09-03-2016, 02:39 PM
(09-02-2016, 01:35 PM)thorn bird Wrote: Hot off the presses of BCA magazine.
It would seem that International attention is focusing on the Adelaide foggy foggy du duck up.
The interesting things to read from the comments on this article from around the world.
Many were incredulous that a low vis approach and auto land was not conducted at Adelaide. Good question, but these were from peers from first world countries. Perhaps the question should be why does Australia, purporting to be a world leading first world country, not have CAT 111 facilities at its primary airports? I could stand corrected but only Melbourne has CAT 111 facilities, and that only recently installed. There could be many possible reasons for this situation, I was flying low Vis operations back in the early eighties and they were not new then.
Could it be that our RAAF infested regulator way back then considered Low Vis was too dangerous for Australia to adopt and therefore refused to allow it? Back then they had teams running around the world surveying airports used by Quaintass to set minima's for them to use, so I wouldn't be at all surprised.
Or maybe since our airports were delivered to entities who's kudos was maximising profits from huge turnovers, to be siphoned off into tax free havens, thus preferring to build car parks than investing in Aviation Infrastructure.
Or this strange government policy that the user must pay and be damned to public safety and convenience, putting the onus on airlines either they pay, or do without, with the obvious consequence.
Ahh the land of OZ, only third world country where you can drink the water.
Quote from BCA:
Quote:Two Boeing 737-800s Bust Minimums At Australian Airport In Bad Weather
When busting minimums is the only choice
Aug 31, 2016 Richard N. Aarons | Business & Commercial Aviation
Comments 45
A Tale of Two Boeings
[/url]At the end of a remarkable chain of inaccurate weather forecasts and missed communications opportunities, two Boeing 737-800s operated by different Australian airlines had to bust minimums within minutes of each other at Mildura Airport to prevent really bad outcomes.
It all happened on June 18, 2013. Boeing VH-YIR, operated by Virgin Australia Airlines as Velocity Flight 1384, and Boeing VH-VYK, operated by Qantas Airways Ltd. as Qantas Flight 735, were on scheduled passenger flights to Adelaide, South Australia.
The story of what happened to these airplanes, crews and passengers is best told by the investigators of the Australian Transport Safety Bureau (ATSB).
Velocity 1384 departed Brisbane, Queensland, at 0638 Eastern Standard Time (UTC +10) with six crewmembers and 85 passengers on board. The estimated time of arrival at Adelaide was 0920. The captain was the pilot flying and the first officer (FO) was the pilot monitoring. The fuel on board at takeoff from Brisbane was 8,800 kg (19,401 lb.)This comprised flight fuel to Adelaide of 6,410 kg (14,132 lb.), variable and fixed fuel reserves of 1,540 kg (3,395 lb.) and additional fuel of 940 kg (2,072 lb.).
Qantas 735 departed Sydney, New South Wales, at 0727 and had six crew and 146 passengers on board. The estimated arrival time at Adelaide was 0917. The captain was the pilot flying, with the FO as pilot monitoring. The fuel on board at takeoff from Sydney was 7,900 kg (17,416 lb.). This comprised flight fuel to Adelaide of 5,000 kg (11,023 lb.), variable and fixed fuel reserves of 1,600 kg (3,527 lb.) and additional contingency fuel of 1,300 kg (2,866 lb.).
At 0700, the Bureau of Meteorology (BoM) issued an updated airport forecast (TAF) for Adelaide calling for a 30% probability of fog developing. At 0800, the BoM issued an updated trend forecast (TTF) that showed that fog had reduced visibility at Adelaide and was expected to clear by 0900.
At this stage, the crewmembers of Qantas 735 were aware of the changes to the TTF and continued to Adelaide on the basis that the fog would clear prior to their arrival. In addition, they had sufficient fuel to hold for about 45 min. should the fog last longer than forecast and land with required fuel reserves.
The pilots of Velocity 1384 were not aware of the changes to the forecast. They were advised of fog at Adelaide by ATC at 0844, once they changed to the en route sector frequency immediately prior to reaching the Adelaide terminal area airspace.
The crew of Qantas 735 elected to hold at waypoint Black, about 48 nm from Adelaide, rather than continue their descent to the airport, which was still affected by fog.
The crew of Velocity 1384 had commenced their descent to Adelaide and gathered further information about the conditions from the Adelaide tower controller. Based on the report from the Adelaide tower controller that conditions were not suitable for landing, and that there had been no successful landing attempts, the crew of Velocity 1384 elected to divert to Mildura, Victoria, at 0904.
The observation reports issued by the BoM at that time indicated that the conditions at Mildura were above the alternate minima for the aircraft, despite the TAF for Mildura indicating a temporary deterioration during the forecast period. The crew’s estimated arrival time at Mildura was 0932.
The crew of Qantas 735 heard Velocity 1384 broadcast their decision to divert to Mildura. On being informed by ATC that the latest trend forecast for Adelaide predicted a 30-min. delay in the fog clearing, and after gathering observation reports for Mildura, the crew of Qantas 735 also elected to divert there at 0913. Their estimated arrival time at Mildura was 0942.
In making the decision to divert to Mildura, the captain of Qantas 735 reported that they were aware that they had the capability to conduct an autoland at Adelaide Airport.
However, based on the reports of significantly better weather at Mildura, a diversion to that airport was assessed as preferable to continuing to Adelaide.
The captain of Velocity 1384 similarly reported that they considered the option of an autoland at Adelaide. However, given the observations of the better weather at Mildura, they also concluded a diversion was a better option at that time.
Arrival at Mildura
At 0916, the pilot of an air ambulance flight departing Mildura made a call to ATC that conditions were deteriorating. He reported the cloud base was at 400 ft. MSL. At the time, neither Velocity 1384 nor Qantas 735 were on this frequency and therefore did not hear this transmission.
At 0918, just after Velocity 1384 transferred to this frequency, the controller for this sector informed them of four other aircraft due to arrive at Mildura around their arrival time. This included Qantas 735. At 0922, Qantas 735 transferred to the same frequency and was advised of the arriving traffic.
Also at 0918, the BoM issued a SPECI (special weather report) for Mildura, showing clouds at 200 ft. AGL but visibility in excess of 10 km (6.2 mi). The Mildura RNAV GNSS instrument approach to Runway 27 required pilots to be clear of cloud at a minimum of 660 ft. (493 ft. AGL), reducing to 560 ft. (393 ft. AGL) using an actual airport QNH (altimeter setting that shows airport ASL elevation when the airplane is on the ground). As the conditions had deteriorated below these minima, the RNAV GNSS approach could not be conducted in normal operations. The airport forecast for Mildura, valid at that time, contained a temporary deterioration with cloud at 600 ft. AGL.
Between 0928 and 0932, three further SPECIs were issued for Mildura, indicating that visibility was decreasing in mist. As the Automatic Weather Information Service (AWIS) for Mildura was out of service, the inbound aircraft could not obtain this information from the AWIS.
At 0936, the controller made a broadcast on the area frequency to traffic at Mildura, informing them of the details of the 0932 SPECI. This SPECI indicated broken cloud at 200 ft. and visibility of 2,100 meters (6,890 ft.) in mist. A review of data from the cockpit voice recorder of Velocity 1384 identified that, for the duration of the controller’s broadcast of the SPECI, the crews of Qantas 735 and Velocity 1384 were busy communicating on the Mildura common traffic advisory frequency.
At 0937, the crew of Qantas 735 contacted the crew of Velocity 1384 to discuss the arrival and the crew of Velocity 1384 stated that they were tracking to the initial waypoint to commence the RNAV GNSS approach to Runway 27.
At 0939, the crew of a QantasLink Bombardier DHC-8 (Dash-8) aircraft broadcast to traffic at Mildura that they were conducting a go around. The crew of Velocity 1384 asked for an assessment of the weather and were told by the Dash-8 crew that at the minima, they “couldn’t see anything.”
At 0940, the crew of Qantas 735 contacted Velocity 1384 to advise that they were commencing the RNAV GNSS approach “due fuel.” The Velocity 1384 FO replied that they were “in the same boat,” but, after discussion between the captain and FO of Velocity 1384, they elected to hold and allow Qantas 735 to continue with the approach. This decision was passed on to the crew of Qantas 735.
The crew of Qantas 735 applied a revised minimum to the approach that was 200 ft. lower than that published. This was based on the knowledge that the cloud base would preclude becoming visual via a normal approach. The crew reported that as they descended toward the revised minimum, the extent of the cloud reduced and they gained sufficient visual reference of the runway environment to continue the approach. At 0946, the crew of Qantas 735 broadcast that they had landed at Mildura. The aircraft landed on Runway 27 with the required fuel reserves intact, and the crew reported that the runway was visible once they descended below the cloud.
At 0948, the crew of the Dash-8 asked Qantas 735 for their assessment of the weather.
The crew replied that the cloud base was at 150 ft. AGL and that they had landed off the approach “due fuel.” At this time, a SPECI was issued for Mildura, showing visibility was now 900 meters (2,953 ft.) in fog and that the cloud was overcast at 100 ft. AGL.
At 0950, Velocity 1384 sought an update on the weather from the Qantas 735 crew, who stated that the fog had appeared to be getting thicker but was now clearing, although the cloud was still below minima.
At 0952, Velocity 1384 updated ATC that they were still holding due to the low cloud at Mildura. ATC asked them to nominate a latest divert time to proceed to a suitable airport.
The FO replied that they did not have the fuel to proceed anywhere else. After obtaining further information from the crew, ATC initiated an alert phase and at 0958, after contacting the crew again, ATC activated the Mildura Airport emergency procedures.
At 0954, the controller made another “all stations” broadcast with the latest TAF issued for Mildura, valid from 1000. This forecast predicted:
Visibility of 3 km (1.9 mi.) in mist;
Scattered cloud at 300 ft. AGL;
An improvement in both visibility and cloud base in the hour from 1000;
A 30% probability of the visibility reducing to 500 meters (1,640 ft.) in fog for the period between 1000 and 1200.
Given their available fuel, the crew of Velocity 1384 determined that they needed to commence an approach just after 1000 to allow for a second approach if needed. They discussed conducting a “sighting” approach to ensure the aircraft was aligned with the runway from the RNAV GNSS approach. The captain was still the pilot flying; however, they briefed that if at any time during the approach the FO sighted the runway, then the FO was to take control and land.
At 1002, Velocity 1384 transmitted that they were on a 4 nm (7 km) final for the RNAV GNSS approach. At 1004, as they were not visual with the runway, the crew initiated a missed approach from 132 ft. AGL. The FO reported that as they commenced the missed approach, it was possible to confirm that they were aligned with the runway by looking directly down. At 1012, ATC initiated a distress phase.
The aircraft was positioned for a second approach, during which the cabin crew were briefed and prepared for an emergency landing, briefing the passengers to brace accordingly. At 1014, Velocity 1384 landed at Mildura in foggy conditions with fuel below the required reserves. As they taxied in, the captain told the cabin crew to stand down and normal arrival procedures resumed.
The Investigators’ Analysis
Following months of investigation, the ATSB observed that the Australian aviation weather reporting, forecasting and distribution systems are world-class but could use improvement. Company flight watch services at both air carriers are usually reserved for long-haul flights, leaving short-haul flight crews with the responsibility to pursue weather updates on their own once they are dispatched. In this situation, the observations and forecasts were changing quickly and information on Adelaide weather (and later Mildura’s weather) just didn’t form a picture for the crews in time to avoid the below-minimums approaches. The ATSB is suggesting further studies by Australian aviation civil and government agencies to see if improvements can be made.
The Safety Bureau looked at decision-making in each cockpit and ultimately found that the pilots made reasonable decisions including the decision to bust minimums.
ATSB Safety Issues
Ultimately, the ATSB identified a series of “safety issues.” Also, as a result of this investigation, the Safety Bureau initiated a research investigation that will “initially examine the reliability of the airport forecasts for Mildura and Adelaide, before expanding to cover other major Australian airports.” The idea is just to see where the system can be improved.
According to the ATSB, a “safety issue” is an event or condition that increases safety risk and (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organization or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time. Here are the safety issues that arise from this event.
The meteorological conditions at Adelaide Airport deteriorated below the landing minima while Velocity 1384 and Qantas 735 were en route to Adelaide.
The inaccuracy of the forecast clearance of the fog at Adelaide Airport compelled the flight crews of Velocity 1384 and Qantas 735 to either conduct an emergency landing at Adelaide or divert to Mildura Airport.
The actual weather conditions encountered by the flight crews of Velocity 1384 and Qantas 735 on arrival at Mildura were below landing minima and significantly worse than the airport forecast and weather reports used by both flight crews to assess its suitability as an alternate destination to Adelaide.
On arrival at Mildura, Velocity 1384 and Qantas 735 had insufficient fuel to divert to any other airport and were committed to a landing in conditions below their landing minima.
For many non major airports in Australia, flight crews of arriving aircraft can access current weather information using an Automatic Weather Information Service via very high frequency radio, which has range limitations. Where this service is available, air traffic services will generally not alert pilots to significant deteriorations in current conditions.
Other factors that increased risk:
The flight crew of Velocity 1384 did not obtain updated weather information for Adelaide while en route and were therefore unaware of the weather deterioration affecting the airport, limiting the options and time available to plan a diversion to an alternate destination airport.
The flight crews of Velocity 1384 and Qantas 735 gave precedence to the airport weather reports at Mildura over the airport forecast when deciding to divert.
Despite the Bureau of Meteorology (BoM) knowing of the deteriorating weather at Mildura from other sources, by not passing on the inflight weather report of deteriorating weather from the departing air ambulance pilot, the controller removed an important source of information for use by the BoM.
The inflight weather report given by the air ambulance pilot was not passed on to the flight crews of Velocity 1384 and Qantas 735 by the controller when they changed frequency in bound to Mildura Airport, removing an important source of information for flight crew planning and decision-making.
The automatic broadcast services did not have the capacity to recognize and actively disseminate special weather reports (SPECI) to pilots, thus not meeting the intent of the SPECI alerting function provided by the controller-initiated flight information service.
Last Thought
These crews were led into a subtle trap when all tolerances added up unidirectionally, leaving only their exceptional airmanship to save the situation. However, the investigation does make the point well that pilot skills must include a high degree of skepticism when evaluating weather information and forecasts when marginal weather is forecast.
This article was originally published on July 29, 2016
(09-03-2016, 11:56 AM)ventus45 Wrote: A "cheap" way of providing an instrument landing system at regional airports ?
http://web.archive.org/web/2010111912543...re2008.pdf
http://www.icasc.co/ifis-documents/12th-...is-papers/
(09-03-2016, 01:30 PM)thorn bird Wrote: Looks like a very cost effective solution Ventus....except!
By the time Australia's regulator got through with certification
the "Australian way" the thing would cost perhaps ten times what it
costs off the shelf and by the time they got it up and running there would
be something new in the market.
Our regulator is still back in the days when a guy stood at the end of the
runway with a table tennis bat in each hand.
As thorny mentioned, in the Av Week publication there is much incredulity & open discussion filtering through in the comments. Here is a sampling remembering that these are coming from primarily the North American professional pilot fraternity...
Quote:CarmineRed
on Aug 31, 2016
Admaonfr
You do realize that Autoland systems themselves have minimum visibility requirements that can limit their usefulness, along with company/flightcrew certification issues that govern the decisions on its use ? I dont think these factors were adequately covered in this brief, so your jumping on their throats like that is unwarranted and your blind faith in autoland systems being able to recover any aircraft regardless of mitigating circumstances is naive.
What we have today in aviation is a strange dichotomy where often the passengers have nearly unlimited access to inane information via Internet connection and the flight crew up front is stuck with receiving updates on VHF just a few minutes prior to reaching their top of descent point (that was the case with Velocity 1384, anyway).
In both cases, the crews acted reasonably well given that most "decisions" in flying are actually educated guesses informed by inputs from myriad sources and coalescing into a plan of action in the minds of the Flight Crew.
Their decisions were arrived at after careful thought and colored by years of previous experience and training--a depth of data that you, Sir, do not possess in anywhere near their quantity.
To say nothing of the fact that they process all this under pressure of time and with the knowledge that stakes are high, with bad decisions easily snowballing into disasters. These pilots decided, to their credit, to err on the side of what they thought was caution...events proved otherwise, but through no fault of their own.
Technology has evolved to the point now where there should no longer be any reason for pilots to have to struggle with stale information obtained often times hours prior to departure and updated sparsely and randomly in hit or miss style, as we had happen here. Information relevant to the flight could be instantly and automatically presented without the need for query on anyone's part. Data on developing trends in visibility, TCUs, precipitation, runway conditions Alert areas and so on could be made easily accessible and digestible to optimize decision making.
Though we live in a wired world, I maintain that aviation is its last holdout and yet the place where connectivity would pay huge safety and even economic dividends.
If we are really serious about safety, a simple and inexpensive augment to all the approach aids and procedures now in place (ie: the final component that would seal completely the current safety gap in low-vis operations)--would be to have a FLIR image displayed on a basic, no nonsense HUD, essentially turning the worst conditions into just another Visual Landing.
Such systems are mature, inexpensive (trivial really, vs the cost of said inflight entertainment systems, for example) and would, in wide use, have the same revolutionary impact on safety that introduction of GPWS has had.
Finally, my hats off to both crews for a job well done.
yarbros@comcast.net
on Aug 31, 2016
As I read the first comments about the autoland capability I thought, "Don't these people know that autoland has minimums too?" If you are faced with minimums at your destination that are below your autoland limits then you are required to either hold there or go to an alternate airport. They chose, based on the data they were given, to go to an alternate. This is exactly the way it is supposed to work. The fault lies with the BOM and the controllers who did not pass onto the crews the updated weather report and the pilot report from the air ambulance. Some of you who are not pilots seem to jump to the conclusion that autoland is a zero/zero option which it is not. That is not to say that knowing the way it worked out the crews would have much preferred the autoland option at Adelaide than the non-precision approach at the final destination airport. In the real world, this is known as "Hindsight". These two crews did a magnificent job and should be highly praised for their professional skills.
Capt. Sterling
on Aug 31, 2016
carmine red -
I agree with you totally sir.
you said in words what my mind was thinking through the process.
my only other thought you didn't mention is my constant thinking that "Thank God ATC is NOT the PIC of an aircraft. (neither is the damnable FAA)".
.
thank you sir.
cjrp@att.net
on Aug 31, 2016
CarmineRed has put it in well. Kudos to both crews on a job done well.
I am sure some of both airline's SOPs have been changed after these incidents. It would be illuminating to find out what they are!!
Conrad
a small cargo pilot, check airman and instructor in the US
mack@solidthink...
on Aug 31, 2016
This could be a great case study of DQ (Decision Quality): "the quality of a decision at the moment the decision is made, regardless of its outcome." It gets into judgement, relative skill levels, what did they know and when did they know it, SOPs, and the trust of automation.
stoof59
on Aug 31, 2016
CarmineRed, totally agree with you. Just because their is autoland capability it does not mean that weather limits do not play in to it.
At my airline, our 737NG's are autoland CATII capable. Qualified crews can use it to 100 ft and RVR of 1300. Adelaide reported that there had been no successful landings. Autoland would not have helped.
user-2309032
on Aug 31, 2016
Carmine red has it the most correct. It was a perfect storm of bad and slow info that led them into this subtle trap but they were doing what they always do which is to error on the conservative side. The tower controller at Adelide said the landing was not possible and no one had made a successful landing. The decision to divert to an alternate RIGHT AWAY or holding for a short time to gauge the trend while you have safe fuel is a very understandable decision and expected. Not getting timely info from the pirep from the commuter plane and an updated forecast on the TREND was a contributing factor also. We do need IMMEDIATE weather info available to us by our own means as you can see that the handoff to different frequencies also allowed valuable info to be missed. As always, it is chain of events that leads to an incident/accident and there was certainly a long chain occurring here. That adage of "a superior pilot never puts himself in a situation where he HAS to use his superior skills to get himself/herself out of it" applies here but only to the required action to provide a safe result. The pilot made sound decisions to keep the thick margin of safety based on THE INFO THAT WAS AVAILABLE TO THEM AT THE TIME. I see this as more of a systemic issue rather than poor judgment on the aviators involved. JB Cap, B-787
xairbusdriver
on Aug 31, 2016
I flew for a very safety-aware company and never had to explain why I called for "extra" fuel (Internationally or Domestic). I suspect these crews will always have "extra" fuel from now on. Hopefully, this is one 'event' that didn't have to end in deaths for changes to be made. Thankfully, it appears that attention has been raised in the appropriate places!
DB
on Aug 31, 2016
Before you jump to criticise, have a look at the airfield charts, available from airserviceaustralia.com. The only ILS approach at Adelaide is on R/W 23 and has a DA of 270ft (250 AGL). So although approved for auto land it can only be used in Cat1 conditions. So these crews had the choice of flying an ILS, either manually or with auto land to land below limits at Adelaide, or diverting to their approved alternate where the weather was believed to be above limits for an RNAV approach. With 40 years experience I know where I would have gone, and it wouldn't be the Adelaide solution.
wayne.mccandles...
on Aug 31, 2016
This case (befalling 2 crews) suggests that fuel reserve criteria need to be revisited. Geography and weather might dictate that reserves can only be consumed in hopes of "waiting out" improvement in weather at the only airports you can reach. In the U.S. context, imagine a storm blanketing east coast airports from Washington DC to Boston. If you planned on landing at JFK, you'd have endurance to reach Boston, Washington, Philadelphia, etc., and maybe even some loiter time for a short hold, but eventually you'd eat your reserves and have to cme down ala Avianca flight 52 in 1990.
nfn21976@naples.net
on Aug 31, 2016
Two first world air carriers dispatched two modern aircraft to a foggy airport with 5400 and 6400 lbs. of alternate and reserve fuel when the alternate has only a 6000' runway, no precision approach and apparently no tower ( radar ) and had an obviously narrow temp-dew point spread. Captains you need to earn your money and say put another 10,000 lbs. on. The article doesn't say if the RNAV approaches were coupled. They were all skilled and lucky. If they'd each had another 5000 lbs. on they wouldn't have been lured into this. I flew the old DC-9 that at only two thirds the MGTOW had the same fuel burn. Five and 6,000 lb reserves were for day VFR arrivals.
Ingelsrw
on Sep 1, 2016
The decision to divert, in this case, is based on the fact that neither aircraft had enough fuel to make an approach at the destination, go "missed", and then proceed to the "alternate" and land with enough fuel remaining. Both crews reached the same decision: Better to divert early and land with a safe fuel reserve.
Just Watching
on Sep 1, 2016
Why were these supposedly 'modern' aircraft equipped with such low specification systems? Autoland should mean precisely that, the HS Trident could, and did, perform Cat 3C zero/zero landings 50 years ago (4th Nov '66). Any explanations as to why the step backwards in capability? Other than 'bean counters' 1 passengers and crew 0!
Rex Booth
on Sep 1, 2016
One needs to understand the Australian rules. Auto land is only certified on two runways in the whole country, Sydney and Melbourne. Of course it is available on a CAT 1 runway for training or in an emergency.
Australia does not require fuel planning to an alternate unless TAF at destination is below alternate minima.
[url=http://aviationweek.com/users/nfn21976naplesnet]nfn21976@naples.net
on Sep 2, 2016
That explains a lot. Maybe it's time to qualify more Cat III and look at the fuel rules. I never understood why there were any minimums for Cat III auto-land except enough to get off the runway. Infra-red camera's on the nose gear would suffice
Okay so to begin don't shoot the messenger but if anyone would care to contribute a comment for our American 'cousins in crime', then I am quite prepared to post a comment on your behalf. For example I note that nowhere in that article is it mentioned that the ATSB report was stalled in investigation for more than 3 years, and that the one safety recommendation to come out of it was not issued until the Final Report was released.
Also it was not mentioned that this isn't an isolated aberration (wx related fuel reserves & no alternates..etc) when you think back on the B717 incident in Perth or indeed the Norfolk Is ditching of VH-NGA - just saying...
MTF...P2
