft operator, as a result of this occurrence, the aircraft manufacturer consulted with the aircraft operator. Following that consultation, the aircraft manufacturer revised the go-around procedure within the manufacturer’s Flight Crew Operating Manual. The aim of that revision was to emphasise the critical nature of the actions by flight crew during a go-around. The revised go-around procedure is at Figure 8 of the report.
ATSB assessment of response/action - The ATSB is satisfied that the action taken by the aircraft manufacturer adequately addresses the safety issue.
Action organisation
Airbus Industrie
Safety action release date
1/03/2010
Safety action status
Closed
1/03/2010
Investigation complete date
5/03/2010
Safely action number
AO-2007-044-NSA-112
Risk category
Minor
Safety issue description
There was no provision in the current CASA Regulations or Orders for third party flight crew training providers. As such, the responsibility for training outcomes was unclear.
Proactive industry safety action description
CASA has advised the ATSB that the proposed CASR Part 142 is under review as a matter of priority and has now been progressed to the Office of Legislative Drafting and Publishing.
ATSB assessment of response/action - The action taken by CASA appears to adequately address the safety issue.
Action organisation
Civil Aviation Safety Authority
Safety action release date
1/03/2010
Safety action status
Closed
1/03/2010
Investigation complete date
5/03/2010
Investigation: AO-2007-046: Collision with terrain, Doongan Station, WA, 25 September 2007, VH-HCN, Robinson Helicopter Company R22 Beta II
Safely action number
AO-2007-046-NSA-074
Risk category
Significant
Safety issue description
V-belt failure or dislodgement was identified as a factor in a number of overseas and Australian R22 accidents.
Proactive industry safety action description
Safety action taken by the Civil Aviation Safety Authority In response to a number of R22 helicopter rotor drive system failures, on 14 August 2009, the Civil Aviation Safety Authority (CASA) issued airworthiness bulletin, AWB 63-006 Issues related to the Robinson Helicopter Corporation (RHC) R22 main rotor drive system. The purpose of the bulletin was to: a. Provide Operators and Maintainers' a consolidated summary of investigations carried out by CASA Airworthiness Specialists based on several information resources including CASA received SDRs, b. to remind maintainers and operators of the need to strictly adhere to the requirements of all current RHC approved data for the operation and maintenance of the R22, and c. provide a guide to the information available, including RHC data in relation to main rotor drive system with emphasis on the main rotor drive veebelts (also known as the main drive belts). CASA also advised that future relevant operational information regarding rotor drive systems failures would continue to be disseminated through advisory material and Directives. ATSB assessment of action The ATSB is satisfied that the action taken by CASA adequately addresses the safety issue.
