First Officer Fatigue Also Cited By ATSB
A cell phone is being blamed, at least in part, for a missed approach performed by the crew of a JetStar flight on approach to Singapore on May 27th, 2010. But it wasn't an errant passenger who had forgotten to turn off the phone ... it was the pilot.The Australian Transportation Safety Bureau also said crew fatigue may have played a role in items on the checklist being overlooked.
According to the ATSB's final report:
"Somewhere between 2,500 ft and 2,000 ft in the descent, the crew heard noises associated with incoming text messages on the captain’s mobile phone. The FO requested that a missed approach altitude of 5,000 ft be set into the Flight Control Unit (FCU) and, after not getting a response from the captain, repeated the request. The FO stated that he attempted to use the ‘RAISE’ method from the operator’s Operations Manual to communicate with the captain.
"The FO recalled that, after still not getting a response from the captain, he looked over and, on seeing the captain preoccupied with his mobile phone, set the missed approach altitude himself. The captain stated that he was in the process of unlocking and turning off his mobile phone at that time and did not hear the call for the missed approach altitude to be set in the FCU.
"Shortly after, the captain alerted the FO to the ECAM message ‘AUTO FLT A/P OFF’. The FO requested the captain to clear the ECAM message and stated that he found the captain bringing it to his attention distracting. Both pilots stated that they heard the automated height call of ‘one thousand’ that was generated by the Flight Warning Computer via the radar gear still not secured in the down position (the landing gear was still in transit to the down position at that time).
"At 1843.40, the flight crew commenced a go-around."
However, the board also cites fatigue as a possible contributing factor in the incident. "The FO stated that he did not feel tired or fatigued before the flight. However, he reported feeling tired on descent into Singapore and that he disengaged the autopilot during the approach in order to hand-fly the aircraft and ‘wake [him] up’. During the return flight to Darwin, the FO had two periods of controlled rest."
The board concluded that "Air traffic control’s request to slow the aircraft earlier in the approach than anticipated, the discussion by the crew of the Singapore skyline, the receipt of the text messages and the late detection of the autopilot-related ECAM alert distracted the crew. That distraction degraded their situation awareness to the extent that they did not identify the incorrect aircraft configuration. These actions, coupled with a lack of effective monitoring by both crew and the FO's fatigue, appear to have impacted their prospective memory. As a result, the landing checklist and gear down procedure were intended but missed. These omissions are an indication of a loss of stage-two situation awareness: comprehension, and stage three situation awareness: projection. That would explain the crew not returning to the relevant checklist and satisfactorily configuring the aircraft for the approach and landing."