Investigation number
AO-2019-059
Occurrence date
Location
28 km N, Sydney Airport
State
New South Wales
Report release date
Report status
Discontinued
Investigation level
Short
Investigation type
Occurrence Investigation
Investigation status
Discontinued
Aviation occurrence type
Unstable approach
Occurrence category
Incident
Highest injury level
None

Discontinuation notice

Section 21 (2) of the Transport Safety Investigation Act 2003 (TSI Act) empowers the ATSB to discontinue an investigation into a transport safety matter at any time. Section 21 (3) of the TSI Act requires the ATSB to publish a statement setting out the reasons for discontinuing an investigation. The statement is published as a report in accordance with section 25 of the TSI Act, capturing information from the investigation up to the time of discontinuance.

Overview of the investigation

During an approach to Sydney Airport’s runway 16L on 16 October 2019, VH-VNR, a Tiger Airways A320, was at a speed in excess of that required for that particular phase of the approach. The pilot in command (PIC), performing the pilot monitoring (PM) role, instructed the pilot flying (PF)[1] to correct the speed and configure the aircraft for landing, however, the required corrections did not occur. As a result, the PIC took control of the aircraft, extended the speed brake to reduce the airspeed and configured the aircraft for landing.

During that configuration, at an altitude of about 1,300 ft, the speed brake was extended while the aircraft was in the landing configuration. This resulted in an EGPWS SPEED[2] alert. The configuration was corrected and the approach was stable by 1,000 ft. The PIC returned control of the aircraft to the PF, and the aircraft completed a stable approach and a safe landing.

On 22 October 2019, the ATSB commenced an investigation into the occurrence. As part of its investigation, the ATSB:

  • interviewed the flight crew
  • examined digital flight data and flight crew training records
  • analysed fatigue related data
  • reviewed the operator’s policy and procedural requirements and the recent occurrence data.

The ATSB determined that the two flight crew system operated as designed, detecting the incorrect approach conditions and correcting those conditions in sufficient time to enable a stable approach. A human factors review of the flight crew’s conduct and a fatigue assessment and examination of the flight crew’s training and the operator’s response to the occurrence, did not identify any factors that justified further investigation.

ATSB comment

Based on a review of the available evidence, the ATSB considered it was unlikely that further investigation would identify any systemic safety issues. Consequently, the ATSB has discontinued this investigation.

The evidence collected during this investigation remains available to be used in future investigations or safety studies. The ATSB will also monitor for any similar occurrences that may indicate a need to undertake a further safety investigation.

Finally, the ATSB briefed Tiger Airways about some of its observations and potential learnings. However, it considered that broader communication of this information would not be of significant benefit to other parties.

__________

  1. Pilot Flying (PF) and Pilot Monitoring (PM): procedurally assigned roles with specifically assigned duties at specific stages of a flight. The PF does most of the flying, except in defined circumstances; such as planning for descent, approach and landing. The PM carries out support duties and monitors the PF’s actions and the aircraft’s flight path.
  2. Enhanced Ground Proximity Warning System.
Aircraft Details
Manufacturer
Airbus
Model
A320-232
Registration
VH-VNR
Aircraft Operator
Tiger Airways
Serial number
5900
Operation type
Air Transport High Capacity
Sector
Jet
Departure point
Brisbane, Queensland
Destination
Sydney, New South Wales
Damage
Nil