[Peetwo]

FSD review ATSB AO-2021-039: Engine Malfunction incident -

Courtesy FSD, via Youtube:

Cessna 441 Engine Issue Traced to Maintenance Mistakes – Episode 158

A Cessna 441 Conquest had an engine issue and landed without incident. A fix was made, but that’s not the end of the story. A second incident occurred that revealed damage not initially discovered. The Flight Safety Detectives share major safety takeaways from this sequence of events.

The focus is on an Australian investigation of a 2021 incident. During some engine maintenance, two adjacent oil lines were transposed. The error was discovered when the engine did not operate properly in flight. A field repair was done, but a short time later there was another engine problem.

The transposed lines led to damage to the oil pump. Fortunately, neither engine incident caused an accident.

This incident would not have met the NTSB criteria for investigation, but the Australian ATSB did gather information and generate a report. That report highlights how seemingly small maintenance errors can cause larger problems.

John Goglia, Todd Curtis, and Greg Feith review the findings. They go beyond the general recommendations made by the ATSB and discuss specific maintenance procedure changes that could improve aviation safety.

Related document: ATSB Aviation Occurrence Report or HERE

MTF...P2 

[Peetwo]

NT C210 inflight breakup prelim report released?? - AO-2022-067

Surprise...surprise, the powers to be at Popinjay central considered this 'defined' accident complex enough to publish a preliminary report a mere 63 days late on compliance with ICAO Annex 13...  

Here's the media blurb, courtesy of this week's Director Transport Safety Stewie Macleod...    
 

Weather, training and procedures among considerations in on-going investigation into Cessna 210’s in-flight break-up



Key points

• Preliminary report details factual information gathered in the investigation’s early evidence collection phase;
  
• Satellite imagery showed the formation of a thunderstorm near to the accident site;
  
• Investigation is continuing.
  

A preliminary report from the Australian Transport Safety Bureau’s on-going investigation into an in-flight break-up of a Cessna 210 over the Northern Territory on 24 December 2022 notes that the accident occurred when the aircraft was in the vicinity of thunderstorm activity.

“This preliminary report details the circumstances of this tragic accident as we currently understand them,” said ATSB Director Transport Safety Stuart Macleod.

“While our findings as to the contributing factors to this accident, and the analysis to support those findings, will be detailed in a final report to be released at the conclusion of our investigation, this preliminary report has been released to provide timely information to industry and the public.”

The report details that the aircraft was conducting a charter flight from Gove to Katherine to transport a single passenger who was scheduled to be in Katherine over the Christmas period. When the aircraft failed to arrive at Katherine at the nominated time, the operator alerted search and rescue officials, and an airborne search coordinated by the Australian Maritime Safety Authority Response Centre was commenced that afternoon.

The following day a search aircraft located a debris field in a remote area of medium-density bushland, approximately 237 km east-north-east of Katherine. The pilot and passenger were fatally injured and the aircraft was destroyed.

“The ATSB’s on-site examination of the wreckage and accident site identified that the location of aircraft’s right wing, approximately 300 metres before the primary point of ground contact, indicated that it had separated from the fuselage in flight, while aircraft components were spread over a distance of 80 metres,” said Mr Macleod.

“Closer examination of the right wing showed extensive permanent deformation of the wing surface with associated compression rippling to the upper skin. The damage was indicative of substantial upward bending forces applied to the wing prior to its failure and separation from the aircraft.”

On the day prior to the accident flight, tropical cyclone Ellie had crossed the coast west of Darwin and tracked to the south. Later that evening Ellie was downgraded to a tropical low, however heavy rain and strong to damaging winds were expected to impact large parts of the Top End.

“Satellite imagery showed the formation of a thunderstorm near to the accident site from about 0910 and its progression through to 1000, with the system persisting for several hours after that initial formation.”

The report notes that the development of the severe weather was consistent with the forecast conditions in the Northern Territory Graphical Area Forecast (GAF) that was issued by the Bureau of Meteorology at 0135 that morning.

“To date, the ATSB has examined the accident site and wreckage, interviewed personnel associated with the operation of the aircraft, collected meteorological and air traffic control radar data, and reviewed the aircraft maintenance and pilot records,” said Mr Macleod.

“As the investigation progresses the ATSB will further review the aircraft wreckage components and recovered electronic devices, environmental influences including analysis of meteorological data,” he said.

“The ATSB will also give consideration to pilot qualifications, experience and training, and the operator’s training policies and procedures.”

A final report will be released at the conclusion of the investigation.

“However, should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so they can take safety action,” Mr Macleod concluded.

Read the report AO-2022-067 In-flight break-up involving Cessna 210N, VH-TFT, 237 km east-north-east of Katherine, Northern Territory, on 24 December 2022

Publication Date
27/03/2023

Plus, finally it is confirmed that the ATSB will investigate the Cirrus YSBK that occurred 11 days ago: AO-2023-011 

 

Summary

The Australian Transport Safety Bureau (ATSB) is investigating the collision with terrain involving a Cirrus SR22, registered VH-XGR at Bankstown Airport, New South Wales, on 17 March 2023.

During landing, the aircraft collided with terrain resulting in substantial damage. The pilot sustained serious injuries. A final report will be released at the conclusion of the investigation.

Should a critical safety issue be identified during the investigation, the ATSB will immediately notify relevant parties, so that appropriate safety action can be taken.

MTF...P2 

[Peetwo]

ATSB release Wedderburn Glasair fatal accident prelim report: AO-2022-068

Although now indicating that the AO-2022-068 is a 'Short' investigation, therefore by definition supposedly less complex, Popinjay HQ has published a preliminary report 63 days late on compliance with ICAO Annex 13...  

Further investigation

To date, the ATSB has examined the aircraft wreckage, interviewed witnesses, gathered personal electronic devices and aircraft components from the accident site. The investigation is continuing and will include consideration of the following:

• analysis of CCTV footage and flight track data
  
• evaluation of witness information
  
• examination of the:
  
  • retained aircraft components
    
  • aircraft maintenance history
    
  • aircraft weight and balance, and performance
    
• meteorological conditions
  
• impact sequence and survivability
  
• flight planning
  
• the conduct of similar amateur-built experiment flight operations
  
• pilot qualifications, experience and medical information.
  

Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken.

A final report will be released at the conclusion of the investigation.

MTF...P2 

[Peetwo]

AO-2022-063 - Final Report

Via Popinjay HQ:

Helicopter’s collision with suburban rooftops after engine power loss highlights importance of forward planning



Key points

• Student pilot did not immediately identify an engine power loss, which limited the opportunities for a safe forced landing;
  
• Helicopter impacted the roof of a house short of identified forced landing area, but pilot maintained control enough to maximise survivability;
  
• [size=1]Accident highlights importance of forward planning for possible forced landings shortly after take-off.
  

A helicopter’s collision with rooftops in Melbourne’s south-east demonstrates the challenges pilots face managing engine power loss at low level, an Australian Transport Safety Bureau investigation report explains.

On the afternoon of 30 November 2022, a Hughes 269C three-seat light helicopter collided with the roofs of two houses near Moorabbin Airport, resulting in serious injuries to the solo student pilot, and substantial damage to the helicopter.

The pilot had been returning to Moorabbin after their second solo navigation training flight, when their approach became unstable, and they commenced a go-around.

“As the helicopter climbed to about 650 ft above ground level, the engine lost power,” ATSB Director Transport Safety Stuart Macleod said.

“While the pilot identified a reduction in performance at this time, they did not immediately recognise the engine had lost power.”

The report notes that while the pilot was troubleshooting the reduction in engine performance, the helicopter passed two suitable sites for a forced landing.

“When the pilot recognised a forced landing was required, they then did not identify a nearby football oval as the closest suitable area, possibly due to it being obscured by the airframe or instrument panel,” Mr Macleod said.

“Instead, they identified a school ground, and attempted a landing there, but collided with rooftops short of this intended location as the helicopter had insufficient height.”

The accident highlights the challenges pilots face when confronted with a loss of engine power at low level, and with few suitable landing areas available.

“Pilots can best mitigate the effects of a power loss by forward planning, which reduces your mental workload under stress,” Mr Macleod said.

The Civil Aviation Safety Authority has provided guidance on this topic, with its Guidelines for helicopters – suitable places to take off and land circular. This recommends that before take-off, pilots make themselves aware of suitable forced landing areas along their planned flight path, from the lift-off point to a safe manoeuvring height.

“The engine power loss occurred at low height over a densely populated area presenting a challenging scenario for the inexperienced student pilot,” Mr Macleod noted.

“While in this case, the selected landing location was unable to be reached, importantly, the pilot maintained control of the helicopter to maximise survivability.”

Read the report: AO-2022-063: Collision with terrain involving Hughes Helicopters 269C, VH-OBK, near Moorabbin Airport, Victoria, on 30 November 2022

Publication Date
30/03/2023

MTF...P2 

[Peetwo]

ATSB to investigate Bloomsbury tragic fatal accident -

No AO number yet but there is this:

Bloomsbury aircraft accident

The ATSB has commenced a transport safety investigation into the collision with terrain of a light aircraft near Bloomsbury, Queensland.

A search and rescue operation was launched on the evening of 2 April after a Piper Cherokee did not arrive at Lakeside Airpark, after departing a property south of Charters Towers. A wreckage site was located on 3 April, approximately 30 km south-west of Proserpine.

The ATSB is deploying a team of transport safety investigators from its Canberra, Melbourne and Brisbane offices, with experience in aircraft operations, maintenance and engineering, and human factors, to the accident site to begin the evidence collection phase of the investigation.

ATSB investigators will survey the accident site and collect any relevant components for further examination and analysis. They will also obtain and review any recorded data, weather information, witness reports, and aircraft operator procedures and maintenance records.

The ATSB anticipates publishing a preliminary report, which will detail factual information established during the investigation’s initial evidence collection phase, in approximately 6-8 weeks.

The ATSB will publish a final report, detailing contributing factors and any identified safety issues, at the conclusion of the investigation.

However, should any critical safety issues be identified at any stage during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate safety action can be taken.

Date 03/04/2023

Via the other Aunty:

Bodies of young couple found in plane wreckage at north Queensland crash site

ABC Tropical North / By Hannah Walsh, Melissa Maddison, Lillian Watkins, and Lucy Cooper



Key points:

• Police have confirmed the wreckage and bodies were found near Proserpine Monday morning
  
• The newlywed couple was travelling from a property near Charters Towers to Bloomsbury
  
• Police say the plane faced a "big storm' during the journey
  

The bodies of a young couple have been found in the search for a plane reported missing in north Queensland.

Rhiley Kuhrt, 22, had taken off from Natal Downs Station, near Charters Towers, Sunday afternoon bound for the Lakeside Airpark at Bloomsbury, north of Mackay.

His plane was due to land at 5pm, but it never arrived.

Mr Kuhrt's 24-year-old wife, Maree, was also on board.

An aerial search of the area near the airfield was conducted last night, with more aircraft joining the search Monday morning.

The wreckage was found at the Clarke Range, west of Proserpine...

P2 comment: I wish someone would take Popinjay to task on this waffle...  

 "..The ATSB anticipates publishing a preliminary report, which will detail factual information established during the investigation’s initial evidence collection phase, in approximately 6-8 weeks..." 

Back to compliance with ICAO Annex 13 and true tin kicker principles please...anyone??    

MTF...P2 

[Peetwo]

Qld R44 mustering fatal accident to be investigated - Popinjay to the rescue??

Via PJ HQ:

Qld Central Highlands R44 helicopter accident

The following statement can be attributed to ATSB Chief Commissioner Angus Mitchell: 

The Australian Transport Safety Bureau (ATSB) has commenced a transport safety investigation into the collision with terrain of a four-seat Robinson R44 helicopter at a station at Bingegang, 140 km west of Rockhampton, Queensland, on Tuesday. 

ATSB investigators have now commenced early evidence collection and assessment activities, including gathering information from first responders and other stakeholders, to inform the scope of investigation activities. 
   
Investigators will also seek to obtain and review any recorded data, weather information, witness reports, and aircraft maintenance records, and will review pilot qualifications and experience.

Date 04/04/2023

It's been a while but yet again we get another 'attributed to' statement from Popinjay...

Hmm...at least there is no non-compliance false promises of 6 to 8 weeks for the preliminary report (non-compliant with ICAO Annex 13)??  -

Via news.com.au:
 

Helicopter crashes during Central Queensland muster

Aisling Brennan
@AislingBrennan9
April 4, 2023 - 5:34PM

A man has died while piloting a helicopter that crashed as it was being used for muster in a state’s central highlands district.

Established grazier Alan Acton has died after the helicopter he was piloting crashed while mustering on a private property in the Central Highlands in Queensland.

The chopper reportedly crashed while mustering on a private property about 60km north of Dingo, Queensland, west of Rockhampton, about 11.30am on Tuesday.

Mr Acton, who was piloting the chopper, died at the scene despite paramedics being called to assist about 11.30am.

He was the only person on board the aircraft.


Alan Acton was well-known in racing circles, having met with Gai Waterhouse.

Capricornia MP Michelle Landry shared her condolences with the Acton family, posting on social media about how “heartbroken” she was to hear the news about his death.

“Alan Acton was a dear friend who offered me great support and kindness over the years,” Ms Landry wrote.

“Alan’s knowledge in all things grazing was astounding and will leave a lasting legacy in the agriculture industry. His loss will be felt for many years to come.

“To Alan’s family, I send you my deepest condolences at your loss. He will be sorely missed by all.”

Mr Acton was heavily involved in horse racing and was a member of the Rockhampton Jockey Club where several of his horses raced.

A Queensland Police spokeswoman told NCA NewsWire the forensic crash unit would be assisting Workplace Health and Safety Queensland with its investigation.

MTF...P2 

[Peetwo]

Sea World cleared for business!

Via the Oz:

Sea World Helicopters back in business after fatal mid-air crash




The company at the centre of January’s tragic mid-air helicopter collision is again operating joy flights at the Sea World theme park on the Gold Coast.

Sea World Helicopters issued a brief statement on Tuesday announcing the resumption of operations from the Sea World Park helipad.

It’s understood a number of bookings had been taken for the short flights over the park and surrounds.

Four people were killed when two helicopters collided mid-air on January 2. Another nine people were injured, three of them critically, including two children.


The resumption of services followed assessment and approval by the Civil Aviation Safety Authority “some weeks ago”.

Sea World Helicopters’ director John Orr-Campbell said it was an emotional occasion for all of those on staff.


“In many ways today is a difficult day for all of us as we pay our deepest respect to (crash victims) Vanessa Tadros, Diane and Ron Hughes, our friend and late chief pilot Ash Jenkinson, their families and those who suffered physically and mentally in the accident,” Mr Orr-Campbell said.

“I know Ash would have wanted to have been flying with us today. Helicopter flying is what we do and our staff wanted to get back to work and continue to provide the service to those who want to fly with us.”

Only one helicopter, a Squirrel was operating the joy flights, after two Eurocopters were destroyed in the crash.

A preliminary report on the tragedy by the Australian Transport Safety Bureau found the helicopter coming into land had not heard from the pilot of the helicopter taking off.


ATSB chief commissioner Angus Mitchell said their final report would look more broadly beyond the issues of radio calls and visibility.

“The ATSB will also consider the operator’s procedures and practices for operating scenic flights in the Sea World area and the process for implementing the recently-acquired EC130 helicopters into operation, and will review the regulatory surveillance of the operator and similar operators,” said Mr Mitchell.

The Civil Aviation Safety Authority confirmed Sea World Helicopters had been given approval to resume operations after replacing the late Mr Jenkinson.

MTF...P2 

[Peetwo]

Bloomsbury AO number; Popinjay (aka Mr Attribution) to the rescue ..etc?? - 



Via Popinjay HQ 'Short' investigation AO-2023-013 : https://www.atsb.gov.au/publications/inv...o-2023-013

Summary

On 2 April 2023, a pilot and passenger departed Natal Downs station, Queensland for Lakeside Airpark on a private flight in a Piper PA-28-180, registered VH-PXR.

When the aircraft did not arrive at the expected time, a search and rescue operation commenced. The following day, a search and rescue aircraft located the accident site. The pilot and passenger were fatally injured and the aircraft was destroyed.

As part of the investigation, the ATSB will obtain information about the pilot's training and experience, meteorological conditions, recorded data, and aircraft maintenance information.

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.

Next courtesy Mr Attribution...

Rat Island runway excursion

Back to top

The following statement can be attributed to ATSB Chief Commissioner Angus Mitchell:

The Australian Transport Safety Bureau (ATSB) has commenced a transport safety investigation into a runway excursion involving a single-engine passenger aircraft with a pilot and six passengers on board at Rat Island, Western Australia, on Thursday morning. 

During landing at Rat Island it was reported that the GA8 Airvan landed long, exited the runway and came to rest in the water, resulting in substantial damage to the aircraft. No injuries were reported. 

ATSB investigators will collect and examine relevant evidence, including interviewing the pilot, analysing relevant weather data, photographs, aircraft operator procedures and maintenance records. 

The ATSB will publish a final report, detailing contributing factors and any identified safety issues, at the conclusion of the investigation. 

However, should any critical safety issues be identified at any stage during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate safety action can be taken.

Date
06/04/2023

Finally yet another TIBA/OnePie related occurrence...

QANTAS 737 AND JETSTAR A320 IN DANGEROUS MIDNIGHT RUNWAY MIX-UP

written by Adam Thorn | April 9, 2023



The ATSB has launched an investigation after a Qantas 737 was in the process of leaving Darwin Airport at the same time as a Jetstar A320 was preparing to land on the same runway.

The incident significantly occurred at 12:17 am on Wednesday when the air traffic control tower was closed.

Images from Flightradar24, above, appear to show the outbound aircraft taking a significant detour from its usual route to avoid a collision.

In a statement released on Friday, the ATSB said it would examine “all available evidence” to determine the extent of the communication between the two narrowbody passenger planes.

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

The statement is yet to clarify exactly how far into the take-off the Qantas 737 was, but it did state the incident is considered an “aircraft separation issue”. Flightradar24 lists the outbound aircraft’s actual time of departure as 12:47 am and the inbound plane’s landing time as 12:59 am.

It comes just a month after Australian Aviation reported how the ATSB would monitor the introduction of new take-off procedures at Sydney Airport after a British Airways 787 and Qantas A330 flew too close to each other in September last year.

The incident saw the Boeing aircraft’s collision avoidance system become activated before its first officer spotted the Airbus.

A report into the loss of separation occurrence’ revealed how an unusual set of circumstances led to the mix-up, including that the traditionally longer-haul A330-200 was operating a domestic flight meaning it had a higher climb performance.

The ATSB’s director of transport safety, Stuart Macleod, said, “Maintaining separation in high traffic terminal areas, such as Sydney, requires that both controllers and flight crews remain vigilant, maintain open communications, and use the available systems and tools to minimise the risk of errors.

“When sequencing departures, controllers should consider a number of factors, including how the flight duration (and the associated fuel load) will likely affect aircraft climb performance.”

Ref: https://www.atsb.gov.au/publications/inv...o-2023-015

MTF...P2 

[Kharon]

A thing of wonder. 

I wonder, quite often, about exactly ‘what’ it will take to manifest the serious changes to the entire operational system of real world aviation ‘safety’. At present the system is dysfunctional, to say the least and; IMO, bordering on dangerous, across the board. This recent fiasco at Darwin shines a very bright light on how the system is imploding. 

First cab off the rank must be the actions taken by both flight crews. Middle of the night in the middle of nowhere; one on STAR, one on SID; two crew apiece, full deck radio, TCAS, good weather, no ATC, so self separation between aircraft required; – strictly, just another day at the office. Is it a company requirement to use SID and STAR for every departure and arrival, if so why? These are procedures designed for use with ATC support; and are very specific and rigid (rightly so) with regard to track and altitude; a railway track if you like. But, these are experienced pilots, well versed in operating their aircraft with all the published data available. One inbound, opposite direction to the departing – both using the same runway – potential for a head butting competition writ large. It would be reasonable to expect that before leaving the ramp, the outbound would make all the required radio calls; and that the inbound would respond – a brief conversation to formulate a ‘plan’ could also be reasonably expected. What should have been a routine self separation devolved into a TCAS (last ditch warning) that a conflict was real and occurring at a fast rate. I wonder just how hide bound to SOP flight crew are required to be. Perhaps the ‘tapes’ and ATSB can provide some sort of answer.

Then we must ask why an ATCO could not take a shift in the tower; even a short one to monitor and manage high capacity arrivals and departures. Particularly during the period of changeable weather as the ‘Wet season’ approaches its end and, indeed during the ‘Wet’ season, when the weather can become ‘awkward’ and uncooperative. Non RPT night traffic is rare (cargo/ medevac/ charter) however it does exist, but the airlines operate 24/7 – 365. Compared to the cost of a mid-air event, the relatively small cost of ‘someone’ doing an easy night shift, after hours, just to cover the scheduled heavies seems a very small price to pay to guarantee that the slim chance of a 737 and an A320 banging heads remains the stuff of nightmares.

All’s well that ends well; and, happily the last hope TCAS performed design function – head- on collision avoided, by a goodly margin. But the deep flaws within the ATC system are beginning to become a norm rather than a rarity; delays, staff shortages and the ‘penny pinching’ mindset of management cost operators a fortune and must; sooner or later, end up with someone, somewhere, one dark and stormy making the big hole into which all rhetoric, deception and denial will land, with thud. What price ‘safety’ then?

Toot – toot… ---…

[Peetwo]

Popinjay to investigate a Virgin long landing - 

Three and a half months after the incident, PJ decides to investigate?? Via PJ HQ: 

Initial summary

The Australian Transport Safety Bureau has commenced an investigation into a long landing involving a Boeing 737-800 aircraft at Gold Coast Airport, Queensland on 24 January 2023.
 
At about 1839 local time, while landing on runway 32 in poor weather conditions, the flight crew was unable to sight the touchdown markers. The aircraft was subsequently landed beyond the touchdown zone.

In early April, the operator provided the ATSB with a copy of their safety investigation report, which provided additional information regarding the incident. After obtaining this information, the ATSB decided to investigate the incident. 

As part of the investigation, the ATSB will examine the circumstances leading to the long landing and determine contributing factors. The investigation will include interviewing the flight crew and other relevant persons, examining available recorded data, obtain weather information, reviewing relevant procedures and collecting other evidence as required.

A final report will be published at the conclusion of the investigation. Should a critical safety issue be identified at any time during the investigation, the ATSB will immediately notify operators and regulators so appropriate and timely safety action can be taken.

Ref: https://www.atsb.gov.au/publications/inv...o-2023-018

Via aeroinside.com :

Virgin Australia B738 at Coolangatta on Jan 24th 2023, long landing

Last Update: April 13, 2023 / 09:35:09 GMT/Zulu time


Virgin Australia VH-YQM, Boeing 737-800 (Photo modified based on photo from Kgbo / Wikimedia Commons / License: CC by-sa 4.0)

A Virgin Australia Boeing 737-800, registration VH-YQM performing flight VA-539 from Sydney,NS to Coolangatta,QL (Australia), landed on Coolangatta's runway 32 in poor weather conditions, the crew was unable to see the touch down zone markers. The aircraft touched down without further incident and taxied to the apron.

On Apr 13th 2023 Australia's TSB (ATSB) reported they have opened an investigation into the occurrence rated a serious incident stating the aircraft touched down beyond the touch down zone. The ATSB wrote:

At about 1839 local time, while landing on runway 32 in poor weather conditions, the flight crew was unable to sight the touchdown markers. The aircraft was subsequently landed beyond the touchdown zone.

In early April, the operator provided the ATSB with a copy of their safety investigation report, which provided additional information regarding the incident. After obtaining this information, the ATSB decided to investigate the incident.

As part of the investigation, the ATSB will examine the circumstances leading to the long landing and determine contributing factors. The investigation will include interviewing the flight crew and other relevant persons, examining available recorded data, obtain weather information, reviewing relevant procedures and collecting other evidence as required.

Metars:
YBCG 241000Z AUTO 03009KT 9999 -RA NCD 22/21 Q1012 RF00.0/017.4 DL-NE/DL-NW=
YBCG 240930Z AUTO 02007KT 9999 -RA SCT009 SCT078 OVC110 23/21 Q1012 RERA=

MTF...P2 

[Gentle]

With regard to a Thing of Wonder, ie the Darwin TRA occurrence…

I posted the text below on the other PRU after reading 5 pages of confusing, erroneous, and occasionally intelligent comments.

It may spark further discussion on the serious issues Kharon has raised….

Posted 17 April 2923 on
> Separation issue involving Boeing 737, VH-VXH, and Airbus A320, VH-VGV, near Darwin

“Coming to this a bit late but…

Bloggs, like you I’ve listened and watched, audio via Live ATC and display by FR24, albeit at 12X (minimum on playback) Even made a little movie of it.

Hmmm, dog’s breakfast that and all, cat’s vomit and also in rodent droppings as well. Not sure the “breakfast” comment refers to the incident or the 5 pages of bulls$#t, stupid, irrelevant and occasionally intelligent, logical factual posts.

To start with the posted copy of the NOTAM seems to indicate at the bottom this TRA is happening for a couple of months, not just a one off with a RAAF controller having a shandy in the Darwin officers mess a couple of hours before the start of duty. Guess I’ll have a listen tonight to confirm.

With regard to alleged / rumoured TCAS, if what I observed n FR24 is correct if I got a TA or RA involving QFA839/JST672 I’d be faulting the equipment. Wouldn’t even have triggered a STCA in ATC land, Shirley… They never got within cooee of each other either in a vertical/lateral context. QANTAS asked JETSTAR did he want to play verticals. JETSTAR replied keep climbing. When QANTAS out of A080 on climb before going to BN Centre QANTAS checked JETSTAR‘S altitude and he was out of A060 on descent…and after a quick goodnight the tapes were silent.

So my click bait headlines QANTAS and JETSTAR try SODPROPS at Darwin in a TRA with only one runway will be saved for another time…

The ghost controller P. Rovidence smiled on aviation again. Had QANTAS pushed backed 2 mis later and JETSTAR inbound 1 or 2 mins earlier then it may have been more instructional to have a listen on how the professionals do it!

Just still not sure why QANTAS did a large left turn towards North East in the middle of it all.

Hope I’m still alive in 3 years when ATSB explains that and why and who submitted the occurrence to them in the first place.”

[Kharon]

SODPROPS  or SODOFF.

Choc frog Gentle; the ‘click bait’ notification worthy of a big smile and a head shake. History - To think that a 40˚ wrong heading could be dialed in and go unnoticed, even for the shortest time, by either crew member when added to the frequency change etc. demonstrates how very quickly even the best laid plans (of mice, men and Murphy) can turn to worms. Mind you that was back in ’97, can’t find the ATSB report, but it was pretty much a ‘one off’.

But; the two minute buffer you mention in the Darwin event - provided by fate speaks volumes. Add the climb and descent rates of the two aircraft and the rate of closure, do the arithmetic against a 120 second time frame – clearly Murphy missed the flight (probably having a Shandy with Master Rovidence). Had that two minutes been used for an ‘all stations’ and a quick sort out; we would never have even known about it all. Had there been a lonesome ATCO on deck then even this remote possibility (STCA) of a midnight, mid-air over Darwin would remain, firmly, in the stuff of nightmare bucket.

Gentle – “Hope I’m still alive in 3 years when ATSB explains that and why and who submitted the occurrence to them in the first place.” Amen…

Toot – toot…

[Gentle]

K, thanks for the frog. The sugar will help with the rising anxiety…

Not sure if more concerned with the quite interesting, sincerely held but divergent opinions of the thread on the other PRU or what’s happening at Darwin every night from 1230 / 2030 UTC from 03271230 to 05212030.

I know Australia is a democracy but some of the posters on the thread are obviously flying jets for QANTAS / VIRGIN / JETSTAR but hmmm!

Sunny SA looked at the Darwin Noise Abatement Procedures and posted on thread of interest named “Separation issue involving Boeing 737, VH-VXH, and Airbus A320, VH-VGV, near Darwin”.

Effectively following the NAP means we have RRO (Reciprocal Runway Operations) [not as sexy as SODPROPS] happening most nights in Darwin within a TRA using some CTAF like procedures under the watchful eye of Darwin FLIGHTWACH! (Rumoured to be RAAF Tower controllers not holding an APPROACH rating. Sitting in the TWR with a radar display.)

I suppose it should make everyone feel better but it just confirms to me Australia’s one true Centre of Excellence is mediocrity. It’s obvious by listening to LiveATC (the Thursday following the occurrence between 1500/1630 is interesting) that the approval to enter the TRA is a joke and just yet another bullshit box ticking exercise.

Sunny SA also commented on the implied misuse of TCAS after noting the overt requirement in the TRA NOTAM with “Given TCAS was designed to operate as a last-resort safety net, when did TCAS switch to being a primary defence“.

I replied on same thread…

Sunny SA…Re TCAS…

so the following questions arise to clarify your query further…

a/. Would an aircraft not equipped with TCAS get approval to operate in the TRA?

b/. Would an RPT jet with unserviceable TCAS get approval to operate in the TRA?

And finally the control questions…

c/. Can an RPT jet with unserviceable TCAS fly from YMML to YSSY wholly contained in A/C airspace with no TRA/TIBA?

d/. Can an RPT jet with unserviceable TCAS fly from YSSY to YMIA where last segment is Class E/G airspace and CTAF?

Some interesting things arose in AsA after Uberlingen,

TCAS was not supposed to be used in target level of safety determination, only resultant level of safety determination ie a true airborne safety net akin to the STCA in the ground based system. One could be forgiven if it appears the distinction is somewhat blurred?

Mind you, senior executive management and the board of ASA after Uberlingen were supposedly assured that a controller in OZ would never resolve compromised separation by a level change. Yeah right, good luck with that!

When we start using safety nets to mitigate staffing issues / traffic levels or just basic air traffic control then the threads don’t save anyone from the high wire act, no matter how easy it looks when done by professionals… and we might as well be in Africa!

Isn’t there a company called Landbridge that already does leasing work in Darwin, maybe they would help out with a contract doing the ATC night shift in Darwin?

I am pretty sure China uses similar ATC equipment.

Maybe just the script of another Utopia episode…

Sigh!

[Gentle]

In reflection, I’m sure ATSB will do a short, dumb investigation with a “nothing to see here, move along” result on the Darwin TRA occurrence totally ignoring the strategic safety issues of TIBA / TRA and the misuse of effectively RROs and SID/STARS in a TRA non ATC environment.

Combining that with the misuse of TCAS and Australia yet again falls down the rungs in the world’s ladder of aviation safety.

Department of Defence, CASA, AsA and ATSB are all partly responsible for this farce…

[Kharon]

For clarification – let us just for a moment, put aside the multiple acronyms, implications, rules, responsibilities and all the other clap-trap and resolve one important issue. Here we are, sat on the ramp at Darwin, 737 strapped on, passengers loaded, engines started, checks done and ready to roll, destination well to the South. Brakes off and we taxi out toward the NAP runway hold point.

At what stage are we (a) made aware of an inbound A320, (b) what the intentions of the inbound are; and, © by whom?

We know the NAP calls for opposite direction take-off and landing; furry muff (wind/weather permitting) – not a problem: provided we know where the inbound is and either communicate directly to sort out their intentions, ETA etc. (routine stuff) or be advised by a third party of those intentions. Once this is known, depending on circumstances, we can put the brakes on and wait a bit or, bugger off before the arrival.

With the required information it is just another day at the office; a doddle. Without any idea of traffic and of it's intentions, it is a game of Russian roulette. Don’t much care how we get that information; DIY or official - BUT it must be made accessible and timely.

The humble “All stations” at brakes off should at least alert anything inbound that we are on the move and open a dialogue – etc. Can’t operate deaf, dumb and blind, not when the one runway direction is used for departure and the opposite direction is used for arrival. No Sir, we cannot, not with impunity.

Toot - toot

[P7_TOM]

FWIW -

ATSB report on WA 737 fire bombing event – HERE -.

[Peetwo]

Popinjay to the rescue - yet again?? 

In follow up to above, the prelim report was 56 days in non-compliance with ICAO Annex 13: 

Under Annex 13 to the Chicago Convention, States in charge of an investigation must submit a Preliminary Report to ICAO within thirty days of the date of the accident, unless the Accident/Incident Data Report has been sent by that time. Preliminary Reports may be marked as confidential or remain public at the investigating State’s discretion.

  
Here is the bollocks media blurb with video and "attributable to" Popinjay narration included -  :

ATSB preliminary report details 737 large air tanker accident sequence of events

Key points

• 737 had been tasked to tag and extend a line of fire retardant which extended downslope;
  
• Flight data and cockpit voice recorder downloads instrumental in establishing accident sequence of events;
  
• Preliminary report outlines factual information collected in the on-going investigation’s early evidence collection phase.
  

An ATSB preliminary report details the sequence of events leading to a Boeing 737 large air tanker’s impact with a ridgeline in Western Australia’s Fitzgerald River National Park while conducting an aerial fire-fighting task on 6 February 2023.

The preliminary report outlines factual information collected in the on-going investigation’s early evidence collection phase, and details that the modified Coulson Aviation-operated 737 air tanker, callsign ‘Bomber 139’, with two pilots on board, had departed from Busselton Airport to assist fire control efforts near Hopetoun, about 600 km south-east of Perth.

“Arriving at the fire ground, the 737 crew was briefed by a bird-dog aircraft that the tasking was to tag and extend an existing retardant line,” said ATSB Chief Commissioner Angus Mitchell.

“The retardant line was to extend downslope, with the bird-dog briefing the 737 crew that their target altitude (above sea level) was 500 feet descending to 400 feet.”

Flight recorder data shows that Bomber 139 descended to about 400 ft and completed a partial drop of three-quarters of their tank before the captain, who was pilot flying, stopped the drop because their retardant line was entering a burnt area.

Bomber 139 then repositioned to commence another drop to use the remaining retardant to further extend the retardant line.

During the second drop, Bomber 139 descended through 400 ft altitude – or 80 ft above ground height – at an airspeed of 110 kt with the engines at high idle as the retardant line was extended downslope.

“Flight recorder data shows the throttles were advanced and the engines had accelerated just before the aircraft struck a ridgeline with the stick shaker activating. The aircraft then cleared a small line of foliage, before impacting the ground a second time and sliding to rest,” said Mr Mitchell.

“Fortunately, and remarkably, both pilots were able to exit the aircraft through a cockpit window, and suffered only minor injuries.”

The aircraft was subsequently consumed in a post-impact fire.

“Despite extensive fire damage, ATSB recorders specialists in our Canberra technical facilities were able to download files from both the flight data recorder and cockpit voice recorder,” Mr Mitchell said.

“As well as information from those recorders, interviews with the flight crews, a 3D map of the accident site created using a drone, and other recorded flight information will be instrumental to the ongoing investigation.”

ATSB investigators have also collected documents and recorded data from the operator as well as records from the WA Department of Fire and Emergency Services.

“The investigation is continuing and will include validation of the recorded data and reviews of the communication procedures for bird-dog and large air tanker pilots, the operator’s crew resource management procedures and practices, and standards and safety margins for 737 retardant drops.”

The preliminary report notes that following the accident, the operator increased their large air tanker minimum retardant drop heights and airspeeds.

Mr Mitchell said that a final report, containing findings and the analysis to support those findings, will be released at the conclusion of the investigation.

“However, should a critical safety issue be identified at any time during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken.”

Read the report: Collision with terrain involving Boeing Company 737-3H4, N619SW, Fitzgerald River National Park, Western Australia, on 6 February 2023

Publication Date
03/05/2023

---

Safety action

Following the accident, Coulson Aviation issued operations bulletin 2023-01 advising their large air tanker pilots operating in Australia that their minimum retardant drop heights and VDROP airspeeds had been increased from 150 ft above ground level and 1.25 VS to 200 ft above ground level and 1.35 VS. Their B-737 normal checklist was amended accordingly to reflect their new minimum VDROP airspeeds.

Hmm...a prelim report is supposed to be a short factual statement, with initial safety issues possibly identified, followed by where the investigation will be focused going forward. IMO this prelim report is a lot more than that and I will be surprised, other than a bit more content, how much the final findings (probably in about 4 years time) and the context of this prelim report will change when the final report is published - verdict save the dosh and either hand over this investigation to the NTSB to complete; or complete to final report in world record time inside of 6 months (there's a challenge for you Popinjay -  )...

Subject next - over to this week's Director Transport Safety Stewie Macleod -  :

Lift-off location following a touch-and-go is more variable and complex to predict than a standing take-off, investigation highlights

Key points

• Aircraft collided with rising terrain after conducting a touch and go from a rural property airstrip during a preparation flight for a commercial pilot licence test;
  
• Preflight planning was likely not performed to identify if the airstrip was suitable for flight training operations;
  
• Touch-and-go likely used more runway than a standing take-off, leading to the aircraft becoming airborne further along the runway, and closer to the rising terrain.
  

Rising terrain in the direction of take-off meant an airstrip being used for a touch-and-go was unsuitable as it exceeded the climb performance of the aircraft, an Australian Transport Safety Bureau investigation has found.

Two pilots, an instructor and student, were fatally injured when their single-engine two-seat Aquila aircraft collided with an embankment after a touch-and-go at Coombing Park airstrip in central west New South Wales, on 4 November 2020.

The flight was being conducted to assess the readiness of the student to complete a commercial pilot licence flight test. The flight had proceeded to overhead Coombing Park, where the student demonstrated the conduct of a precautionary search, to assess the suitability of conducting a landing there.

Following the precautionary search, a touch‑and‑go (landing without coming to a stop and accelerating to take-off again) was performed at Coombing Park. As the aircraft climbed through 200 ft above the lift-off point, a climbing left turn was conducted before flying straight again in the direction of a small dam, beyond which was a less wooded area. The aircraft then passed over the small dam and collided with an embankment on the far side of the dam.

“The ATSB found that pre-flight planning was likely not performed to identify if Coombing Park was suitable for flight training operations, which placed more importance on the conduct of the precautionary search to identify the rising terrain hazard in the overshoot area of the runway,” said ATSB Director Transport Safety Stuart Macleod.

“The precautionary search was conducted at a height and position that likely made assessing the hazard less effective.”

Further, the take-off was conducted on an uphill slope with a probable tailwind. A standing take-off in the more favourable reciprocal direction would likely have cleared all obstacles and terrain.

“Particularly at an unfamiliar airstrip, pilots must carefully consider the aerodrome characteristics to confirm if a touch-and-go is feasible, or if a full-stop landing and standing take-off should be completed instead,” Mr Macleod said.

“This accident demonstrates that the lift-off location following a touch-and-go is more variable and complex to predict than a standing take-off.”

The investigation also found that the aircraft operator had based its operations manual on the sample operations manual published by the Civil Aviation Safety Authority (CASA), which allowed for flight training into any aerodrome listed in the En-Route Supplement Australia (ERSA), including ALAs, although ALAs are not assured to any operational standard.

In addition, the investigation found that recommendations contained in the since-replaced CASA guidance CAAP 92-1(1) did not provide assurance that an aircraft would be able to outclimb rising terrain after take-off more than 900 metres from the runway end.

“Operators should also be aware that aerodromes meeting the recommendations in the now-obsolete CASA guidance publication CAAP 92-1(1) are not assured that an aircraft will be able to successfully climb away after take-off more than 900 metres past the runway end,” said Mr Macleod.

“The new performance-based recommendations of AC 91-02 now require operators to consider obstacle clearance beyond 900 metres.”

Flight training operators should also note that there are no standards for ALAs, even those listed in the ERSA as uncertified aerodromes.

“The published data, including obstacle information, for these uncertified aerodromes are potentially incomplete or inaccurate,” said Mr Macleod.

“This means that for take-off from ALAs, the new guidance requires pilots and operators to know the climb gradient needed to clear all obstacles by a safe margin until the aeroplane reaches the minimum height for flight,” Mr Macleod concluded.

Read the report: AO-2020-059: Collision with terrain involving Aquila AT01, VH-OIS, Coombing Park Airstrip, 27 km south of Orange, New South Wales on 4 November 2020

Publication Date 04/05/2023

     
Hmm...64 pages of?? - Don't even know where to begin with this one...

MTF...P2 

[Kharon]

Of the winnowing of Wheat from Chaff.

One of the most difficult (least liked) jobs we have toiling for Aunt Pru is 'winnowing' – fact from fiction, without friction; agenda from base intent; and rumour from reality. All fraught with peril; particularly the 'rumour' elements. Much depends on 'who' told the tale, their 'agenda' and why. Sometimes, it is no more than a third or fourth hand yarn, embellished for effect; or, for a laugh in the Pub. But, every once a while, a part of a puzzle lands on screen, or the phone rings – and one element, a nugget if you will, of information lands which, stand alone is 'something of nothing', noted and tucked away. Then, there is the 'other' type of rumour; the one which steadily gains credibility through 'source' and diversity of provider. These are the interesting ones – of the no smoke without fire type. They are also problematic for many reasons. For example; 'we' were very interested in the back room rumours emanating from the Coulson 737 fire bombing event.

Bloggs - “I think most of us are sitting quietly shaking our heads, unable to speak or type...

True enough; the wise knew to await the report; the 'safety action' speaks volumes:-

Following the accident, Coulson Aviation issued operations bulletin 2023-01 advising their large air tanker pilots operating in Australia that their minimum retardant drop heights and VDROP air speeds had been increased from 150 ft above ground level and 1.25 VS to 200 ft above ground level and 1.35 VS. Their B-737 normal checklist was amended accordingly to reflect their new minimum VDROP air speeds.

That's biggish lump of machinery to be throwing around, low, slow, heavy, close to the deck in hot bumpy weather, smoke etc, etc. Boeing 'book numbers' are very good for 'normal' operations – but I doubt there is section dedicated to 'agricultural' ops. Perhaps in the 'Sim' and 'on paper' it all looks kosher; but the 'safety' advice reflects what many believe to be the core issue. Clearly, someone wrote the ops spec in use at the time into the 'book' and CASA senior inspectors must have approved it as part of the AOC issue. Looks very much, on the surface at least, that some senior folk who thought it all 'hunky-dory got their collective 'hunks and dory's muddled. Or, did they?  Rumour #1 says perhaps not. That, alone was worth some homework, all the way back to the beginning. So we began digging and rummaging through the history of the application, operational approval and the event.

It has been impossible to gather anything that even vaguely resembles 'fact' let alone 'provable' evidence. Rumour by the cart load, opinion by the bushel; speculation and gossip enough for a small mountain of the stuff. In short; nothing that could withstand a legal challenge. However; there were a few tales from the woods which were at least consistent, a thread running through tapestry which touched the same points. Whether true or false we have no idea; pure speculation and pub conjecture will not pass any legal litmus test. So, dear reader, I shall leave it up to you to decide if there is indeed 'something rotten in the state of Denmark'. Paraphrased below, nut shell version are the most consistent, most reiterated rumours we were offered. True of False – I have no idea. Handing over....

Item 1:- Senior CASA inspectors were, for the reasons stated in the ATSB safety actions, opposed to the issue of the Coulson AOC - as presented.

Item 2:- These worthies were overruled by Reg Services based on preference being given to an opinion based on personal relationship and faith in that element of the equation.

Item 3:- There allegedly exists a small mountain of internal complaints against Reg Services top dogs; the usual stuff alleged bullying, harassment etc, etc. Along with calls for a major change of the top order.

Item 4:- Apparently, the calls for change are ignored by the top floor. Seems that the protection of certain species is a prerequisite of executive KPI bonus for 'diversity'.

These persistent rumours have no supporting evidence non whatsoever. I could even be just making it all up as I go along. Consistency and diversity of source however make one wonder about smoke and fire.

Aye well, no pleasure taken in it all; leaky buckets are of neither intrinsic or practical value. However, duty done and there's an end to it. FWIW.

Toot toot.....

[Kharon]

P2  -(HERE) - “Hmm...64 pages of?? - Don't even know where to begin with this one..”.

Warning - Rant follows.

Perhaps with first principals !!– and maybe a refresher for instructing or check pilots. In the 64 pages of stuff and some nonsense; the essential elements were overlooked. Item 1 – this was to be a precautionary search and LANDING. This is an essential part of grass roots training; the underpinning notion simple, yet important; definitely not in the 'tick-a-box' grouping. The scenario is – here we are travelling East from the West to home base Bankstown, we need to cross the Blue mountains and the weather is against us; trapped – so; is there an airstrip handy? Yes – it is unfamiliar, so before committing; we execute a precautionary search, no animals, no power lines, no big holes etc, so after a good look, we execute a short field landing and STOP. That is the only reason we are here; to safely stop and wait out the weather. 

So, the weather clears up and now we can begin our return to base. What do we do? Well, we can take a long hard look at the departure track, asses the terrain, even talk to the owner about the local traps for young players and decide how we are going to complete the next element – Safely Go. - Short field take off briefed – Tick. Best rate of climb speed noted – Tick – Engine run up and checked – Tick – flight path and speed brief complete – Tick. Next step, fire up and bugger off home.

The operator should have the differences in operations clearly defined – Precautionary Search v Touch and Go – different animals – different approach to task - . Had they survived the episode, that instructor and I would be having 'tea and biscuits' on return. Failure to understand, teach and execute the fundamental object of the exercise in inexcusable. But, for the ATSB to produce a 64 page epistle detailing everything the aircraft did, only omitting what the crew had for breakfast is risible. Missing the radical cause is unpardonable. One paragraph would have nailed it – the aircraft was to execute a precautionary search & landing at an ALA. Due to rising terrain on the departure track a short field, max rate climb along a suitable exit path should have been briefed and discussed. This was not done – the instructing pilot called for a touch and go. This completely made null and void the purpose of this essential part of pilot training for a Commercial Pilot Licence. -  End of rant?  Not quite......

Addendum: This ATSB confection also fails, utterly, to mention one other fairly important element. They mention a tail wind (5 kts ish) + up hill and down dale airstrip. So the question a good instructor would ask the 'wannabe' - .. “uphill with a tailwind for landing and downhill for the take off into wind sound about right to you?” Herewith the real lesson begins. It begs the question; what have we got for instructors these days, and, importantly WTF are ATSB thinking about (or not).

Toot – FCOL – Toot.........

[Wombat]

“We execute a short field landing and STOP. “

I was almost killed by a young instructor and her school that taught short field landings via demonstration of a STOL touch and go at a short airstrip. The flaps jammed down and the poor little C150 couldn’t climb out of ground effect and the terrain rose in front of us. We survived the impossible turn around a tree.

There should be no such thing as a “short field touch and go” in the vocabulary.