Confused Jetstar pilots forgot to lower the wheels and had to abort a landing in Singapore just 150 metres above the ground, after the captain became distracted by his mobile phone, an investigation has found.
The Australian Transport Safety Bureau report on the May 27, 2010 incident on Flight JQ57, from Darwin to Singapore, reconstructed a scene of cockpit chaos.
The captain, of more than 13,000 hours flying experience, was distracted by incoming text messages on his phone, while the first officer, of more than 4000 hours experience, was probably fatigued, the report said.
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The pair had lost their "situational awareness", leading to poor decision-making and hampered communications, investigators found.
The problems aboard JQ57 began when the co-pilot, the first officer, switched off the autopilot on the 220-seat Airbus A320 to make preparations to land.
Somewhere between 2500 feet and 2000 feet, the captain's mobile phone started beeping with incoming text messages, and the captain twice did not respond to the co-pilot's requests.
The co-pilot looked over and saw the captain "preoccupied with his mobile phone", investigators said. The captain told investigators he was trying to unlock the phone to turn it off, after having forgotten to do so before take-off.
At 1000 feet, the co-pilot scanned the instruments and felt "something was not quite right" but could not spot what it was.
At this stage the captain still did not realise the landing gear had not been lowered, and neither pilot went through their landing checklist.
At 720 feet, a cockpit alert flashed and sounded to warn that the wheels still hadn't been lowered.
At 650 feet, the captain moved the undercarriage lever "instinctively" but then a "too low" ground-warning alarm sounded as the plane sunk through 500 feet, indicating the landing gear was not fully extended and locked.
The co-pilot was confused by the captain's action in lowering the wheels, as he was getting ready to do quite the opposite — to abort the landing and re-ascend to the skies, investigators said.
Neither spoke to each other about their intentions.
At 392 feet, the crew aborted the landing and powered up the thrust.
At this time the pilots had lost track of their altitude, thinking they were much higher, at about 800 feet.
A further piloting error occurred, with the wrong flap setting during the ascent.
When the mistakes were recreated in a simulator, investigators determined there were two minutes of descent, from 2800 feet to 1000 feet, where the pilots failed to take any necessary actions, including putting the wheels down.
Jetstar said it had incorporated the the lessons learned from the incident in its pilot training.
"Pilot distraction meant all the landing checklist items weren't completed before the aircraft passed an altitude of 500 feet, at which point a go-around was required under our operating procedures," said Jetstar's Chief Pilot, Captain Mark Rindfleish.
"The combination of factors on JQ57 has provided new learnings and the opportunity to add to these safeguards, which we take very seriously.”
Changes introduced included completing landing checklists before 1000 feet and a reminder to pilots to ensure their mobile phones are switched off before take-off, he said.