[Peetwo]

And so the ATsB should investigate the wing strike. Although Virgin used its typical watered down weasel words and said there was no safety risk to passengers, that is complete bullshit. It turned out to be minor damage, but it could have been a very different outcome. Fires have started from such contact in the past with other airlines.

Excellent point you make Gobbles, these taxiing rash occurrences have the potential for far more calamity and mayhem than you will ever read about in a dodgy half-assed & pc'd ATSB report.

Take for example the following off the ATSB - 'search for IP thread': 

ATSB post Beaker: From the sublime to the ridiculous -  

Today the ATSB released a final report that took 1105 days to investigate into a pushback incident, which saw a Virgin B737 collide with the tail cone of a Jetstar A320  - UDB!

Collision during pushback between Boeing B737-8FE, VH-YID and Airbus A320-232, VH-VGR Melbourne Airport, Victoria, on 10 August 2013
 
Investigation number: AO-2013-125
Investigation status: Completed
 

• Final Report
  
• Photo
  

Final Report
Download Final Report
[ Download PDF: 1.35MB]
 
 
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Alternate: [ Download DOCX: 10.15MB]
 
What happened

On 10 August 2013, an Airbus A320-232, registered VH-VGR (VGR) and operated by Jetstar Airways Pty Ltd was holding short of gate D2 at Melbourne Airport, Victoria. At the same time, a Boeing B737-800, registered VH-YID (YID) and operated by Virgin Australia Airlines Pty Ltd. (Virgin) was approved by air traffic control for a pushback from bay E1 once VGR was on the gate at bay D2. The dispatcher for YID assessed VGR was on the gate and commenced the pushback. During the pushback, the left wingtip of YID collided with the tail cone of VGR, damaging both aircraft. There were no injuries.

What the ATSB found

The ATSB found that the dispatcher for YID could not visually confirm the position of VGR relative to gate D2 and assessed that because the aircraft hadn’t moved, it was on the gate. The pushback ground staff followed the normal practice for a pushback from bay E1. However, this practice did not allow for visual monitoring of the left side of the aircraft, such as by using a wing walker. This meant it was not possible for the dispatcher to identify the collision risk in time to prevent the collision.

What's been done as a result

Virgin advised that following this occurrence, they issued a local instruction to ground staff, mandating the use of wing walkers from certain bays at Melbourne Airport, including bay E1.

Safety message

This occurrence highlights the importance of ensuring that adequate clearance exists prior to commencing pushback. This includes using sufficient personnel to ensure visibility of each side of the aircraft at all times.
 
Photo

Download Wing tip damage to the Virgin Australia aircraft VH-YID - Source: ATSB

Download Gates D2 and E1 - Apron diagram of Melbourne Airport. Source: Apron diagram Melbourne Airport, occurrence details by ATSB

Download Figure 3: Damage to the tail cone of VGR aft of the APU, looking from left to right of the aircraft. Source: ATSB

Download Figure 4: Screenshot of YID during pushback, 5 seconds before the collision with VGR and showing the position of the tug and the dispatcher. Source: Melbourne Airport, modified by the ATSB

Download Figure 5: Pushback of the same Virgin flight from bay E1 on the next day. Source: ATSB 

General details

Date: 10 Aug 2013
 
Investigation status: Completed
 
Time: 9:33 EST
 
Investigation type: Occurrence Investigation
 
Location   (show map): Melbourne Airport
 
Occurrence type: Taxiing collision/near collision
 
State: Victoria
 
Occurrence class: Operational
 
Release date: 18 Aug 2016
 
Occurrence category: Accident
 
Report status: Final
 
Highest injury level: None
 
 
Aircraft 1 details

Aircraft manufacturer: Airbus
 
Aircraft model: A320
 
Aircraft registration: VH-VGR
 
Serial number: 4257
 
Operator: Jetstar Airways
 
Type of operation: Air Transport High Capacity
 
Damage to aircraft: Substantial
 
Departure point: Melbourne, Vic.

Aircraft 2 details

Aircraft manufacturer: The Boeing Company
 
Aircraft model: 737
 
Aircraft registration: VH-YID
 
Serial number: 38709
 
Operator: Virgin Australia
 
Type of operation: Air Transport High Capacity
 
Damage to aircraft: Substantial
 
Departure point: Melbourne, Vic.
 
 
 


Last update 18 August 2016

Planetalking has picked up on this report and more than adequately highlights the totally farcical laughing stock that the ATSB has become in the world of ICAO Annex 13 aviation accident/incident investigative authorities:

ATSB takes three years to investigate pushback bingle

Australia's safety investigator exhaustively concludes that airlines need to keep a sharp lookout while reversing their jets. Really? Yes.

Ben Sandilands

This is the Virgin violated tail cone of the Jetstar A320

In what might be an attempt to embarrass Government over lack of resources the ATSB has today published its final report into a low speed terminal area bump and grind between a Virgin 737-800 and a Jetstar A320 at Melbourne Airport three years ago on August 10.

It was a minor incident although it carried the risk of a becoming major had fuel in the wing of the Virgin flight caught fire when it ripped off the tail cone of the Jetstar plane.
After 36 months the ATSB concluded that:

This occurrence highlights the importance of ensuring that adequate clearance exists prior to commencing pushback. This includes using sufficient personnel to ensure visibility of each side of the aircraft at all times.

No shit Sherlock. This is really laying it on the line about the under funding of the transport safety investigator. No-one takes three years to investigate the aviation equivalent of a car in a shopping carpark reversing into a stationary vehicle.

The clear message, and it is a genuine safety message, is that the ATSB has been so gutted of resources that this bingle which should have taken less than a month to exhaustively investigate was left to only fitful moments of attention for three years while the safety investigator struggled to sort out more serious matters.

Not that it always succeeds in such efforts. It not only screwed up a compromised investigation into the Pel-Air medivac charter crash of 2009, but seems hopelessly lost in dealing with its past serious errors and coming up with a credible and comprehensive new final report.

It took three years to fail to address the principle safety issue which saw a Virgin and a Qantas 737 both forced to land short on fuel at a fog shrouded airport in Mildura the same year because neither needed to be fuelled under Australia rules to find an alternative to Adelaide airport when it was closed by a deterioration in the weather when neither had anywhere else they could go.

But while there are many valid grounds for criticising or despairing about the ATSB, it hasn’t been given the government support necessary to actually do its job in a timely manner.  It treatment is a reflection on successive governments who have adopted policies of cutting back on spending on public services until they break.

If the ATSB can’t deal with a pushback incident at Melbourne airport in less than three months let alone three years, it is broken.

It may be severely broken but the questions are can it be fixed; is Greg Hood the man to fix it; and/or has he been given a mandate to fix it? If the answer is no to any of those questions, then I am afraid the ATSB is doomed to irrelevance and the eventual scrap heap...

Then reflect on the Ferryman's thoughts off the blog on this incident:

Three strikes.

• Posted by admin
  
• on August 20, 2016
  
• • Accidents and Inquiry, Senate Estimates - Unplugged
  

20Aug

“The ATSB found that the dispatcher for YID could not visually confirm the position of VGR relative to gate D2 and assessed that because the aircraft hadn’t moved, it was on the gate. The pushback ground staff followed the normal practice for a pushback from bay E1. However, this practice did not allow for visual monitoring of the left side of the aircraft, such as by using a wing walker. This meant it was not possible for the dispatcher to identify the collision risk in time to prevent the collision.”

The Sandilands article – HERE – begins by describing the ground collision between two aircraft as a super market car park bingle, then, after skipping several essential omissions in the ATSB report, takes a shotgun approach to the wide range of problems ATSB have, hitting the odd one or two, while the flock escapes. Missing an opportunity for a defining snap shot of where the ATSB is utterly failing the nations travellers.

ATSB – “This occurrence highlights the importance of ensuring that adequate clearance exists prior to commencing pushback. This includes using sufficient personnel to ensure visibility of each side of the aircraft at all times.”

The ATSB statement above, properly analysed, is terrifying.  It clearly defines the utter ineffectiveness of the agency, at all levels.  It also clearly defines the willing emasculation of the ATSB under Dolan.  I shall try, in my clumsy way, to make this simple for the politicians who need to get off their collective beam ends and make sure that either (a) this report is the tool used to close down the ATSB, disband it and save a fortune; or (b) return the ATSB to its proper role as the primary, independent arbiter of ‘safety’.  ATSB  cannot be allowed to wallow along as an ineffective, toothless, captive waste of time and money.  Australia is now so far away from true ICAO compliance that, if we were honest, a token ‘investigator’ parked in an office at the rear of the CASA building would suffice and be on a par with the other ‘token’ ICAO compliance requirements we need to be ‘seen’ to meet.

A good question; but not the first from ‘Dan Dair’ – “Now I think about it, I’d have probably asked what systems of assessment the airline or ground handler has in place before pushing-back an aircraft.”

Anyone who has suffered through a crowded shopping centre car park will understand what a busy air-side parking area – Ramp – is like when it is busy.  Arriving and departing a ramp (or gate) is probably one of the most dangerous parts of the entire journey.  Think on – a vehicle, about half the size of a football pitch, without rear view mirrors needs to be reversed about 100 meters into traffic.  The typical 737 is 12+/- meters high, wing span in the 30 meter range and some 35 meters long and weighs in somewhere between 65,000 and 85,000 kg.  I’ll leave the Kinetic energy calculation and the calorific potential in the fuel tanks to you; but it’s a big number.

To get this aircraft ‘pushed-back’ onto a live taxi way requires the coordinated effort of every safety agency we have and the company ‘system’.  It is a massive effort; laws need to be in place through parliament; CASA must turn that law into a rule set which define responsibility, procedure and method. The company must transmogrify that rule into practical, workable solutions, develop a system which ensures legal and operational safety; train staff within that system and maintain the machinery which completes the act.  Flight crew need to be trained to comply with their end of the story and provide the essential link between traffic control and ground crew.  The ATCO managing the ‘ground control’ station has to coordinate traffic all over the aerodrome; from newly landed off the runway, those moving to designated parking areas and those pushing back to begin a journey.  Why is the fool rambling on about this? – well, consider the amount of links in that chain; the potential for an incident is huge.

The point I am labouring to make that somewhere, somehow a link in that safety chain failed and an incident occurred. But which link and why?  It is for this answer we must depend on an impartial ATSB.

Were the company procedures robust, did they comply?
Was the ATC sufficiently trained?
Did the CASA approval of the procedure comply with safety rules?
Did the tug driver make an error.
Were the sight lines obstructed?
Was fatigue an issue?
Was lighting a problem?
Were the push back lines clearly defined?
Who is to make the adjustments to procedure to prevent a reoccurrence?
Who is to approve those adjustments?
What new procedures have been initiated?

I could, if pushed, develop a page of questions which should have been answered.  I would bet a beer or even two, that the companies involved Safety Management Systems (SMS) asked and provided answers to those questions, and more.  I have no doubt of that; but I cannot prove it as fact.  The findings of the ‘internal’ investigations will, quite rightly, remain private.

The ATSB public findings will not assist in the prevention of a reoccurrence; why?  Well there ain’t any; well, not any that are worth a good god damn.

I have no quarrel with SMS.  What I object to is that there may have been a slackening of requirements which allow a company to legitimately reduce (for example) say the number of personnel required to effect a simple push-back; which increases the risk of a repeat.  We don’t know and no one else is telling the tale,
Perhaps it’s just my curiosity curse, I like to know what happened and what was done to prevent it happening again.  For this I rely on the ATSB; if the ATSB cannot provide those answers; then what is the purpose of them?

Long ramble over, but it seems to me there was a little more to consider than a simple ‘beg-your-pardon’ in a carpark.

“Just be careful crossing the road kids” – last words ever heard by young Jimmy as he chased the bouncing ball.

Toot – knitting? – toot.  Apologies to 737 type specialists.

 
Hmm..do I get some sort of a premonition of a common link here (read causal chain... ), nah couldn't be - or could it??

MTF...P2