Accidents - Domestic

Yeah: tailwinds and clear skies for 'Swervin Mervin'.

It seems outrageous that ATSB can simply decline to investigate a fatal; and yet, having said that, looking back at the delays, the rubbish and Popinjay's continuous ' self-accreditation' as 'the final arbiter all knowledge' – perhaps the matter is best left to the Qld police, who have a good reputation, solid track record, and tend not to mess about too much.

Sad, bad business.....
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Port Phillip Bay Midair Collision Marchetti S.211- RIP! Angel

Via blancolirio YouTube channel:


Quote:Pinned by blancolirio

@stephenwalters8061
22 hours ago (edited)

Sadly - This morning, Tuesday in Australia, the main fuselage section with the bodies of pilot and cameraman were located in waters off the Mornington Peninsula by Victoria Police Search and Rescue Divers. Recovery operations will soon commence. [The Age Newspaper- breaking news, 4 mins ago.]

Via the ATSB:

Quote:Port Phillip Bay mid-air aircraft accident

The ATSB will investigate a mid-air collision between two aircraft over Port Phillip Bay on Sunday afternoon.

The two-seat, civilian-operated ex-military jet trainer aircraft were reported to be conducting a formation flight over the Bay. After the collision one of the aircraft is reported to have lost control and subsequently impacted the water, while the second recovered to Essendon Airport.

ATSB transport safety investigators are preparing to gather evidence from a range of sources including conducting interviews, retrieving all available recorded data, and gathering weather, aircraft maintenance, operator procedure and pilot information and documentation.

The ATSB asks anyone who may have witnessed and has footage of the accident, or who has footage of the aircraft in any phase of their flights, to contact us via the witness form on our website at their earliest convenience.

The ATSB will release a preliminary report detailing factual information established in the investigation’s evidence gathering phase in about two months. A final report will be released at the conclusion of the investigation and will detail analysis and findings.

However, if at any point during the investigation we uncover any critical safety issues we will immediately inform relevant parties so they can take safety actions.

Date 19/11/2023

MTF...P2  Cool
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AO-2022-041: VFR into IMC CFIT, VH-EHM, 29 August 2022 - Final Report

Via Popinjay's attributable to bollocks Media Release... Dodgy

Quote:Plan continuation bias probably influenced decision to continue flight despite forecast unsuitable weather conditions

[Image: AO-2022-041%20News%20Item%20image.jpg?itok=3yy-xRF7]

Plan continuation bias probably influenced a pilot’s decision to continue their visual flight rules flight despite forecast unsuitable weather prior to a controlled flight into terrain accident west of Brisbane, an ATSB investigation report explains.

On the morning of 29 August 2022, a Cessna R182 Skylane RG operating an air transport (charter) flight with a pilot and two passengers on board collided with terrain in the D’Aguilar Range, about 36 km north-west of its destination of Archerfield Airport. All on board were fatally injured.

The Cessna had departed from Dalby toward forecast en route weather unsuitable for visual flight, despite the pilot only being qualified for flight in visual conditions.

After crossing a section of the Great Dividing Range below cloud, and with minimal terrain separation, the pilot continued the flight in similar conditions toward the Lake Manchester VFR route, adjacent to the D’Aguilar Range.

“The aircraft very likely entered cloud while manoeuvring in this area, resulting in the pilot losing visual reference with the ground, eventually leading to controlled flight into terrain,” ATSB Chief Commissioner Angus Mitchell said.

“The pilot was probably influenced by plan continuation bias – an internal pressure or desire to get to the destination – to continue the flight, which probably became stronger as they got closer to Archerfield,” Mr Mitchell said.

However, due to a lack of information, the ATSB was unable to determine the reasons why the pilot continued the flight at cruise speed and low level into unsuitable weather in the vicinity of known high terrain. The ATSB considered it unlikely that there was any direct or perceived organisational pressure on the pilot to continue the flight.

As the report notes, the safety risks of visual pilots flying into non-visual conditions are well documented.

“This Christmas period, especially with wet weather around the country, the ATSB urges all VFR pilots to be mindful of the subtle pressures of plan continuation bias,” Mr Mitchell said.

“Be prepared to amend and delay plans to fly due to poor or deteriorating weather and environmental conditions, and not to push on,” he said.

“Have alternate plans in case of unexpected changes in weather, and make timely decisions to turn back, divert or hold in an area of good weather.”

Mr Mitchell noted there is a range of reference material available to pilots with guidance on avoiding VFR flight into adverse weather, including from the US Aircraft Owners and Pilots Association Air Safety Institute, and the ATSB itself.

While not determined as a contributing factor in the accident, the ATSB also found the operator’s hazard and risk register did not identify inadvertent entry into non-visual conditions as a hazard.

“Not including inadvertent entry into non-visual conditions in its hazard and risk register – which formed part of the operator’s safety management system – reduced the operator’s ability to effectively manage that risk,” Mr Mitchell explained.

Since the accident, the operator has removed aeroplane operations from its Air Operator’s Certificate and, after a risk assessment, plans to implement two risk controls for its helicopter operations by February 2024.

First, the operator will update its operations manual to include a formal organisational policy for supporting pilots to land or return to a safe landing site if they assess that they will be unable to maintain visual meteorological conditions.

Second, annual operator proficiency checks will include techniques for avoiding, and recovering from, inadvertent entry into non-visual conditions.

Read the report: VFR into IMC and controlled flight into terrain involving Cessna R182, VH-EHM, 36 km north-west of Archerfield Airport, Queensland on 29 August 2022


Publication Date
21/12/2023

Hmm...no comment, instead let me refer to a BRB member's OBS, which IMO totally nails it... Wink

Quote:What a load of crap. "Probably, plan continuation bias”? ???. Now there’s a bias ‘label’ for everything. I don’t know how this helps anyone. I had “climb up a ladder
 bias” today ??. I thought VFR into IMC was off their radar (excuse the pun)?
Whether that’s in their SMS would make no f…ing difference. Poor choice - simple.

Luckily I didn't fall off the ladder. Thank god it's in my personal SMS?. Falling from great heights isn't always compatible with life! ??
 

MTF...P2  Tongue

PS: As a side OBS I note that unlike the Croc'o'shite report and despite this investigation being 'defined', there was a section under the heading of 'Regulatory Oversight':

Quote:Regulatory oversight

CASA’s surveillance manual outlined that the surveillance program for Authorisation Holders (AH), such as Executive Helicopters, used a systems and risk-based approach to obtain, record, and analyse results to evaluate safety performance. The scheduling of surveillance events was driven by many factors such as external intelligence, outstanding safety findings, time since the last surveillance event, and safety-related risks specific to each AH.

CASA last conducted a surveillance event on the operator in October 2018. That surveillance was classified as ‘Level 1’[43] and conducted on-site at the operator’s premises. The scope of the surveillance included a review of airworthiness assurance, crew scheduling, and flight operations. The surveillance event resulted in 3 findings regarding crew rostering, navigation logs, and operations manual document control.

The operator responded to each finding with satisfactory corrective action and CASA acquitted the 3 findings in January 2019. Another Level 1 scheduled surveillance event was planned for March 2022 but was not conducted as all CASA surveillance events were postponed due to the flight operations regulations transition.

CASA used an Authorisation Holder Performance Indicator (AHPI) tool to assist with surveillance. The AHPI tool was one of a number of factors used to determine the need for surveillance events. The AHPI tool was a questionnaire-based tool consisting of several factors and sub-factors associated with organisational characteristics and performance commonly thought to affect or relate to safety performance behaviour. The assessment would result in the AH being assigned to either category 1 (higher level surveillance focus required) or category 2 (normal surveillance level appropriate). Since January 2019, 3 AHPI assessments had been conducted on Executive Helicopters — in May 2019, May 2020, and November 2021 — with each resulting in the operator being assigned to category 2 indicating that the normal level of surveillance was appropriate.


A short but thorough summary of the conducted CASA surveillance activities of this operator - KUDOS choccy frog well deserved. Meanwhile in the topend of Australia rotary wing operators/pilots (Croc Wrangler, Thomas Broome) get away with multiple illegal and unsafe commercial operations totally un-surveilled by CASA for a number of years??

[Image: giphy.gif]
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“Another one bites the dust.........”

Picture this – Single pilot, operating IFR, middle of a dark, weather limiting night, icing on descent to the initial instrument fix; cloud, wind, rain and turbulence forecast all the way down to the instrument minima, heavy aircraft, carrying a bit of ice through the low level turbulence. All forecast...

“Are you ready, hey, are you ready for this?
Are you standing on the edge of your seat?
Out the doorway the bullets rip
To the sound of the beat, yeah, yeah, yeah”

Every chance of a missed approach – 6o:: 40% certainty. Alternate selected; fuel sufficient; action plan 'sorted' – in you go – one shot – no fuel to bugger about. Minima, not visual, power up clean up and back into the crap you go. What rule was not broken? The bloody minima is what. Why not? Well, thirty seconds of clarity will tell you the answer and if you need that explained, then you have no business flying an aircraft; non whatsoever..

“A superior pilot uses his superior judgement to avoid situations which require the use of his superior skill.” Frank Borman.

That message should be the one hammered home, hard and often; then repeated as often as necessary until it is beaten into the thickest of skulls. Instead of that wise counsel being promoted; the ATSB provide  (fatuously) a new label for gross ignorance, an excuse to excuse the inexcusable; “Plan continuation bias”. Can you believe an 'aviation safety outfit' promoting this 'new age' crappola? WTD.

“What a load of crap. "Probably, plan continuation bias”? ???. Now there’s a bias ‘label’ for everything. I don’t know how this helps anyone.”

Let us get the terminology right: there is no such animal as 'inadvertent' or 'unintended' entry into IMC (with a few exceptions) it is a deliberate, aforethought act. There are times when a little judicious 'scud running' or scampering through valleys are totally acceptable methods of 'getting the job done' – done myself, countless times – but always with the back door wide open. The vagaries of the weather forecast demand serious pre flight consideration. That and the map provide all the information needed to find not only a back door, but 'decision' points. All that is then needed is the self discipline (in the interests of self preservation) to stick to those markers. If that all proves intellectually challenging; then grab an IFR chart and check the LSALT – these 'heights' clearly define an acceptable lowest height for operating 'in cloud'. If you are VFR and daft enough to deliberately enter clouds, then its probably a good bet to make sure that you and the bricks are properly separated.

Bad weather flying under the VFR demands much, much more discipline than IFR; especially when there is a functioning 'auto pilot'. The most important word in the lexicon is No, closely followed by No Way. There are old pilots, and there are bold pilots; but very few 'old-bold' pilots.

'Plan continuation bias'  - who dreams up these 'new speak' platitudes?

“I don’t know how this helps anyone.”

Neither do I mate: its rubbish, psycho babble, a distraction from core issues and an indecent cop out. (no prize for the right answer).

Aye, rant over – but seriously folks.

Toot – toot.........

Addendum...



Golden rule for ALL pilots:-


Hope for the best – expect the worst.” For example:-


- HERE – (Sky news).
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YLZI C208B runway overrun crash - Popinjay to the rescue??

Via ABC:

Quote:People injured after light plane crashes while taking off from Lizard Island on Great Barrier Reef

ABC Far North / By Holly Richardson and Meghan Dansie
Posted Mon 8 Jan 2024 at 10:55am Monday 8 Jan 2024 at 10:55am, updated Mon 8 Jan 2024 at 5:35pm

[Image: 92bdc209452775b27cf9a901ff8596d6?impolic...height=485]

Two people are being treated for minor injuries at Cairns Base Hospital after a light aircraft crashed on a remote island in the Great Barrier Reef.

Queensland Ambulance Service Acting Assistant Commissioner Brina Keating said a call for help was received around 7:30 on Monday morning after a plane taking off from Lizard Island's runway collided with trees and flipped.

She said nine adults and one 14-year-old girl were on board, with one adult sustaining a minor head injury and another a minor arm injury.

[Image: ca7531996a2e7ea175aa367423b68476?impolic...height=575]Those involved in the crash were brought to Cairns for treatment.(ABC Far North: Holly Richardson)

"All were walking — they were able to get out of the aircraft," she said.

"To walk away from something like that is incredible."

Two rescue helicopters and a Royal Flying Doctor Service aircraft were sent to the island, about 250 kilometres north of Cairns.

Ms Keating said the cause of the crash was being investigated, with access to the island challenging.

"We were on the scene quite quickly, with RFDS deploying first."

The Cairns Hospital and Health Service said all 10 patients were in a stable condition.

Plus, via 9News:


Still a bit unclear on the details, however the overlay depiction and commentary would seem to suggest a runway undershoot rather than an overrun?? Doesn't matter either way because according to Popinjay it was a collision with Terrain... Rolleyes

Via PJ HQ:

Quote:Collision with terrain involving Cessna 208, VH-NWJ, at Lizard Island, Queensland on 8 January 2024

The ATSB is investigating a collision with terrain involving a Cessna 208, registered VH-NWJ, at Lizard Island, Queensland. on 8 January 2024.

During initial climb, the aircraft experienced engine issues and the pilot attempted to return to Lizard Island. During landing the aircraft collided with trees and came to rest inverted. The aircraft sustained substantial damage and there were reports of serious injuries among the occupants.

The evidence collection phase of the investigation will involve interviewing the pilot, witnesses, first responders and other involved parties, reviewing recorded data, maintenance records and the collection of other relevant evidence.

A final report will be released at the conclusion of the investigation. Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties, so that appropriate safety action can be taken.


I note that at this stage this investigation is listed as a 'Short' and there was no bollocks press release contribution from Mr Attribution PJ, nor any notification on social media.

[Image: SYDEX-media_image001.jpeg]

Hmm...wonder why not? Shy

MTF...P2 Tongue
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AO-2023-057 prelim published: Popinjay to the rescue! Dodgy

First the usual bollocks MR attributed to Popinjay:

Quote:ATSB releases Port Phillip Bay jet mid-air collision preliminary report


The Australian Transport Safety Bureau has released a preliminary report into its ongoing investigation of a mid-air collision involving two jet trainer aircraft over Port Phillip Bay, south of Melbourne, in November.

On 19 November 2023, a pair of SIAI Marchetti S-211 aircraft were being used for an aerobatic formation filming flight when they came into contact, with one of the two aircraft subsequently departing controlled flight before colliding with the water below, fatally injuring both occupants.

“Today’s preliminary report provides factual information from the early evidence gathering phase of our ‘no blame’ transport safety investigation,” ATSB Chief Commissioner Angus Mitchell explained.

“It does not include any analysis or findings, which will be detailed in the final report we will release at the conclusion of the investigation.”

The preliminary report notes the S-211s, both ex-military aircraft used for pilot training, had left Essendon in what was designated ‘Viper formation’.

Viper 1, the lead aircraft, was carrying a pilot and safety pilot, while Viper 2 was carrying a pilot and camera operator.

“As discussed in the pre-flight briefing, the pilots’ first planned manoeuvre involved Viper 1 flying inverted, straight and level, so Viper 2 could move alongside it, upright, to then manoeuvre as required to maintain separation and conduct filming,” Mr Mitchell said.

During the second attempt at this manoeuvre, when Viper 1 rolled inverted, the pilot of Viper 2 passed below and to the left of Viper 1.

“The safety pilot in Viper 1 observed Viper 2 pass beneath and alerted the pilot of Viper 1 to the manoeuvre,” Mr Mitchell said.

“Afterwards, the pilot of Viper 2 advised the pilot of Viper 1 that it provided a good filming opportunity, and asked to repeat it.”

After the pilots discussed this manoeuvre, they decided to attempt it again.

“On this next attempt, after Viper 2 passed beneath, it began to pitch up and bank away from Viper 1, and the right wings of each aircraft collided,” Mr Mitchell said. 

Video footage taken from fixed cameras on board Viper 1 showed that as the aircraft collided, the outer right wing structure of Viper 2 immediately failed, with deformation to the forward wing spar and separation of the lower wing skin. The right aileron control system also appeared to be significantly damaged.

Witnesses observed Viper 2 impact the water in a near-vertical, nose down attitude at high speed. The aircraft was extensively damaged and came to rest on the floor of Port Phillip Bay at a depth of 24 metres.

Fortunately, Viper 1 was able to return to Essendon, having sustained only minor damage.

“Several impact marks and paint transfers from Viper 2 were present on the upper surface of Viper 1’s right wing, and its landing light cover was shattered,” Mr Mitchell detailed.

As the ATSB’s investigation progresses, it will include consideration of formation flying procedures and practices, further analysis of recorded video and audio, a review of the category of operation, and a range of other investigative activities.

“A final report will be released at the conclusion of the investigation, but if we identify a critical safety issue during the course of the investigation, we will immediately notify relevant parties so appropriate and timely safety action can be taken.”

Read the preliminary report: Mid-air collision involving SIAI-Marchetti S211s, VH-DZJ and VH-DQJ, 25 km west of Tyabb Airport, Victoria, on 19 November 2023

Publication Date 17/01/2024

Still bemused by why PJ feels the need to produce such waffle when (much like the UK AAIB) all they really need do is inform via social media etc. that the prelim report has been released. Much like the descriptor below the ATSB Youtube video:

Quote:11,100 views  Jan 17, 2024  CANBERRA

We have published our preliminary report into the mid-air collision involving SIAI Marchetti S-211s, VH-DZJ and VH-DQJ, which occurred over Port Phillip Bay, Victoria on 19 November 2023.

Preliminary report: https://www.atsb.gov.au/publications/inv...o-2023-057
 

However in this particular situation Popinjay then followed up on the bollocks attributed to MR, with several news channel appearances from two locations presumably from his place of residence... Dodgy

Quote:

6,769 views  Jan 17, 2024  #7NEWS #BREAKINGNEWS

Air Safety Investigators have released chilling images of the moment two jets collided over Port Phillip Bay, killing a pilot and cameraman. Their preliminary report reveals new details on the decisions that led to disaster.

Plus: https://www.9news.com.au/videos/national...n59r8ctprr



Final moments of fatal plane crash at Melbourne's Port Phillip Bay revealed

By Mikaela Ortolan

Posted Wed 17 Jan 2024 at 3:23pm, updated Wed 17 Jan 2024 at 6:33pm

[Image: 2880f9c03c599a6be393a3f078e9adbe?src]

Quote:"Today's preliminary report provides factual information from the early evidence gathering phase of our 'no blame' transport safety investigation," Mr Mitchell said.

"The next part for us is to analyse that data ... not only uncover what's occurred but more importantly what were the things that went wrong that allowed it to happen and … is there any recommendation that we can make to lessen the likelihood of something like this happening again."

Apparently not satisfied with those appearances, PJ then followed up the next day with this on Sunrise:


Quote:9,881 views  Jan 18, 2024  #7NEWS #BREAKINGNEWS

Experts are considering new recommendations for aircraft stunts after an investigation revealed the cause of a fatal mid-air collision of two military style jets in November.

Hmm...err no comment -  Blush

MTF...P2  Tongue
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AO-2023-022: Final Report Release

Godlike to the rescue (Popinjay gets a day off), via PJ HQ -  Dodgy

Quote:Safety action underway to address airliner separation event

[Image: AO-2023-022%20Figure%201.jpg?itok=AcxTDJZP]

Several safety actions been made or are planned in response to a close proximity event between two 737 aircraft at Sydney Airport last year, an Australian Transport Safety Bureau final report details.

On 29 April 2023, a Qantas-operated Boeing 737 was lined up to take off from Sydney’s runway 16L, while a second Qantas 737 was on approach to land on the same runway.

Shortly after the first aircraft began its take-off roll, the aerodrome controller in the Sydney Airport air traffic control tower identified that the second aircraft was too close behind for runway separation to be assured.

After being delayed by about 12 seconds due to an inadvertent interjection by the tower shift manager, the controller instructed the second aircraft to go-around, while the first continued its take-off.

Shortly after the go-around, the controller then instructed the second aircraft to turn left after reaching 2,100 ft altitude.

“The flight crew of the second aircraft, at this time of high workload, misinterpreted this instruction as overriding the published missed approach procedure, which calls for a left turn at 600 ft,” ATSB Director Transport Safety Dr Stuart Godley said.

Due to misinterpreting the controller’s instruction, the crew of the second aircraft maintained the runway heading as they climbed through 600 ft and, as the two aircraft climbed away from the runway, separation reduced to a minimum of 1.5 km laterally and 330 ft vertically.

The controller had both aircraft in sight throughout the occurrence, and the ATSB assessed that adequate visual separation had been maintained.

In response to the incident, the air traffic services provider, Airservices Australia, advised the ATSB that it had undertaken, and would undertake, a range of safety actions.

“These include a detailed analysis of landing runway occupancy times at Sydney, and possibly other major airports, to determine expected runway occupancy times for different types of aircraft and conditions,” Dr Godley noted.

Further actions, detailed in the final report, include adding defensive controlling techniques and minimum assignable altitudes for go-around scenarios, conducting an assurance review of go-arounds at Sydney involving a second aircraft requiring controller intervention, and adding night-time go-around scenarios to compromised separation training.

“In complex airspace settings, it is inevitable errors will sometimes be made by controllers and pilots alike,” Dr Godley said.

“Consequently, the system within which these activities take place should be designed to be resilient to error and to reduce the impact that individual actions can have on the overall safety of operations.”

Read the report: Separation occurrence involving Boeing 737, VH-VZM, and Boeing 737, VH-VZW, near Sydney Airport, NSW on 29 April 2023

Publication Date: 31/01/2024

This investigation was only a 'Short' and didn't meet it's KPI requirement for 7 months completion, however I do question why they bothered to continue when the safety issues identified would have been addressed internally within weeks of the incident occurring??

MTF...P2  Tongue
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Latest unnecessary, bollocks Popinjay Media Releases Dodgy 

The chalk, via PJ HQ:

Quote:Cessna 172 go-around accident emphasises importance of appropriately actioning checklists

[Image: Picture1.jpg?itok=RroL0wy1]

A Cessna 172 that collided with terrain during a forced landing at Murwillumbah was likely not configured correctly during an attempted go-around, an Australian Transport Safety Bureau investigation has concluded.

The aircraft was on final approach at Murwillumbah during a private flight from Gold Coast Airport on 15 October 2023, when the pilot estimated the aircraft was too high for a landing and elected to conduct a go-around.

An experienced pilot on the ground adjacent to the runway, who witnessed the accident, recalled hearing the engine running at a low power setting, before producing a loud bang or ‘pop’, about half way down the runway, which sounded like the throttle had been pushed forward too quickly.

The Cessna pilot, meanwhile, believed the aircraft had not responded with adequate power as they commenced the go-around, although the ATSB investigation found it was unlikely the engine was not producing power.

“The pilot assessed they had insufficient power to climb and that there was insufficient runway remaining to land,” said ATSB Director Transport Safety Stuart Macleod.

“Accordingly, the pilot elected to conduct a forced landing in a field about 1 km to the north of the airport.”

During the forced landing, the aircraft was substantially damaged, and the pilot sustained minor injuries.

“Prior to the forced landing, the pilot advised they were concerned about an aerodynamic stall, so kept the flaps at 40 degrees to reduce the stall speed,” Mr Macleod explained.

“This would have created a large amount of drag and subsequently impaired climb performance.”

Mr Macleod noted the 40 degrees flap setting was not in line with the 20 degrees prescribed for a go-around in the Cessna 172M Pilot Operating Handbook.

“This accident highlights the importance of pilots appropriately actioning checklists and following procedures in the Pilot’s Operating Handbook.

“The improper or non-use of checklists has been cited as a factor in several aircraft accidents.”

While not contributory in the accident, the ATSB also found an unsecured nose-wheel steering tow bar in the aircraft increased the risk of serious injury to the pilot.

“Loose items in the baggage area or cockpit can become dangerous projectiles and may cause serious injuries during an abrupt stop, turbulence or an accident sequence.”

Read the report: Collision with terrain involving Cessna 172M, VH-JUA, 1km north-east of Murwillumbah, New South Wales on 15 October 2023

Publication Date: 14/02/2024

Quote:Lake Macquarie runway near collision highlights the importance of effective radio communications and an effective visual scan at non-towered aerodromes

[Image: AO-2023-024%20News%20item%20image.jpg?itok=volcuIKI]

The pilots of two aircraft involved in a runway accident at Lake Macquarie did not hear each other on the radio, nor see one another, before a near collision occurred and one aircraft struck the ground while taking avoiding action, an ATSB investigation report details.

On 12 May 2023, an instructor and student pilot were conducting wheel balance exercises in a gyroplane on runway 07 at Lake Macquarie Airport.

Following one of these exercises, the student made a radio broadcast while the instructor turned the gyroplane around, about halfway down the runway, and taxied back toward the western threshold, to repeat the exercise.

“Meanwhile, an Extra EA 300L aerobatic aircraft with a pilot and passenger on board had taxied from the apron toward the eastern end of the runway to conduct a commercial joy flight,” ATSB Director Transport Safety Stuart Macleod said.

“The Extra pilot made two radio broadcasts before entering the runway, and beginning to taxi down the runway toward the western end, for a planned take-off from runway 07.”

At about this time, the gyroplane commenced another exercise, and accelerated down runway 07, toward the taxiing Extra.

“Neither aircraft’s pilots heard the radio broadcasts of, or saw the other, until the pilots in the gyroplane observed the Extra about 20 m in front of them on the runway,” Mr Macleod said.

In reaction, the gyroplane’s instructor pilot took control and banked right to avoid collision.

The aircraft’s rotor blades impacted the runway surface before the gyroplane veered off the runway and struck the ground, coming to rest on its side. The gyroplane was substantially damaged, the instructor was seriously injured, and the student pilot sustained minor injuries.

“When none of the pilots heard radio calls from the other aircraft, aircraft separation became reliant solely upon visual acquisition,” Mr Macleod explained.

“As such, several factors likely reduced the ability of the pilots to then visually identify each other, including the small angular size of each aircraft, the complex background features with low relative contrast, and minimal relative movement between the aircraft.”

In addition, the Extra’s tailwheel configuration limited the pilot’s forward visibility while taxiing, while sun glare likely also affected the Extra pilot’s ability to detect the gyroplane.

“This accident highlights the limitations of unalerted see-and-avoid around non-towered aerodromes,” Mr Macleod said.

“Reducing the collision risk around non-towered airports is one of the ATSB’s key SafetyWatch concerns, and this accident serves to remind pilots of the importance of effective radio communications to increase traffic awareness, and to ensure an effective visual scan to identify conflicting traffic.”

The ATSB’s publication A pilot’s guide to staying safe in the vicinity of non-controlled aerodromes outlines many of the common problems that occur at non-controlled aerodromes, and offers useful strategies to keep yourself and other pilots safe.

Additionally, the Civil Aviation Safety Authority's Pilot Safety Hub also has extensive information on non-controlled operations.

Since the accident, Lake Macquarie Airport’s operator released a bulletin to all aircraft operators highlighting the importance of visual lookout in addition to radio discipline. The airport operator has also acquired radio recording equipment to allow communications to be periodically reviewed.

The operator of the Extra updated operational procedures, and the representative body for gyroplanes, the Australian Sport and Rotorcraft Association, has advised ATSB of its intent to replace the one-off human factors exam with a recurrent exam.

Read the report: Collision with terrain involving Magni M16C Tandem Trainer gyroplane, G1850, while avoiding Extra EA 300L, VH-IOG at Lake Macquarie Airport, New South Wales on 12 May 2023

Publication Date: 13/02/2024

Blah..blah..blah!! - Why? Let the report talk for itself - FDS!

The cheese, courtesy the UK AAIB, via X:

Quote:AAIB
@aaibgovuk

A report has been published into a serious incident involving a Leonardo AW189 (G-MCGT) which sounded a terrain warning during a go-around due to rising ground ahead at Ballintoy Harbour, County Antrim on 26 July 2021
https://www.gov.uk/government/news/aaib-...-july-2021

[Image: GGXrrWvXYAAEbQm?format=jpg&name=small]


From the AAIB link (above):

Quote:Report into a serious incident involving a Leonardo AW189 (G-MCGT) which sounded a terrain warning during a go-around due to rising ground ahead at Ballintoy Harbour, County Antrim on 26 July 2021.


From:  Air Accidents Investigation Branch

Published 15 February 2024

The Search and Rescue helicopter was on its third approach, in poor visibility, to collect a casualty from a site adjacent to high ground. The Pilot Flying (PF) selected a mode of the Automatic Flight Control System (AFCS) which would bring the helicopter to a hover. As he did so, the helicopter unexpectedly yawed towards the high ground. When a further selection was made on the AFCS to effect a go-around, the helicopter accelerated towards the terrain while maintaining height. The Helicopter Terrain Awareness Warning System (HTAWS) triggered a visual and aural caution terrain alert. The crew immediately made a climbing turn onto their planned escape heading during which a warning terrain alert triggered. The helicopter recovered to a safe height and returned to its home base.

The unexpected yaw was caused by a mismatch between the previously selected AFCS heading reference and the heading flown by the PF. While the helicopter and the flight control system were found to be serviceable and performed as designed, the crew did not have a complete understanding of the functionality of all the AFCS modes. Other factors included:
  • Overriding the engaged modes by manually flying the helicopter.
  • A lack of clarity between the role of PF and Pilot Monitoring (PM).
  • Ineffective communication and co-ordination between the pilots.
  • Imprecise application of Standard Operating Procedures (SOPs).

The operator took a number of safety actions to raise awareness of the event, improve knowledge of the autopilot modes and include the event as part of their initial and recurrent training.

Read the report.

Simple, just the facts, no self-aggrandisement, no biased opinion and no attempted cover-ups; or arse-covering - TOP STUFF!  Wink 

MTF...P2  Tongue

PS: I know it's not our area but you can't keep a good muppet down - 'Popinjay to the RESCUE!!':

Quote:Train collision highlights shared responsibility of train drivers and operators in managing fatigue[Image: RO-2019-022%20News%20image.jpg?itok=C7MO6DlC]
An ATSB investigation into a fatal collision between freight trains north-east of Perth highlights the shared responsibility of train drivers and operators in managing fatigue.

In the early morning of 24 December 2019, the driver of a Pacific National intermodal freight train was fatally injured when it collided with the rear of a stationary grain train at Jumperkine.
The freight train driver had passed a signal at caution, and a signal at danger – instructing them to stop – prior to the collision, but emergency braking was only applied when the grain train came into view.

“Despite being closely behind another train, the driver had passed 33 consecutive green signals over the two hours prior to reaching the signal at caution,” Chief Commissioner Angus Mitchell said.

“The driver was likely experiencing a level of fatigue known to adversely affect performance, and was almost certainly unaware they had passed the signal at caution, and then the signal at danger,” Chief Commissioner Angus Mitchell said.

The driver’s responses to the locomotive vigilance system timed alerts became slower as the journey progressed, but – consistent with the known limitations of these systems – it did not identify when the driver was fatigued and not attentive to rail signals.

“The ATSB concluded several fatigue-related factors, relevant to both individuals and organisations, either contributed to, or increased risk, in this accident.”

The driver’s fatigue was likely due to a combination of insufficient sleep in the 48 hours prior to the accident, and operating in the window of the circadian low, the investigation found.

“This accident highlights the consequences that can arise when train drivers perform their duties without sufficient sleep, and that the responsibility for managing fatigue in the rail sector is shared between drivers and operators,” said Mr Mitchell.

“Drivers have a responsibility to effectively use rostered breaks to rest, and self-report if they have had less sleep than required, and operators should promote an environment in which identification of fatigue concerns is encouraged, and any barriers to fatigue reporting are examined and understood.”
Since the accident, Pacific National has taken a range of safety actions to address issues with its fatigue assessment and reporting processes, as well as the limited controls available to manage the risk of signals being passed at danger during driver-only operations, including incidents associated with fatigue.
The investigation also noted that, like much of Australia’s freight rail network, the railway between Kalgoorlie and Perth lacks an automatic safety system to prevent a train from passing a signal at danger, or to stop a train which has passed such a signal.

This means the safeworking system is reliant on rail traffic crews observing and complying with displayed signal aspects.

“Although reliance on signal compliance has been central to the rail safety system in Australia for many years, it is fundamentally limited in situations where the driver is not fully attentive to the rail corridor or misperceives a signal,” Mr Mitchell said.

“Until automatic train protection or similar technology is considered viable, rail transport operators should ensure that the set of risk controls they have in place provides sufficient assurance to minimise the risk associated with signals passed at danger (SPADs) or other overruns of authority.

“The ATSB encourages rolling stock operators, industry bodies and others to develop technological improvements to vigilance systems or other technologies to enhance the ability to identify when drivers are fatigued or otherwise inattentive.”

Since the accident, the rail infrastructure manager, Arc Infrastructure, has also taken a number of safety actions, including amending its rules to require NCOs to make an emergency radio call to all rail traffic on the corridor when a train exceeds its limits of authority.

“Additionally, in response to this accident both Pacific National and Arc Infrastructure entered into enforceable voluntary undertakings with the Office of the National Rail Safety Regulator (ONRSR), prescribing a range of safety steps to be taken in response to the accident,” Mr Mitchell said.

Read the report: Collision between freight trains 7MP5 and 2K66, at Jumperkine, Western Australia, on 24 December 2019.


Publication Date
15/02/2024

Hmm...good to see that elongated investigations of 2+ years is not isolated to aviation... Rolleyes

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Popinjay to the rescue: Clearing Fudging the books?

Via PJ's BOLLOCKS concocted Media Pages:

Quote:A350 pitot probe covers left on prior to pushback demonstrates how assumptions, procedural omissions can lead to unsafe conditions
[Image: AO-2022-032%20News%20Story%20Image.jpg?itok=77XK070r]

A Singapore Airlines Airbus A350 was about to be pushed back from the gate at Brisbane’s international terminal on 27 May 2022 when a refueller in an adjacent bay noticed covers were still on the aircraft’s pitot probes, an ATSB investigation final report describes. 

Upon being alerted to this, the licenced aircraft maintenance engineer (LAME) responsible for the aircraft’s turnaround returned to the aircraft and removed the pitot covers. The aircraft then proceeded for its planned passenger service to Changi, Singapore, without further incident. 
 
Pitot probes, which provide airspeed data to aircraft systems and flight crew, are routinely covered during turnarounds at Brisbane due to the nesting behaviour of a species of invasive mud wasp, which has been known to block the tubes in as little as 20 minutes. The covers must be removed prior to take-off. 

In a serious incident in 2018, a Malaysia Airlines A330 took off from Brisbane with its pitot covers still in place, and its crew had to conduct an emergency return landing without airspeed data. 

In this more recent occurrence, the ATSB found Singapore Airlines’ contracted engineering provider at Brisbane, Heston MRO, had not yet implemented an acceptable method for accounting for tooling and equipment prior to aircraft pushback, although that was identified in the ATSB’s investigation into the 2018 occurrence. 

“Additionally, the procedural risk controls which were in place for the removal of the pitot probe covers were circumvented when the LAME certified for their removal in the technical log and removed a relevant warning placard from the flight deck, without visually or verbally confirming that they had been removed,” ATSB Chief Commissioner Angus Mitchell said. 

“The final walk around inspection of the aircraft was also not conducted by the LAME or the headset operator. That inspection is intended to ensure that the aircraft is correctly configured for flight with all panels and doors closed and all covers removed. 

“This incident demonstrates how assumptions and procedural omissions can lead to unsafe conditions; in this case, the potential for an aircraft to take-off with erroneous or absent airspeed indications.” 

While the ATSB was not able to formally establish that fatigue contributed to the occurrence, the investigation did note the LAME had reported the workload associated with their dual role of LAME/regional manager had become considerably more demanding following the COVID-19 pandemic. 

“The engineering provider did not track the work-related hours of personnel with dual roles like the LAME involved in this incident (who was also the regional manager) for fatigue calculation purposes,” Mr Mitchell said. 

“This meant there was an increased risk of a fatigue-related incident with these personnel.” 

The report notes that, since the occurrence, Heston MRO no longer requires the Brisbane regional manager position to undertake dual responsibilities, and tracks work hours of all employees for fatigue management purposes. 

Also, during the ATSB’s investigation, a review of CCTV footage of pre-flight inspections by Singapore Airlines flight crew for the occurrence flight and others around the same time showed they were truncated, and not undertaken in accordance with company procedures. 

“The pre-flight walk-around occurs before the pitot probe covers are to be removed, so this did not contribute to this incident,” Mr Mitchell noted. 

“Nonetheless, it was identified in our investigation as a safety issue, which Singapore Airlines has subsequently addressed.” 

The airline, the report notes, has communicated with flight crews about the importance of pre-flight walk-around checks to be completed in their entirety and in accordance with the procedures. 

The airline has also provided Heston MRO with pitot probe covers with longer streamers, to improve conspicuity. 
Read the final report: Flight preparation event involving Airbus A350-941, 9V-SHH, Brisbane Airport, Queensland, on 27 May 2022
[/size]


Publication Date 15/03/2024

This 'defined' investigation took 659 days complete, had a prelim report that took 55 days longer than the 30 day maximum (after the incident/accident) for an ICAO Annex 13 preliminary report copy to be dispatched to ICAO (if in fact it was dispatched at all? Ref: Dear Betsy RE: Bring back Lachie; & where's the ICAO report please?

I also note that this FR has 4 associated 'safety issues' published that have apparently been 'adequately addressed' and subsequently 'closed' by PJ's crew: 

1. https://www.atsb.gov.au/safety-issues/AO-2022-032-SI-01

Quote:Action description

In January 2024, Heston MRO advised that they would be completing a review of their transit toolbox procedures, with any changes to be implemented when a new revision of their manual was released in January 2024. The changes will incorporate a more specific requirement to review and document a check of the transit toolbox prior to certified release to service, which will include the use of a checklist.

2. https://www.atsb.gov.au/safety-issues/AO-2022-032-SI-02

Quote:Action description

In January 2024, Heston MRO advised they had taken the following safety action:
  • They have employed an independent regional manager who will not hold a maintenance authority within the organisation. The intention of the business is to reduce reliance on dual function managers and LAMEs.
  • There was a policy change that required salaried staff (such as the regional manager/LAME) to supply a timesheet with start and finish times so that accurate fatigue management calculations could be conducted in accordance with the Heston MRO fatigue management framework.

3. https://www.atsb.gov.au/safety-issues/AO-2022-032-SI-03

Quote:Action description

In January 2024, Singapore Airlines advised the ATSB that it was initially emphasised to their A350 pilots via the publication of a memo and later to all pilots through an Internal Notice to Airmen (INTAM) on 12 December 2023, the importance of adhering to standard operating procedures in relation to the completion of exterior checks.

4. https://www.atsb.gov.au/safety-issues/AO-2022-032-SI-04

Quote:Action description

In January 2024, Singapore Airlines advised the ATSB that they had engaged Heston MRO at Brisbane to use pitot probe covers with better conspicuity by increasing the length of the streamers. Usage of such covers has been implemented by Heston MRO on Singapore Airlines aircraft at Brisbane (see images below).

Annex 13 Para 7.4 also says:

"When matters directly affecting safety are involved, it shall be sent as soon as the information is available and by the most suitable and quickest means available"

No idea if this actually occurred, in regards to these safety issues, as again there is no listed 'issue' date in the (publicly available) ATSB website safety issue database: https://www.atsb.gov.au/safety-issues-an...r_value=AO 

Finally for a contradiction in ATSB investigative processes, priorities and 'related occurrences' for flight preparation incidents, I note the following 22/09/2021 'short investigation' FR: Aircraft flight preparation occurrence involving Boeing 787-9, VH-ZNJ Melbourne Airport, Victoria on 22 September 2021

Although obviously no where near as serious as departing with pitot/static covers attached, the AO-2021-040 didn't have any associated 'safety issues' identified and therefore a much lower probability of the subsequent MLOSA lessons learnt being disseminated across industry. There is a possibility (remote I know -  Wink ) that if the lessons learnt from the QF incident, had been more effectively disseminated by the ATSB, then maybe the Singapore A350 incident may not have occurred... Rolleyes

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Short Investigation AO-2023-041: What a load of bollocks!! - Dodgy

Stewie Macleod is apparently the DTS at Popinjay HQ for this week and responsible for yet another WOFTAM, BOLLOCKS media release - FDS! Blush

Quote:Fokker’s descent below minimum safe altitude a reminder of the importance of monitoring auto-flight systems

[Image: AO-2023-041%20Figure%202.JPG?itok=tlSXxvlu]

A Fokker 100’s descent below minimum safe altitude during an approach into Adelaide late last year highlights the importance of flight crew continuously monitoring auto-flight systems, an ATSB investigation report details.

On the morning of 30 August 2023, the flight crew of an Alliance Airlines-operated Fokker 100 was conducting a BLACK 3A standard instrument arrival into Adelaide’s runway 23, at the conclusion of a passenger service from Brisbane.

“The FMS failed to capture the 3,800 ft minimum safe altitude between the waypoints KERRS and GULLY and the aircraft descended through this altitude,” ATSB Director Transport Safety Stuart Macleod explained.

The flight crew were monitoring the altitude and observed the breach.

“In response, the captain pressed the altitude control knob to command the aircraft to hold the current altitude, but this did not arrest the descent,” Mr Macleod said. “The first officer then increased the selected altitude to 4,700 ft, but the aircraft continued to descend.

“During this time, the aircraft was in and out of cloud, but the flight crew reported they had sufficient visibility with the ground and terrain to assess that adequate separation existed.”

Assessing the aircraft was continuing to descend in auto-flight mode, the first officer disconnected the autopilot and initiated a climb, with the aircraft at about 3,487 ft – approximately 480 ft below the minimum safe altitude for the segment.

The aircraft then entered a gradual climb but, at about the same time, it passed through waypoint GULLY, entering a new segment with minimum safe altitude 3,200 ft, so no further climb was necessary.

The flight crew then proceeded with the instrument approach and conducted an uneventful landing.

“Fortunately, the flight crew were monitoring the instruments and disconnected the automatic flight system when they detected the descent below the selected altitude, and initiated a climb,” Mr Macleod said.

“This incident reinforces to pilots the importance of continuously monitoring auto-flight systems, and reacting quickly when the aircraft is not on the expected flight path, to ensure that limits are not exceeded.”

Despite the ATSB consulting with the aircraft manufacturer, Fokker, and the flight management computer manufacturer, Honeywell, the reason the aircraft did not level at the selected altitude could not be determined.

Read the final report: Descent below segment minimum safe altitude involving Fokker 100, VH-FGB, near Adelaide Airport, South Australia on 30 August 2023

Publication Date: 12/04/2024

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More pointless Spin'n'bollocks Investigation Report Media Releases??Dodgy

This week's Popinjay DTS is Dr Godlike and apparently he is attributable for this bollocks press release... Rolleyes

 
Quote:Near collision highlights how line of sight limitations make non-mandatory radio calls essential

[Image: AO-2023-025-News%20item%20image.jpg?itok=PDCZUtAA]

The pilots of two aircraft had incorrect mental models of local traffic when their aircraft took off from intersecting runways at the same time, an ATSB final report details.

During the 6 June 2023 incident at Mildura Airport, a Piper PA-28 Cherokee was conducting a solo private flight to Broken Hill, while a QantasLink Dash 8 with 3 crew and 33 passengers was departing on a scheduled service to Sydney.

The Cherokee had taxied to the threshold of runway 36, while the Dash 8 had taxied to the threshold of runway 09.

Both aircraft had made the required mandatory calls on the local common traffic advisory frequency (CTAF), used by pilots to coordinate and self-separate at non-controlled aerodromes, such as Mildura. 

However, ATSB Director Transport Safety Dr Stuart Godley said, during their calls, the pilot of the Cherokee had incorrectly identified Mildura’s runway 36 as ‘runway 35’.

“This occurred while the Dash 8’s pilots were obtaining their pre-departure information from air traffic control, and had the volume turned down on the CTAF radio,” Dr Godley explained.

“In addition, the Dash 8 crew only received certain elements of the Cherokee’s calls due to an over transmission from air traffic control.”

The incorrect runway identification compounded with these factors to create an incomplete comprehension of local traffic in the Dash 8 crew’s mental models – specifically, both Dash 8 pilots did not believe that the Cherokee was at Mildura, given that the nearby Wentworth Airport also uses the same CTAF.

Additionally, when the Cherokee was ready for its take-off roll on runway 36, its pilot believed the Dash 8 would still be backtracking on runway 09 – but the Dash 8 was in fact also about to begin its own take-off roll. 

“Subsequently, both aircraft began take-off rolls towards the intersection of their respective runways, and the Dash 8 passed about 600 m in front of the Cherokee,” Dr Godley outlined.

The report notes the pilot of the Cherokee gave a rolling call on the CTAF at the start of their roll, while the Dash 8 crew did not – but that rolling calls are not mandatory.

“However, due to terrain and buildings at Mildura Airport, aircraft are not directly visible to each other on the thresholds of runways 09, 27 and 36,” Dr Godley said.

“With the inability to see another aircraft when each aircraft is at the threshold at Mildura Airport, the lack of a requirement for mandatory rolling calls increased the risk of aircraft not being aware of each other immediately prior to take-off.”

Since the incident, Mildura Airport established a permanent requirement for Mildura Airport operations as of 4 April 2024 for mandatory rolling calls from all aircraft immediately prior to take-off due to the increased risk of aircraft not being aware of each other. 

In addition, QantasLink has made rolling calls part of the minimum requirements for operations at CTAF aerodromes.

“Communication and self-separation in non-controlled airspace is one of the ATSB’s SafetyWatch priorities,” Dr Godley said.

“Pilots can guard against occurrences like this one by making the recommended broadcasts when in the vicinity of a non-controlled aerodrome, actively monitoring the CTAF while maintaining a visual lookout for other aircraft and constructively organising separation through direct contact with other aircraft, and ensuring transponders, where fitted, are selected to transmit altitude information.”

While the ATSB did not identify radio interference or shielding as contributing to this occurrence, another ongoing investigation into a similar event that occurred at Mildura later in 2023 (AO-2023-050), is considering these factors.

As part of that investigation, the ATSB is continuing to work with Qantas Safety, Mildura Airport, the Australian Communications and Media Authority, the Civil Aviation Safety Authority and Airservices Australia.

Read the report: Near collision involving Piper PA-28-161, VH-ENL, and Bombardier DHC-8-315, VH-TQH, at Mildura Aerodrome, Victoria, on 6 June 2023

Listed as a 'Short' desktop investigation, this report took 344 days to complete and included a 'safety issue' that was apparently only publicly released 3 days ago.. Rolleyes : AO-2023-025-SI-01

Quote:Date issue released: 14/05/2024

Safety Issue Description

Due to topography and buildings at Mildura Airport, aircraft are not directly visible to each other on the threshold of runway 09, 27 and 36. The lack of a requirement for mandatory rolling calls increased the risk of aircraft not being aware of each other immediately prior to take-off.

However Mildura has already acted on and notified action on this safety issue:

Quote:Action description

Mildura Airport has advised that it has been successful in establishing a permanent NOTAM for Mildura Airport operations as of 4 April 2024.

The NOTAM includes the advice that aircraft are not directly visible to each other on the thresholds of Runway 09, 27 and 36 and that mandatory rolling calls are required from all aircraft immediately prior to take-off due to the increased risk of aircraft not being aware of each other. This permanent NOTAM is to be subsumed into the ERSA publication for Mildura Airport in the 2406 amendment cycle on 13 June 2024.


There is some interesting commentary on a UP thread currently running on this report.. Shy : Mildura 2023 near miss final report out

Quote:Checklist Charlie

The occurrence

Quote:In the early afternoon of 6 June 2023, a Piper PA-28-161 (PA‑28), registered VH-ENL taxied for runway 36[1] at Mildura, New South Wales, for a private flight to Broken Hill

Ooooops, proof reading not a strong point there ATSB

CC



SIUYA

Geez C.Charlie.......

Give the poor buggers a break.

At least they got this report out in less than the stock-standard 2 (maybe 3?) years.

Next, Godlike with another 'Short' investigation report bullshit presser... Dodgy

Quote:Increased pilot workload during Parafield descent below minimum safe altitude incident

[Image: AO-2022-039%20News%20Item%20Image.jpg?itok=AeoAjL36]

A Beech Baron’s descent below minimum altitude on approach to Adelaide’s Parafield Airport highlights to pilots the importance of vigilance of their aircraft’s altitude and workload management, an ATSB investigation report details.

On 12 August 2022, the twin-engined Baron was being repositioned from Port Augusta to Parafield, with weather conditions necessitating an instrument approach (using the RNAV GNSS RWY 21R instrument approach procedure).

“While in cloud on the approach segment between the initial approach fix and intermediate fix, the aircraft descended below the 3000 ft segment minimum safe altitude,” ATSB Director Transport Safety Dr Stuart Godley explained.

“The aircraft continued to descend and entered the next segment at 2000 ft, below that segment’s minimum safe altitude of 2200 ft.”

The approach controller then received an automated warning, and contacted Parafield tower, who alerted the pilot. The pilot subsequently climbed the aircraft back above the minimum altitude.

“The pilot was experiencing an increased workload from conducting an instrument approach in cloud and turbulence and did not detect their flight below the segment minimum safe altitude.

“This incident is a good reminder to pilots of the importance of close monitoring of the aircraft’s vertical and lateral navigation, in particular during high workload phases of flight.”

The investigation report notes that once the pilot returned above minimum safe altitude, they continued the climb. The aircraft was about 7 NM from the runway and 850 ft above the recommended profile, when the pilot elected to continue the approach.

“Continuing the approach from that position, above the recommended profile, required a higher-than-normal descent rate, and had the potential to increase the pilot’s workload,” Dr Godley added.

The pilot established visual reference with the runway about 4 NM from the threshold, and landed without further incident.

The ATSB report notes the pilot was referring to a hand-held paper copy of the instrument approach procedure, but that the aircraft’s control yoke did not have a chart holder, nor did the pilot have a document holder or kneeboard available.

This increased the difficulty monitoring the check altitudes and segment minimum safe altitudes.

“Continuous monitoring of the aircraft’s altitude relevant to the various segment minimum safe altitudes, and having the instrument approach procedure available in a suitable location, are both key to minimising workload and conducting an instrument approach safely,” Dr Godley said.

“Pilots also need to remain vigilant about the relationship between the procedure commencement altitude and the constant descent final approach path, including that the correct waypoint has been identified for managing the descent profile and ensuring the distance-based check altitudes are correctly interpreted.”

Read the report: Flight below minimum altitude involving Beech Aircraft Corp 95-B55, VH-ALR, 20km north-north-east of Parafield Airport, South Australia, on 12 August 2022

Publication Date: 15/05/2024

This time there was apparently no safety issues identified but the report did take a more normalised 643 days to produce... Blush

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