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ASN Wikibase Occurrence # 195491
Last updated: 21 October 2017
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Date:14-JAN-2016
Time:14:04 EDT
Type:Silhouette image of generic A320 model; specific model in this crash may look slightly different
Airbus A320-232
Owner/operator:Jetstar Airways
Registration: VH-VQS
C/n / msn: 2515
Fatalities:Fatalities: 0 / Occupants: 159
Other fatalities:0
Airplane damage: None
Category:Incident
Location:near Ballina/Byron Gateway Airport, NSW -   Australia
Phase: Initial climb
Nature:Domestic Scheduled Passenger
Departure airport:Ballina/Byron Gateway Airport, NSW
Destination airport:Melbourne Airport (MEL)
Investigating agency: ATSB
Narrative:
On 14 January 2016, Airbus A320, registered VH-VQS (VQS) and operating as Jetstar 465 taxied for departure runway 06 at Ballina/Byron Gateway Airport, Australia. The flight was a scheduled domestic passenger service originally scheduled to depart for Melbourne at 13:30 LT but had been delayed until 14:04 by previous schedule disruptions. The flight crew consisted of a captain, who was pilot flying (PF) and a first officer (FO) who was pilot monitoring (PM).

As VQS taxied, a Beech 76 Duchess, registered VH-EWL (EWL), was conducting navigation aid training in the Ballina area. EWL had commenced a practice RNAV Z instrument approach for runway 06, with the intention of conducting a missed approach manoeuvre from a point approximately 660 ft above the landing threshold. EWL had an instructor and a student on board, with the student pilot hand flying the practice approach and responsible for communicating on the radio. As part of the exercise, the student was using a hood that inhibited vision outside the cockpit, simulating a reduced visibility approach, while the instructor maintained a visual lookout. The approach was also conducted with a simulated single engine failure.

At 14:06, while VQS was taxied towards the holding point prior to entering runway 06, the instructor of EWL reported being on a 5 nautical mile (9 km) final passing 2,000 ft and estimating the missed approach point at 14:12. The captain of VQS confirmed with the pilots of EWL that they intended to conduct a missed approach rather than land and, at 14:07, the FO broadcast that they were entering the runway and backtracking. The FO reported that, as the aircraft backtracked, EWL was sighted on a long final approach and that the captain and FO were confident of maintaining adequate separation during the take-off. The instructor in EWL reported expecting the crew of VQS to delay commencement of the take-off until EWL was in the missed approach. However, the captain of VQS advised that the intent was to depart prior to EWL reaching the missed approach point. That intention was not conveyed to the pilots of EWL.

As VQS taxied and EWL was conducting the practice approach, a third aircraft, a Boeing 737-800, registered VH-VUE (VUE) and operating as Virgin 1141, approached the Ballina area from the south with the initial intention of carrying out an RNAV X instrument approach and landing on runway 06. All three aircraft communicated on the Common Traffic Advisory Frequency (CTAF) in order to coordinate separation assurance between the aircraft. During this process, the crew of VUE elected to discontinue tracking for the RNAV X approach, and instead join the traffic pattern from overhead the runway at 3,000 ft before conducting a visual circuit to runway 06. As part of the communication, the instructor in EWL also agreed to conduct a left turn on reaching the missed approach point to assist with separation. Additionally, the crew of VQS agreed to remain below 2,000 ft on departure until clear of VUE.

Once VQS had entered the runway, there were no further exchanges on the CTAF between the crew and EWL. However, there were exchanges between the crews of VQS and VUE to confirm that VUE would be maintaining 3,000 ft and that VQS would not climb above 2,000 ft on departure until both aircraft had adequate separation. These radio exchanges contributed to the decision by the crew of VQS to hold in the line-up position for 41 seconds while EWL continued the approach. Both the captain and FO of VQS were heard transmitting on the CTAF. Although the PF making radio calls was contrary to that role, the FO indicated that the captain's reason for making the transmissions as PF may have been to expedite understanding of the intentions of the crew of VUE.

At 14:10, the captain of VQS commenced the take-off roll and shortly after the FO transmitted an 'all stations' radio call to announce the take-off. Although the crew had previously calculated and briefed the use of a reduced thrust take-off power setting as per standard operating procedure, the captain actually selected take-off/go-around (TOGA) power. The FO stated that the commencement of the take-off at that time and the selection of TOGA thrust were unexpected. However, as TOGA thrust was in excess of that required for take-off, the FO did not challenge this selection. Additionally, the FO assessed that the initiation of the high-energy take-off limited the opportunity for further discussion on the position of EWL.

As EWL was on short final and approaching the missed approach point over the landing threshold of runway 06, the instructor noticed VQS commence the take-off roll and then heard the associated radio call from the FO of VQS on the CTAF. The instructor told the student to look up from under the hood because it was felt that VQS should not be commencing take-off. There were no radio exchanges between the two aircraft at that time and the instructor recalled that EWL was just short of the runway as VQS rotated. The instructor stated that they were satisfied with continuing as planned and that they did not lose sight of, nor overtake VQS.

The captain of VQS stated that as the aircraft accelerated towards 100 kt, they noticed a proximate traffic symbol on the navigation display. This symbol indicated an aircraft approximately 400 ft above and directly behind VQS, which the captain believed to be EWL. The captain pointed this out to the FO and sought confirmation of the position of the traffic while continuing with the take-off. The FO reported that in response, after rotation, the FO assessed the traffic alert and collision avoidance system (TCAS) display and advised the captain that the aircraft was about '1 mile' (nautical mile, 1.9 km) behind and 400 ft above their aircraft. The captain advised not being happy to fly through EWL's level.

VQS rotated at approximately 134 kt, which coincided with the calculated maximum speed at which the crew could initiate a rejected take-off and stop the aircraft within the runway confines. Neither the captain nor the FO reported discussing rejection of the take-off following identification of the TCAS traffic and the captain recalled that, given the length of the runway, they did not want to abort. Calculations by Jetstar Airways identified that had the take-off been rejected just prior to V1, the aircraft could have been stopped 239 m from the runway end.

The captain of VQS rotated the aircraft to an initial take-off pitch angle of approximately 10 and after lift-off, the FO commenced retracting the landing gear. At approximately 150 ft above the runway, the pitch angle was reduced to 5 and the rate of climb reduced to approximately 600 ft per minute. The captain reported taking this action in order to avoid flying through EWL's level until adequately laterally separated.

As a result of the lower pitch angle and TOGA thrust setting, the airspeed rapidly increased towards 200 kt, which was the maximum flap limit speed for the take-off configuration selected (CONFIG 2). The FO recalled calling 'speed' in order to alert the captain of the impending flap overspeed and that the captain reacted by retarding the thrust levers to idle power. The captain then called for the FO to retract the flap to the CONFIG 1 position, which had a higher maximum limiting speed. The FO carried out this action.

The aircraft master warning activated due to the thrust lever being retarded below take-off thrust while the landing gear was not down and locked and the aircraft was at a low altitude. The master caution also activated as a result of the autothrottle system disengaging when the thrust was manually reduced.

The crew of VQS stated that on assessing that the aircraft was clear of EWL and accelerating away, they manually re-established a normal climb out pitch attitude and thrust setting. At approximately 1,700 ft VQS conducted a right turn to intercept the outbound track, which was contrary to the left turn stipulated in the Jetstar Airways departure procedures. The remaining flight to Melbourne was normal.

Contributing factors
- Despite a steady overall increase in passenger numbers and a mixture of types of operations, Ballina/Byron Gateway Airport did not have traffic advisory and/or air traffic control facilities capable of providing timely information to the crews of VH-EWL and VH-VQS of the impending traffic conflict. It is likely the absence of these facilities, which have been shown to provide good mitigation at other airports with similar traffic levels, increased the risk of a mid-air conflict in the Ballina area.
- In addition to conducting the pilot flying role, the captain of VH-VQS assumed control of the radio to ensure separation with the incoming aircraft VH-VUE. This increased the captain's workload, resulting in reduced positional awareness of the more proximal VH-EWL and a subsequent traffic conflict with that aircraft

Sources:

http://www.atsb.gov.au/media/5772794/ao-2016-003_final.pdf

Accident investigation:
cover
Investigating agency: ATSB
Status: Investigation completed
Duration: 1 year and 4 months
Accident number: AO-2016-003
Download report: Final report

Images:


Revision history:

Date/timeContributorUpdates
19-May-2017 17:22 harro Added
19-May-2017 17:31 harro Updated [Photo, ]

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