Created Friday, Sep 12th 2025 17:53Z, last updated Wednesday, Jun 17th 2026 14:56Z
A Jetstar Airbus A320-200, registration VH-VQL performing flight JQ-890 from Sydney,NS to Hervey Bay,QL (Australia), was on final approach to Hervey Bay's runway 11 at about 13:45L (03:45Z) when the PAPIs failed to activate. The approach became unstabilized but was continued to a landing without further incident.

Australia's ATSB opened an investigation into the occurrence rated an incident.

On Jun 17th 2026 the ATSB released their final report concluding the probable causes of the incident were:

- The flight crew selected DIR TO (direct to) the initial approach fix into the flight management guidance system near top of descent which, due to a known software issue not remembered by the flight crew at the time, almost certainly resulted in erroneous vertical guidance being computed.

- Jetstar had deferred an optional safety enhancement (software update) to correct the issue in the A320 fleet flight management system, in order to await a newer update that ultimately did not become available. As a result, for nearly 5 years Jetstar continued to rely on a procedural control that was subject to human factors limitations.

- The pilot monitoring used the incorrect, outdated radio keying sequence to activate the pilot activated lighting (PAL) system at Hervey Bay, rather than the sequence published in the relevant notice to airmen (NOTAM).

- The flight crew did not identify that the aircraft had deviated from the normal approach profile, partly due to being presented with erroneous vertical guidance and the absence of precision approach path indicator (PAPI) lighting.

- On approach to land, the flight crew likely did not fully recognise multiple exceedances of the stable approach criteria, or erroneously considered some exceedances to be momentary.

- The flight crew continued the approach without clearly voicing or acting on their concerns after perceiving indications that multiple aspects of the approach were unusual or marginal.

The ATSB analysed:

Erroneous vertical guidance

The Jetstar A320/A321 flight crew operating manual (FCOM) contained information related to the flight management temporary abnormal behaviours (TAB). This included that a number of flight management system (FMS) computations, including vertical guidance, could be erroneously generated if pilots execute the DIR TO (direct to) function when close to top of descent.

The flight crew forgot about the TAB and FCOM procedure at the time of the occurrence.

As a result, they engaged the DIR TO function at a time that doing so was known to trigger the TAB, resulting in the FMS almost certainly computing an erroneously high descent rate and steep approach path.

However, the crew did not recognise this as an initial indication of an erroneous calculation of the descent profile by the FMS. The vertical path, for both the descent and approach, was displayed to the flight crew via the PFD and would have indicated they were following the correct profile. However, the actual profile being flown did not correlate with the published approach path.

Flight crews are required to be familiar with any TABs applicable to their aircraft, and there were 38 TABs listed in the FCOM. The flight crew reported that they had previously been aware of the existence of this TAB, but the captain reported they had never experienced this particular TAB before.

Availability of updated software

Airbus had made an optional, updated software standard (version) available to address the TAB in December 2020. There was no airworthiness directive associated with this update. Jetstar had considered the service bulletin when it was issued, but for various reasons decided to wait for the next standard to be made available, which was expected at the time to be in 2021/22. Ultimately, however, this newer standard did not become available, and Jetstar’s 2020 decision not to implement the available standard was not revisited in the interim. As a result, Jetstar continued to rely on a procedural control to avoid the software issue at the time of the occurrence for nearly 5 years.

Approach lighting not activated

Precision approach path indicator (PAPI) lights are a useful tool available for flight crews to verify their approach profile. As the aircraft approached Hervey Bay Airport the PM attempted to activate the PAPI lights through the pilot-activated lighting (PAL) system.

Numerous attempts were made by the PM to activate the PAL while on descent. The PM recognised that they were unsuccessful, however, they attributed the unsuccessful attempts to being too far away from the airport. The PM also thought that they heard the AFRU readback say that the airport lighting was on. The PM ultimately believed that the PAL had been successfully activated.

However, the PAPI lights were serviceable but were not activated because the PM used a keying sequence that was no longer current at Hervey Bay as per the NOTAM. The flight crew were required to review the NOTAMs as part of their flight preparation, but it is likely that this NOTAM was overlooked.

Flight path monitoring

During the final approach to land, the flight crew were presented conflicting information between the electronic vertical guidance and the runway visual profile. The absence of PAPI approach guidance meant it was more difficult to visually confirm that they were correctly flying the intended approach. Pilots who fly by instrument flight rules (IFR) procedures are trained and conditioned to rely heavily on their aircraft’s instruments and navigation systems rather than visual cues from the environment. The FAA Instrument Procedures Handbook (Federal Aviation Administration, 2017) noted:

The pilot must trust the flight instruments concerning the aircraft’s attitude regardless of intuition or visual interpretation.

The pilots correctly recognised and discussed that the aircraft appeared to be high on profile when visually observing the runway. However, the information presented to the pilots via the instruments indicated that the aircraft was following the correct vertical path.

The pilots continued to believe the aircraft was on the correct profile based solely on the indications from the PFD and did not attempt to verify it using other sources.

Conflicting information has been shown to have deleterious effects on decision-making including reduction in accuracy of decisions, longer decision times and less confidence that the decision was correct (Carroll, Sanchez, & Wilt, 2021). In this case, the cues used to judge the aircraft’s vertical flight path were conflicting, erroneous, and/or absent.

The crew rationalised their observation believing it to be a result of a runway visual illusion: they knew a narrow runway could make the correct approach seem too high, and so didn’t realise that it actually was too high.

The absence of PAPI guidance removed an additional mechanism for approach profile verification by the pilots. The aircraft’s high vertical speed should have also indicated a deviation from the normal approach profile.

The FAA Instrument Procedures Handbook (Federal Aviation Administration, 2017) suggests that crossing the FAF at the published altitude is often a critical component of a successful approach. As the approach was conducted using visual procedures, the flight crew were not required to conduct a height check at the FAF, thus removing an opportunity to identify the erroneous electronic vertical guidance caused by the TAB at that point of the approach. Standard rules of thumb are also available to help in determining their approach profile, such as checking that the aircraft’s height above the runway should be 300 ft for every nautical mile to the runway, or multiplying groundspeed in knots by 5 to estimate the correct descent rate in feet per minute (Skybrary 2021). The flight crew did not perform any of these secondary checks of the flight profile after realising that they were receiving conflicting information.

Exceedance of the stable approach criteria

The key altitudes of 1,000 ft height above aerodrome (HAA) and 500 ft HAA were the critical points for determining if the approach is stable. Both flight crew have responsibility to call exceedances at or after these points, particularly the PM whose main role it is to monitor flight parameters. Elements of the stable approach criteria (requiring flaps to be fully extended, speed brake not deployed below 1,000 ft, and vertical speed to be under 1,000 fpm) were not met at the 1,000 ft check. This constituted an unstable approach (requiring a missed approach) and was not fully recognised by the flight crew. Most notably, the vertical speed was above 1,000 fpm for 15 seconds either side of the 500 ft call. Both flight crew were aware that some parameters were approaching or had gone beyond the stabilised approach criteria, but considered these to be brief and/or transitory.

The PM hesitated before making the 500 ft call, but thought the vertical speed was not excessively high and both flight crew thought the PF was getting it under control. The flight crew continued, probably not fully recognising these deviations in the dynamic, time-compressed situation with a high workload.

A higher than normal cognitive workload was a result of the aircraft flying a steeper than usual approach that required a high vertical rate of descent and the use of speed brake to manage the aircraft’s energy. It also seemed strange to the flight crew, based on their understanding that a normal 3° profile was being flown. The information observed by the flight crew (normal profile) conflicted with the outcome (difficulty managing aircraft energy from steep approach) resulting in a high cognitive workload and reduced capacity to recognise the situation and initiate a missed approach.

Ultimately, the exceedances were not detected and a missed approach was not called for, likely due to a combination of factors including:

- the high cognitive workload being experienced by the flight crew
- the flight crew misjudging some of the deviations as being marginal or momentary
- the PM’s understanding at the time that the vertical speed only needed to meet the stabilised approach requirement at 500 ft
- the PM having called the vertical speed exceedance (notifying the PF) and the descent rate subsequently being reduced.

Recognition of multiple unusual or marginal aspects of the approach While on descent and approach the flight crew were presented with, and likely aware of, multiple indications that the approach was unusual:

- auto flight system delaying descent during the approach
- PAPI lights not being activated
- the need for speed brake use on final approach to manage speed
- high vertical speed throughout the approach
- delayed descent just prior to commencing the final approach
- several 1,000 ft AAH configuration requirements being close to, or beyond, the limit
- 500 ft AAH configuration requirements being above the limit.

It can be challenging for flight crews to recognise the point at which multiple individually minor issues start to become serious. The flight crew indicated they felt a level of discomfort (the PM describing it as ‘extremely uncomfortable’) that the approach was not proceeding as intended but did not identify any clear ‘red flags’ that would have prompted them to initiate a go-around. Individually these abnormal aspects, or ‘yellow flags’ may not constitute a threat, but collectively formed an indication of a situation that was drifting towards unsafe territory, which the flight crew likely did not completely recognise at the time.

One way to address discomfort is to voice concerns as part of crew resource management. Monitoring and calling exceedances, however slight, can help both flight crewmembers recognise a deteriorating situation. Once acknowledged, concerns can be assessed and corrective actions discussed between crewmembers.

Related Flight: JQ890, Jetstar Airways News
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