[ventus45]

"Lack of trust" is the bottom line, and that is the result of a manifest "lack of credibility" from the far too many BS reports of late, but worse, the lack of "transparency", lack of "due dilligence", and lack of "timely action", on the really important ones.

Two "current investigations", now over two years old and counting, specifically "Mildura" and "Albury", have established the "lack of everythings" - "beyond all reason-(able) doubt" M'lud.

Both "Mildura" and "Albury" are well "on track" to become another "Norfolk".

I, for one, "no longer have any confidence in the efficacy of the "system" itself".

We can not trust the ATSB any more, it is as simple as that.

Probably the only thing we can do now, is prepare for the inevitable royal commission, after the now inevitable "big bang" happens.

The first thing is to draft the "necessary" TERMS OF REFERENCE (TOR's),  because "when" it happens, the biggest battle to fight will be the "very first battle", the "framing" of the TOR's themselves, because history clearly shows, that by and large, governments in this country, do not create royal commissions to find the truth, they do so to bury it.  

The first "turning of the sod" is always a "sanitised" set of TOR's.

If they "get up" without a fight, the truth is lost before the start, and the rest of the process simply becomes an abject farce.

(only took 20 minutes with edits M'lud - can NOT spare any more time today !!)

[MrPeaBody]

I was on the ATSB sight the other day and noted a number of well overdue investigations dating back to 2013 and 2014 suddenly getting an update............not to the content but the expected completion dates for the reports.

Could it be something political in the air that has suddenly stirred some action.........of a sort???

PB

[ventus45]

Quite likely Mr "P".

Standard routine in the public service Late April to Early May, - is preparation of a "snapshot" of the "state of play" in the Department / Agency / Branch / Section, in readiness for nailing down all the KPI's etc ready for drafting the yearly report.

From long experience in the system, I can tell you that the worst thing (for you) that you can give the bosses, is an "unknown" status or expected completion date, and worse yet, uncommitted funds, let alone unexpended funds. Finance is everything.

If you didn't spend this year's budget in full, you will likely get a cut next year.

Your bosses do NOT like that one little bit !

They also don't like a lot of uncompleted projects / tasks either, because they then appear to be inefficient managers.

So, the pressure is on - at this time of year - to "tidy up the ledger" as it were, from the bottom up, both financially and operationally.

Sometimes things do unavoidably "slip to the right" into the next financial year, most often for valid reasons, but sometimes not. In either case, an "updated status report" is hastily generated to cover your arse, with a new "expected completion date or expenditure date, as applicable.

Now having a few "tasks / jobs / projects" behind the curve and slipping to the right is one thing, almost normal, expected even, but to have a whole heap of them, especially if they are "high profile" in someone's eyes (higher up the food chain, external stakeholders, or worst, Ministerial, is quite another matter. In short, "the panic" is on !!

So, how many were "recently updated" Mr P, and were they "high profile" or "low profile" investigations ?

If the later, it is "just" the stats for the KPI's, and no one really cares.
But if the former, someone may need some KY, to ease the pain from incoming pineapple !!

[Peetwo]

Definitely overdue & incessantly obfuscated

The AQON to the Nick Xenophon ATSB QON 192 at Add Estimates takes the biccy in bureaucratic O&O:

Senator Xenophon, Nick asked:

Senator XENOPHON: I go to the issue of the 22 February 2000 Bureau of Meteorology report about the reliability of Norfolk Island forecasts. Did your first report and does the subsequent report that you have been asked to do in relation to the Pelair incident take into account the fact that those matters do not appear to have been followed through by other agencies in terms of the lack of reliability on the Norfolk Island weather forecasts?

Mr Dolan: Mr Walsh is supervising the reopened investigation.

Mr Walsh: Can I clarify the question. Are we looking at the reliability or are we looking—

Senator XENOPHON: No, there was a report issued on 22 February 2000 about the reliability of Norfolk Island forecasts. It appears that certain things were not followed through. I would like to put it to your agency that it appears that down the chain there were things that were not followed through as a result of the very clear report on the lack of reliability. Was that something that was taken into account with respect of the first investigation report on the Pelair incident and also now with the second report that is being considered?

Mr Walsh: I cannot speak to the first investigation because I was not involved. In the second one, I would have to actually take it on notice.

Senator XENOPHON: Perhaps you could take that on notice in relation to the first report. I go now to the issue of the LAHSO operations. There is a report being undertaken in respect of the 5 July incident 2015. Do you have an approximate time line of when that report will be completed?

Answer:

A review of our records did not reveal any documentary evidence that indicates the Australian Transport Safety Bureau’s 22 February 2000 report and recommendation to the Bureau of Meteorology was considered as part of that investigation.

The re-opened investigation includes consideration of the 22 February 2000 report and recommendation to the Bureau of Meteorology.

What a typically disingenuous answer from the ATSBeaker, if it wasn't actually a real AQON it could be quite humorous as a skit in Hollowmen or Utopia -  


MTF...P2  

[Kharon]

(Q) Heaven or Hell?  (A) It depends on your perspective.

I’m just amazed at the ease with which ‘they’ get away with it.  Dolan, Sangston, Walsh and the invisible Manning just expect, with some certainty to be allowed to continue on the road to perdition without let or hindrance.  Open contempt for the Senate committee followed by the endless game of providing non answers to serious questions.  

For 16 years air services, essential to Norfolk Island, have been plagued by the vagaries of weather forecasting, which is a tough enough job for the Met crew, without the ‘other’ elements such as budgets and disregard for passenger safety.  Passenger safety depends, solely and wholly on the integrity of the flight crew.  The whole weight of aviation law rests on the one or two heads ‘up front’ driving the bus, there is no wriggle room for them, no ‘joint’ responsibility and probably little company support in the event of an ‘incident’.

The Pel-Air ditching provided a perfect example of how this works and will for the foreseeable future continue to work.  Did the flight crew bugger it up? of course they did. But they had lots of help and yet only one of that flight crew has been severely punished and continues to be punished.  BoM, off the hook; CASA off the hook; ASA off the hook; Minister off the hook; company off the hook; even so, all played a part in the incident, all contributed.  The Rev Forsyth did his level best; the TSBC did what they could and a bit more; the ABC even tried to focus attention; the Senate inquiry vainglorious in it’s attempt now patiently awaiting a second report.  The ToR for that report were so narrow that the report, if it ever eventuates will be nugatory before the ink is dry – if anyone with the power to change things ever deigns to skim through the executive summary.

To the likes of the IOS, this has to stop.  However, the real question to my mind is why would those ‘in power’ want to stop such a perfect system?  It has worked so very well, time and time again; withstood some tremendous attacks and proven to be ‘the’ perfect defence for the minister and government.

Aye, it’s a worry; but not to those hiding behind the pot plants or listening to whispered instructions before entering the ring for a rigged bout, knowing the fix is in. Despicable? You bet.  Fact of life? That also.

Toot - toot.

[ventus45]

It has worked so very well, time and time again; withstood some tremendous attacks and proven to be ‘the’ perfect defence for the minister and government.

(Q) Minister:     But will it work against the inevitable RC when the "big one" happens ?
(A) Sir Humphry:  Yes Minister - of course.
(Q) Minister:     How can you be so confident Sir Humphry ?
(A) Sir Humphry: Don't worry Minister. It will be I who writes the ToR's Minister. A draft is in my top drawer. I update it every now and then. Can we move on Minister ?  There are other far more important matters.

[thorn bird]

As I have always said, "yes Minister" was not a comedy.It was a documentary!!

[Peetwo]

Three years for this?? - FDS  

Today the ATSB Mildura fog duck-up report was finally released - hoorah! 

AO-2013-100 - Landing below minima due to fog involving Boeing 737s, VH-YIR and VH-VYK Mildura Airport, Victoria on 18 June 2013.

Final - 31 May 2016

Findings

From the evidence available, the following findings are made with respect to the landing below minima due to fog involving two Boeing 737s, registered VH-YIR and VH-VYK, which occurred at Mildura Airport, Victoria on 18 June 2013. These findings should not be read as apportioning blame or liability to any particular organisation or individual.

Safety issues, or system problems, are highlighted in bold to emphasise their importance. 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 organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time.

Contributing factors

• 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 aerodrome 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.
  

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 aerodrome weather reports at Mildura over the aerodrome 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 in-flight 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 in-flight weather report given by the air ambulance pilot was not passed to the flight crews of Velocity 1384 and Qantas 735 by the controller when they changed frequency inbound 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 recognise and actively disseminate special weather reports (SPECI) to pilots, thus not meeting the intent of the SPECI alerting function provided by controller-initiated flight information service. [Safety issue]
  
• For many nonmajor 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 weather conditions at such airports, increasing the risk of flight crew not being aware of the changes at an appropriate time to support their decision making. [Safety issue]
  

Other findings

• The flight crews of Velocity 1384 and Qantas 735 planned for, and uploaded, sufficient fuel for the forecast conditions at Adelaide Airport in accordance with the respective operator's fuel policies.
  
• The flight crew of Qantas 735 proactively sought weather information for various airports soon after departing Sydney.
  
• The meteorological information obtained from an Aerodrome Weather Information Service (AWIS) is operationally equivalent to that provided in routine (METAR)/special weather (SPECI) reports. However, as the AWIS broadcast doesn't contain the label 'SPECI', pilots are required to recognise and interpret its operational significance.
  
• Critical to the assurance of safe flight, all elements of the aviation system including weather services, air traffic services, aircraft operators and flight crews need to have a clear understanding of their roles and responsibilities in that system.
  

Safety issues and actions
The safety issue identified during this investigation is listed in the Findings and Safety issues and actions sections of this report. The ATSB expects that all safety issues identified by the investigation should be addressed by the relevant organisation(s). In addressing those issues, the ATSB prefers to encourage relevant organisation(s) to proactively initiate safety action, rather than to issue formal safety recommendations or safety advisory notices.

All of the directly involved parties were provided with a draft report and invited to provide submissions. As part of that process, each organisation was asked to communicate what safety actions, if any, they had carried out or were planning to carry out in relation to each safety issue relevant to their organisation.
The initial public version of these safety issues and actions are repeated separately on the ATSB website to facilitate monitoring by interested parties. Where relevant the safety issues and actions will be updated on the ATSB website as information comes to hand.

Limited provision of flight information service for some nonmajor airports
For many nonmajor 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 weather conditions at such airports, increasing the risk of pilots not being aware of the changes at an appropriate time to support their decision making.

ATSB Safety Issue No: AO-2013-100-SI-01
 
Alerting function of special weather reports (SPECI) is not met by the automatic broadcast services

The automatic broadcast services did not have the capacity to recognise and actively disseminate special weather reports (SPECI) to pilots, thus not meeting the intent of the SPECI alerting function provided by controller-initiated flight information service.

ATSB Safety Issue No: AO-2013-100-SI-02
ATSB Recommendation No: AO-2013-100-SR-057
 
Additional safety action

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence.

Bureau of Meteorology
Although no safety issue was identified by the ATSB, the Bureau of Meteorology advised of the following safety action in response to this occurrence:

• A review of Trend Forecast services was undertaken through a consultative process with the aviation industry and the Australian Defence Force. The reasons for reviewing Trend Forecast services include:
  

The TTF format is unique to Australia.

Although the TTF and TAF are forecasts for the same aerodrome, they convey different information concerning the probability and timing of meteorological phenomena.

Perceived conflict information between TAF and TTF as TAF can mention probabilities of 30 and 40 per cent, whereas TTF is a forecast of the most likely outcome over the next three hours.

The report on the Review of the Trend Forecast was released for comment on the 29 September 2015. The closing date for feedback is 29 January 2016. At the time of release of this report, the BoM was progressing the action items from the report and will discuss the outcomes with CASA.

• Aviation Cameras for Forecasters (AvCam). For the 2015–16 financial year [FY] the BoM will install weather cameras at 15–20 locations at major capital city aerodromes, including Adelaide airport, and key regional aerodromes. The AvCam project [will] provide an additional tool for forecasters to assess current weather conditions, including fog, to supplement human observations or other automated present weather sensors and instrumentation.
  
• Trial Automation of Observations at Cairns and Canberra (TAOCC) Project. Information from the trial could be used to enhance observations and better define the capability requirement at all airports (completion expected 2017).
  
• Centralised Aerodrome Weather Information Service (C-AWIS) Project (completion expected 2015/16 FY). The Centralised-AWIS (C-AWIS) project aims to deliver a cost effective and reliable replacement to the current AWIB/AWIS that will centrally process AWS data.
  
• Aviation Verification System (AVS) 2 (due to be completed in 2017). The implementation of the next generations of TAF verification, AVS2, aims to:
  

- Improve the accuracy of forecasts in relation to predicting the onset and cessation times for thunderstorms and below minima conditions at airports;

- Result in developing a less conservative forecast approach for significant weather events (with below minima conditions);

- Improve forecaster responsiveness in amending forecasts after weather events have passed;

• Climatology Interface Development Project. This project aims to develop a new national climatological interface for the display and interpretation of climate information at aerodromes and key aviation locations (due to be completed in 2017).
  
• In September 2015 the BOM implementation of Himawari 8 satellite data. Himawari-8 provides observations that enable the Bureau to create true-colour images of the Australian region, every ten minutes, based on reflected visible light. These are useful, for example, for identifying fog and low cloud, which may not be visible in thermal infrared images because it has a similar temperature to the ground below.
  
• The BoM’s Aviation Weather Services already has a formal process in place to conduct regularly consultative meetings/workshops with key aviation stakeholders to identify improvements and current and future requirements.
  

Virgin Australia Airlines Pty. Ltd.
Although no safety issue was identified by the ATSB, Virgin Australia Airlines Pty. Ltd. (Virgin) advised of the following safety action in response to this occurrence:

• The flight following policy was rewritten. This included clarification of the minimum requirements of the service provided (i.e. definition of notifiable updates) and removal of the differentiation between passive and active flight following such that all flights are now flight followed.
  
• Amended flight planning policy to apply ‘worst case’ of TAF or TTF forecast conditions.
  
• Introduction of an adverse weather flight planning policy.
  
• Review of Flight Watch/Following activities across several carriers to obtain best practice for this activity – Virgin America and Westjet were visited.
  
• Central Flight Watch desk dissolved and Flight Following introduced mid 2014 with desks split up into regions and Flight Following assigned to individual desks.
  
• Pilot weather updating requirements have been clarified and enhanced and ACARS [aircraft communications addressing and reporting system] equipment continues to be rolled out across the Virgin fleet.
  

Alerting function of special weather reports (SPECI) is not met by the automatic broadcast services

Issue number: AO-2013-100-SI-02

Who it affects: All pilots operating into non-major airports accessing an automatic broadcast service

Issue owner: Airservices Australia in consultation with the Bureau of Meteorology

Operation affected: Aviation: Air transport

Background: Investigation Report AO-2013-100

Date: 31 May 2016

Safety issue description

The automatic broadcast services did not have the capacity to recognise and actively disseminate special weather reports (SPECI) to pilots, thus not meeting the intent of the SPECI alerting function provided by controller-initiated flight information service.

Proactive Action

Action organisation: Airservices Australia
Date: 31 May 2016
Action status: Released

In response to this safety issue, Airservices advised the following:
Airservices appreciates the opportunity to provide comment on the additional safety issue and supporting documentation in relation to ATSB Investigation A0-2013-100 provided on 26 April 2016.

Airservices agrees with the safety issue and acknowledges that automatically generated SPECls from Automatic Broadcast Service (ABS), while operating as designed, may not be readily apparent to crew in situations where weather conditions change rapidly and differ from forecast conditions.

As discussed with the ATSB and Bureau of Meteorology (BoM) on 16 April 2016, just as it is not practical for pilots to continuously monitor SPECls whilst within one hour flight time of destination, it is also not practical for ATC to continuously monitor and disseminate SPECls. This is due to the volume and frequency of automatically generated SPECI data at locations with ABS, particularly in recent times where more sensors are available at unmanned weather stations. There is currently no mechanism as part of the ABS to filter the SPECI data to delineate that which is operationally significant to a flight.

To address the safety issue Airservices considers that a meteorological system-based solution is likely to be required, and Airservices is available to support the BoM to progress the feasibility assessment work and identify suitable design and implementation options. This work could potentially be progressed in the form of a BoM-led working group including the aviation industry.

ATSB response:

The ATSB notes Airservices agreement with the issue and intention to work with the Bureau of Meteorology to establish a solution. However the ATSB is concerned that Airservices, as the agency that provides flight information service in Australia, has not taken responsibility for the resolution of this safety issue. In addition, the indefinite nature of the proposed activity does not provide a high degree of confidence that the safety issue will be adequately addressed.

As a result, the ATSB has issued the following safety recommendation.

Recommendation

Action organisation:Airservices Australia
Action number: AO-2013-100-SR-057
Date: 31 May 2016
Action status: Released

The ATSB recommends that Airservices Australia as the safety issue owner works in collaboration with the Bureau of Meteorology to instigate a system change to reinstate the alerting function of SPECI reports currently not available through an automatic broadcast service

On my first run through I have to say WTH was the hold up


MTF? Definitely - P2

[Peetwo]

Three years for this?? - FDS  

Today the ATSB Mildura fog duck-up report was finally released - hoorah! 

AO-2013-100 - Landing below minima due to fog involving Boeing 737s, VH-YIR and VH-VYK Mildura Airport, Victoria on 18 June 2013.

Final - 31 May 2016

Findings

From the evidence available, the following findings are made with respect to the landing below minima due to fog involving two Boeing 737s, registered VH-YIR and VH-VYK, which occurred at Mildura Airport, Victoria on 18 June 2013. These findings should not be read as apportioning blame or liability to any particular organisation or individual.

Safety issues, or system problems, are highlighted in bold to emphasise their importance. 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 organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time.

Contributing factors

• 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 aerodrome 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.
  

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 aerodrome weather reports at Mildura over the aerodrome 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 in-flight 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 in-flight weather report given by the air ambulance pilot was not passed to the flight crews of Velocity 1384 and Qantas 735 by the controller when they changed frequency inbound 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 recognise and actively disseminate special weather reports (SPECI) to pilots, thus not meeting the intent of the SPECI alerting function provided by controller-initiated flight information service. [Safety issue]
  
• For many nonmajor 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 weather conditions at such airports, increasing the risk of flight crew not being aware of the changes at an appropriate time to support their decision making. [Safety issue]
  

Other findings

• The flight crews of Velocity 1384 and Qantas 735 planned for, and uploaded, sufficient fuel for the forecast conditions at Adelaide Airport in accordance with the respective operator's fuel policies.
  
• The flight crew of Qantas 735 proactively sought weather information for various airports soon after departing Sydney.
  
• The meteorological information obtained from an Aerodrome Weather Information Service (AWIS) is operationally equivalent to that provided in routine (METAR)/special weather (SPECI) reports. However, as the AWIS broadcast doesn't contain the label 'SPECI', pilots are required to recognise and interpret its operational significance.
  
• Critical to the assurance of safe flight, all elements of the aviation system including weather services, air traffic services, aircraft operators and flight crews need to have a clear understanding of their roles and responsibilities in that system.
  

Safety issues and actions
The safety issue identified during this investigation is listed in the Findings and Safety issues and actions sections of this report. The ATSB expects that all safety issues identified by the investigation should be addressed by the relevant organisation(s). In addressing those issues, the ATSB prefers to encourage relevant organisation(s) to proactively initiate safety action, rather than to issue formal safety recommendations or safety advisory notices.

All of the directly involved parties were provided with a draft report and invited to provide submissions. As part of that process, each organisation was asked to communicate what safety actions, if any, they had carried out or were planning to carry out in relation to each safety issue relevant to their organisation.
The initial public version of these safety issues and actions are repeated separately on the ATSB website to facilitate monitoring by interested parties. Where relevant the safety issues and actions will be updated on the ATSB website as information comes to hand.

Limited provision of flight information service for some nonmajor airports
For many nonmajor 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 weather conditions at such airports, increasing the risk of pilots not being aware of the changes at an appropriate time to support their decision making.

ATSB Safety Issue No: AO-2013-100-SI-01
 
Alerting function of special weather reports (SPECI) is not met by the automatic broadcast services

The automatic broadcast services did not have the capacity to recognise and actively disseminate special weather reports (SPECI) to pilots, thus not meeting the intent of the SPECI alerting function provided by controller-initiated flight information service.

ATSB Safety Issue No: AO-2013-100-SI-02
ATSB Recommendation No: AO-2013-100-SR-057
 
Additional safety action

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence.

Bureau of Meteorology
Although no safety issue was identified by the ATSB, the Bureau of Meteorology advised of the following safety action in response to this occurrence:

• A review of Trend Forecast services was undertaken through a consultative process with the aviation industry and the Australian Defence Force. The reasons for reviewing Trend Forecast services include:
  

The TTF format is unique to Australia.

Although the TTF and TAF are forecasts for the same aerodrome, they convey different information concerning the probability and timing of meteorological phenomena.

Perceived conflict information between TAF and TTF as TAF can mention probabilities of 30 and 40 per cent, whereas TTF is a forecast of the most likely outcome over the next three hours.

The report on the Review of the Trend Forecast was released for comment on the 29 September 2015. The closing date for feedback is 29 January 2016. At the time of release of this report, the BoM was progressing the action items from the report and will discuss the outcomes with CASA.

• Aviation Cameras for Forecasters (AvCam). For the 2015–16 financial year [FY] the BoM will install weather cameras at 15–20 locations at major capital city aerodromes, including Adelaide airport, and key regional aerodromes. The AvCam project [will] provide an additional tool for forecasters to assess current weather conditions, including fog, to supplement human observations or other automated present weather sensors and instrumentation.
  
• Trial Automation of Observations at Cairns and Canberra (TAOCC) Project. Information from the trial could be used to enhance observations and better define the capability requirement at all airports (completion expected 2017).
  
• Centralised Aerodrome Weather Information Service (C-AWIS) Project (completion expected 2015/16 FY). The Centralised-AWIS (C-AWIS) project aims to deliver a cost effective and reliable replacement to the current AWIB/AWIS that will centrally process AWS data.
  
• Aviation Verification System (AVS) 2 (due to be completed in 2017). The implementation of the next generations of TAF verification, AVS2, aims to:
  

- Improve the accuracy of forecasts in relation to predicting the onset and cessation times for thunderstorms and below minima conditions at airports;

- Result in developing a less conservative forecast approach for significant weather events (with below minima conditions);

- Improve forecaster responsiveness in amending forecasts after weather events have passed;

• Climatology Interface Development Project. This project aims to develop a new national climatological interface for the display and interpretation of climate information at aerodromes and key aviation locations (due to be completed in 2017).
  
• In September 2015 the BOM implementation of Himawari 8 satellite data. Himawari-8 provides observations that enable the Bureau to create true-colour images of the Australian region, every ten minutes, based on reflected visible light. These are useful, for example, for identifying fog and low cloud, which may not be visible in thermal infrared images because it has a similar temperature to the ground below.
  
• The BoM’s Aviation Weather Services already has a formal process in place to conduct regularly consultative meetings/workshops with key aviation stakeholders to identify improvements and current and future requirements.
  

Virgin Australia Airlines Pty. Ltd.
Although no safety issue was identified by the ATSB, Virgin Australia Airlines Pty. Ltd. (Virgin) advised of the following safety action in response to this occurrence:

• The flight following policy was rewritten. This included clarification of the minimum requirements of the service provided (i.e. definition of notifiable updates) and removal of the differentiation between passive and active flight following such that all flights are now flight followed.
  
• Amended flight planning policy to apply ‘worst case’ of TAF or TTF forecast conditions.
  
• Introduction of an adverse weather flight planning policy.
  
• Review of Flight Watch/Following activities across several carriers to obtain best practice for this activity – Virgin America and Westjet were visited.
  
• Central Flight Watch desk dissolved and Flight Following introduced mid 2014 with desks split up into regions and Flight Following assigned to individual desks.
  
• Pilot weather updating requirements have been clarified and enhanced and ACARS [aircraft communications addressing and reporting system] equipment continues to be rolled out across the Virgin fleet.
  

Alerting function of special weather reports (SPECI) is not met by the automatic broadcast services

Issue number: AO-2013-100-SI-02

Who it affects: All pilots operating into non-major airports accessing an automatic broadcast service

Issue owner: Airservices Australia in consultation with the Bureau of Meteorology

Operation affected: Aviation: Air transport

Background: Investigation Report AO-2013-100

Date: 31 May 2016

Safety issue description

The automatic broadcast services did not have the capacity to recognise and actively disseminate special weather reports (SPECI) to pilots, thus not meeting the intent of the SPECI alerting function provided by controller-initiated flight information service.

Proactive Action

Action organisation: Airservices Australia
Date: 31 May 2016
Action status: Released

In response to this safety issue, Airservices advised the following:
Airservices appreciates the opportunity to provide comment on the additional safety issue and supporting documentation in relation to ATSB Investigation A0-2013-100 provided on 26 April 2016.

Airservices agrees with the safety issue and acknowledges that automatically generated SPECls from Automatic Broadcast Service (ABS), while operating as designed, may not be readily apparent to crew in situations where weather conditions change rapidly and differ from forecast conditions.

As discussed with the ATSB and Bureau of Meteorology (BoM) on 16 April 2016, just as it is not practical for pilots to continuously monitor SPECls whilst within one hour flight time of destination, it is also not practical for ATC to continuously monitor and disseminate SPECls. This is due to the volume and frequency of automatically generated SPECI data at locations with ABS, particularly in recent times where more sensors are available at unmanned weather stations. There is currently no mechanism as part of the ABS to filter the SPECI data to delineate that which is operationally significant to a flight.

To address the safety issue Airservices considers that a meteorological system-based solution is likely to be required, and Airservices is available to support the BoM to progress the feasibility assessment work and identify suitable design and implementation options. This work could potentially be progressed in the form of a BoM-led working group including the aviation industry.

ATSB response:

The ATSB notes Airservices agreement with the issue and intention to work with the Bureau of Meteorology to establish a solution. However the ATSB is concerned that Airservices, as the agency that provides flight information service in Australia, has not taken responsibility for the resolution of this safety issue. In addition, the indefinite nature of the proposed activity does not provide a high degree of confidence that the safety issue will be adequately addressed.

As a result, the ATSB has issued the following safety recommendation.

Recommendation

Action organisation:Airservices Australia
Action number: AO-2013-100-SR-057
Date: 31 May 2016
Action status: Released

The ATSB recommends that Airservices Australia as the safety issue owner works in collaboration with the Bureau of Meteorology to instigate a system change to reinstate the alerting function of SPECI reports currently not available through an automatic broadcast service

On my first run through I have to say WTH was the hold up

Update: Before it gets muzzled on the UP, there is currently a thread running commenting on that bollocks report with some worthy posts:

Ozbiggles - 3 years later The Mildura report

---

3 years later the ATSB final report finally appears.
Cover page - First safety message. Pilots are reminded of their responsibility for collecting all relevant information to support inflight decision making...
Qantas did that and ended up in the situation they did.
The report says the forecast was inaccurate in terms of significance and length of the fog at Adelaide and the Mildura met wasn't accurate either.
I have a feeling this report will make the Norfolk report look like a Shakespearian classic.

---

Nothing to see here.

Quote: This occurrence has highlighted the effect of various factors coming together to create and influence a rare event.

The VA 737 landed with less than 15 mins of fuel and essentially no one stuffed up (not BOM, not ATC, not Crew, not Ops Control/Dispatch). - and if it wasn't for the QF skipper taking extra fuel they would have been in the same boat...

What is wrong with the ATSB?!!



When will we be like the rest of real world and carry technical alternates.

---

framer - From the report:

Quote: The availability of a code grey forecast is unique to Australia, and is used to highlight the possibility of weather conditions that airline operators may wish to consider in terms of flight planning.

How are code grey forecasts promulgated?
Can a crew look at them on the internet or is it only available to Airlines?

---

ozbiggles - 3 years to tell us what the aircraft did, nothing new from the interim report.

This was an opportunity for a top down dissection of how business Is done in this country. Two aircraft from different companies ended up on a country airstrip conducting emergency landings and the conclusion is they should have been getting more regular updates on inaccurate forecasts?

What about the infrastructure? All modern jet aircraft can auto land, in fact the report mentions when emergency autolands have saved us in the past. No recommendation to mandate it at capital airports at least? The bean counters will tell you it's not statiscally significant to warrant the expense but how many times has it saved the day already?

The NOC, National Operations Centre. What the hell does it do, it seems to have got involved right about the time both aircraft were in the circuit area at Mildura. Shouldn't the NOC be the centre of knowledge and information for these types of unfolding events or is it just somewhere in Canberra to sit and drink coffee? Surely we should have a central point for ASA,BOM, major airlines to co-ordinate unfolding scenarios so all the missed opportunities that occured here don't happen?if not why not?

ASA who the hell decided that not passing on SPECIs wasn't going to cause any real problems? That if they can only get that information within visual range it wouldn't be an issue. What the hell is going on there with risk mangement and what other chocolate eggs are hidden?

How did it happen the AIP didn't reflect the intent of the change at ASA? Where else is this a problem. How come the majority of the pilot group didn't know this was the intent?

This just on the first read, I'm sure there is more

How did it happen they had to ask CASA for an interpretation of inflight fuel requirements? Haven't we sorted that out in 100 years of flying.

Nothing on if current fuel policy is appropriate or what other countries might use.

We did cover the big issue that the air ambulance pilot didn't start his radio call with Airep, glad that made it in.

---

Quote:When will we be like the rest of real world and carry technical alternates.

Probably when parasitic corporate bean counters stop running flt ops. I would advise not to hold your breath.

---

ozbiggles - This report should have been a good chance to begin a move to mandate it. But it didn't touch that elephant in the room. That would have been a bit bold. Unless it's mandated the inmates will continue to run the asylum charging $1 tickets....checked baggage not included. Surely fuel policy and facilities should have been the main thrust of this report. Forecasting is a black art, getting lost in the aviation world. It will never be 100% therefore the risk controls would be fuel, facilities and timely supply of bad news...but we did find out the air ambulance pilot didn't say Airep....

---

P2 - And for a possible candidate for QOTM...

hotnhigh - Quote: When will we be like the rest of real world and carry technical alternates

They did.....Mildura

  

MTF...P2

[Kharon]

The winner is:-

P-362436 won the prized Tim Tam; closest to a word perfect repeat of the ATSB report in a close run competition.  The following was almost letter perfect in no less than 30 out of 40 entries. Although the semi illiterate drafting and grammatical faux-pas were difficult to replicate, many managed it. Bravo - CF all around.

The safety issue identified during this investigation is listed in the Findings and Safety issues and actions sections of this report. The ATSB expects that all safety issues identified by the investigation should be addressed by the relevant organisation(s). In addressing those issues, the ATSB prefers to encourage relevant organisation(s) to proactively initiate safety action, rather than to issue formal safety recommendations or safety advisory notices.

Now read that again - as an exercise in English and logic.  Then weep.
   
It is unanimous that the above paragraph could have been generated in three minutes which would have saved three years of resources being allocated.  

There you go Greg, 3.4 days off a week, 0.6 day for coffee and chats; 0.5 to sign off on the boiler-plate paragraphs provided, then the weekend is your own, to do with as pleases you best.  Great new job mate; enjoy.

JFHCOAC.

[Peetwo]

Three years for this?? - FDS  

Today the ATSB Mildura fog duck-up report was finally released - hoorah! 

AO-2013-100 - Landing below minima due to fog involving Boeing 737s, VH-YIR and VH-VYK Mildura Airport, Victoria on 18 June 2013.


ATSB Safety Issue No: AO-2013-100-SI-01
 
ATSB Safety Issue No: AO-2013-100-SI-02

ATSB Recommendation No: AO-2013-100-SR-057 

Recommendation

Action organisation:Airservices Australia
Action number: AO-2013-100-SR-057
Date: 31 May 2016
Action status: Released

The ATSB recommends that Airservices Australia as the safety issue owner works in collaboration with the Bureau of Meteorology to instigate a system change to reinstate the alerting function of SPECI reports currently not available through an automatic broadcast service

Ozbiggles - 3 years later The Mildura report

---

3 years later the ATSB final report finally appears.
Cover page - First safety message. Pilots are reminded of their responsibility for collecting all relevant information to support inflight decision making...
Qantas did that and ended up in the situation they did.
The report says the forecast was inaccurate in terms of significance and length of the fog at Adelaide and the Mildura met wasn't accurate either.
I have a feeling this report will make the Norfolk report look like a Shakespearian classic.

---

Nothing to see here.

Quote: This occurrence has highlighted the effect of various factors coming together to create and influence a rare event.

The VA 737 landed with less than 15 mins of fuel and essentially no one stuffed up (not BOM, not ATC, not Crew, not Ops Control/Dispatch). - and if it wasn't for the QF skipper taking extra fuel they would have been in the same boat...

What is wrong with the ATSB?!!



When will we be like the rest of real world and carry technical alternates.

---

framer - From the report:

Quote: The availability of a code grey forecast is unique to Australia, and is used to highlight the possibility of weather conditions that airline operators may wish to consider in terms of flight planning.

How are code grey forecasts promulgated?
Can a crew look at them on the internet or is it only available to Airlines?

---

ozbiggles - 3 years to tell us what the aircraft did, nothing new from the interim report.

This was an opportunity for a top down dissection of how business Is done in this country. Two aircraft from different companies ended up on a country airstrip conducting emergency landings and the conclusion is they should have been getting more regular updates on inaccurate forecasts?

What about the infrastructure? All modern jet aircraft can auto land, in fact the report mentions when emergency autolands have saved us in the past. No recommendation to mandate it at capital airports at least? The bean counters will tell you it's not statiscally significant to warrant the expense but how many times has it saved the day already?

The NOC, National Operations Centre. What the hell does it do, it seems to have got involved right about the time both aircraft were in the circuit area at Mildura. Shouldn't the NOC be the centre of knowledge and information for these types of unfolding events or is it just somewhere in Canberra to sit and drink coffee? Surely we should have a central point for ASA,BOM, major airlines to co-ordinate unfolding scenarios so all the missed opportunities that occured here don't happen?if not why not?

ASA who the hell decided that not passing on SPECIs wasn't going to cause any real problems? That if they can only get that information within visual range it wouldn't be an issue. What the hell is going on there with risk mangement and what other chocolate eggs are hidden?

How did it happen the AIP didn't reflect the intent of the change at ASA? Where else is this a problem. How come the majority of the pilot group didn't know this was the intent?

This just on the first read, I'm sure there is more

How did it happen they had to ask CASA for an interpretation of inflight fuel requirements? Haven't we sorted that out in 100 years of flying.

Nothing on if current fuel policy is appropriate or what other countries might use.

We did cover the big issue that the air ambulance pilot didn't start his radio call with Airep, glad that made it in.

---

Quote:When will we be like the rest of real world and carry technical alternates.

Probably when parasitic corporate bean counters stop running flt ops. I would advise not to hold your breath.

---

ozbiggles - This report should have been a good chance to begin a move to mandate it. But it didn't touch that elephant in the room. That would have been a bit bold. Unless it's mandated the inmates will continue to run the asylum charging $1 tickets....checked baggage not included. Surely fuel policy and facilities should have been the main thrust of this report. Forecasting is a black art, getting lost in the aviation world. It will never be 100% therefore the risk controls would be fuel, facilities and timely supply of bad news...but we did find out the air ambulance pilot didn't say Airep....

  

Further update 01/06/16:

Virgin jet forced to land at fog-bound airport after 'inaccurate forecasts'
Date May 31, 2016 - 6:18PM

• 401 reading now
  
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Matt O'Sullivan
Transport Reporter

A Virgin 737-800 similar to the one pictured had no choice but to land at Mildura because it was close to running out of fuel. Photo: Brendon Thorne

Inaccurate forecasts were partly to blame for a Virgin Australia jet making a last-ditch attempt at an emergency landing as it nearly ran out of fuel, air-safety investigators have found.

Passengers on board the Boeing 737-800 endured a terrifying ordeal as they were told to "brace, brace, brace" and keep their heads down as the plane was forced to land at a fog-bound Mildura Airport on June 18, 2013.

The Virgin jet, which had 85 passengers and six crew on board and was on route from Brisbane, had earlier diverted from landing at Adelaide Airport due to fog.

Location of the fuel quantity indication on the upper display unit (circled in yellow). Photo: Australian Safety Transport Bureau

A Qantas 737 carrying 152 people bound for Adelaide from Sydney had also re-routed to Mildura, only to find fog and cloud had enveloped the Victorian town's airport.
Advertisement

Once circling above Mildura, the two planes had no choice but to land because they did not have enough fuel left in their tanks to divert to other airports.

In one exchange between the two planes, the Qantas pilots told their counterparts on the Virgin 737 that they were going to land at Mildura "due [to] fuel".

The Virgin pilots replied that they were "in the same boat" but decided to let the Qantas plane land first, which it managed to do safely.

Shortly afterwards, the Virgin plane made a "missed approach" during which the pilots were able to confirm that they were aligned with the runway as they looked directly down.

The Virgin pilots then briefed cabin crew to prepare for an emergency landing, and passengers were told to "brace". The plane eventually landed safely at Mildura.

In a final report released on Tuesday, the Australian Safety Transport Bureau found the deterioration in weather at Adelaide did not appear on the forecast when the two planes took off.

An updated forecast also predicted that the fog would lift at Adelaide sooner than it actually did.

It led to the Qantas jet flying on to Adelaide because the crew had reasoned that the fog would clear by the time they had reached South Australia's capital.

Investigators said the forecasting also influenced the decision making of Virgin's flight watch staff who did not pass the amended weather report onto the pilots of the airline's 737 en route.

By the time the planes reached Mildura, the weather was "significantly worse" than originally forecast, and they were forced to land in conditions below the level usually allowed for planes do so.

In response to the incident, the manager of the country's airspace, Airservices Australia, said it will look at "feasible options" to provide information about significant deteriorations in weather to solve limitations of automated broadcast services.

The Bureau of Meteorology has also said it has made "various system changes".

The final report from the ATSB comes two years after it was scheduled to be released


Read more: http://www.smh.com.au/national/virgin-jet-forced-to-land-at-fogbound-airport-after-inaccurate-forecasts-20160531-gp82j8.html#ixzz4AH1VkKC2
Follow us: @smh on Twitter | sydneymorningherald on Facebook

Next from Planetalking posting from OS yesterday... :

ATSB reports on two 737s blindsided by fog at Mildura ... in 2013

Virgin Australia and Qantas each found one of their 737s in peril three years when they were forced by inadequate fuel loads to divert to Mildura in a weather crisis that became much worse as they prepared to land at the country town


Ben Sandilands


Where the Virgin and Qantas 737s were when it all went pear shaped one foggy foggy morning

One of the most serious incidents ever involving Virgin Australia and Qantas when they landed 737s diverted to Mildura only to be blindsided by fog and carrying low fuel reserves, has finally been reported upon by the ATSB three years after it happened.

The safety agency’s report is as disappointing in its summary form as the incident, on June 18, 2013, is itself frightening.

It was brought about by a combination of factors described in detail in the full report, which Virgin Australia and Qantas may well hope no one in the flying public takes time to read.

As reported by Plane Talking last year and on many other occasions, both jets, a Virgin Australia flight to Adelaide from Brisbane, and a Qantas flight to Adelaide from  Sydney, couldn’t complete their journeys as they approached South Australia because of fog.

They diverted, as did a number of smaller regional flights, to Mildura, for which they were given incorrect meteorological data suggesting the Riverina town was clear, but it wasn’t.

It too lay under a deep blanket of fog.  The upshot of various missed approaches by the jets was that the Virgin 737 eventually had to land despite considerable uncertainty as to whether it would find the runway, with the cabin prepped for a crash landing, passengers in the brace position, and calls of ‘brace, brace,brace’ from the flight attendants.

There was about as much fuel left in the tanks of the Virgin jet as the body mass of five adults. There wasn’t enough fuel to perform another go around. It had to land, or crash.

This was a very confronting moment for air safety in Australia, raising troubling questions (as yet unanswered) as to why Australian airlines are allowed to skimp on inter city fuel compared to those in most of the developed and much of the undeveloped world. It highlighted the standard and quality and competency of our meteorological services for aviation.

And it brings out, now, in the craven language of the summary of that incident, the chronic evasiveness of our aviation safety guardian, the ATSB, when it comes to anything that might conceivably embarrass the airlines, or the authorities, or cause legitimate concerns among travellers.

The full report is another matter. It will no doubt cause controversy in pilot ranks and more than a little concern as to whether Australia is actually capable of dealing with serious issues in air safety regulation and investigations at all, but it doesn’t on first reading on the other side of the world, do anything more offensive than trying to bury them from coming to the attention of inquiring minds.

MTF...P2

[Peetwo]

The winner is:-

P-362436 won the prized Tim Tam; closest to a word perfect repeat of the ATSB report in a close run competition.  The following was almost letter perfect in no less than 30 out of 40 entries. Although the semi illiterate drafting and grammatical faux-pas were difficult to replicate, many managed it. Bravo - CF all around.

The safety issue identified during this investigation is listed in the Findings and Safety issues and actions sections of this report. The ATSB expects that all safety issues identified by the investigation should be addressed by the relevant organisation(s). In addressing those issues, the ATSB prefers to encourage relevant organisation(s) to proactively initiate safety action, rather than to issue formal safety recommendations or safety advisory notices.

Now read that again - as an exercise in English and logic.  Then weep.
   
It is unanimous that the above paragraph could have been generated in three minutes which would have saved three years of resources being allocated.  

There you go Greg, 3.4 days off a week, 0.6 day for coffee and chats; 0.5 to sign off on the boiler-plate paragraphs provided, then the weekend is your own, to do with as pleases you best.  Great new job mate; enjoy.

JFHCOAC.

P2 edit - in case this was missed...

[Peetwo]

Three years for this? - Part III 

Risk mitigation in the real World
  
Meanwhile in Dunce-under land the ATSB is putting out crap like this:

AO-2013-100 - Landing below minima due to fog involving Boeing 737s, VH-YIR and VH-VYK Mildura Airport, Victoria on 18 June 2013.

[b]Nothing to see here.
[/b]

Quote: This occurrence has highlighted the effect of various factors coming together to create and influence a rare event.

The VA 737 landed with less than 15 mins of fuel and essentially no one stuffed up (not BOM, not ATC, not Crew, not Ops Control/Dispatch). - and if it wasn't for the QF skipper taking extra fuel they would have been in the same boat...

What is wrong with the ATSB?!!



[b]When will we be like the rest of real world and carry technical alternates.[/b]

ATSB Safety Issue No: AO-2013-100-SI-01
 
ATSB Safety Issue No: AO-2013-100-SI-02

ATSB Recommendation No: AO-2013-100-SR-057 

Recommendation

Action organisation:Airservices Australia
Action number: AO-2013-100-SR-057
Date: 31 May 2016
Action status: Released

The ATSB recommends that Airservices Australia as the safety issue owner works in collaboration with the Bureau of Meteorology to instigate a system change to reinstate the alerting function of SPECI reports currently not available through an automatic broadcast service

 
No further comment, just disgusted

At the risk of flogging a dead horse, in regard to ATSB O&O'd & PC'd investigations and final reports, I came across yet another disturbing historical revelation in regards to alternate fuel requirements and related min/exhausted fuel occurrences. This despicable revelation has yet another connection to the PelAir Norfolk Island ditching of VH-NGA and lends more weight to there being nefarious reasons that the 'powers to be' wanted to slate all blame to the pilot Dominic James.

Fortunately the thread on the UP (quoted from above) has continued and there is still some excellent discussion on the subject of the ATSB Mildura fog duck-up final report. One of the contributor's (Buzzbox) further posts included a link to an old (2006) ATSB research paper:

BB - It could also be argued that the INTER/TEMPO holding fuel requirements are only intended to cater for inaccuracies in the weather forecast. They provide some protection in case the weather is worse than forecast and ends up below landing minima, preventing the aircraft from landing. In that light, the enroute holding has no bearing on the destination holding requirement. The INTER/TEMPO holding fuel should therefore be available until the aircraft is close to the destination and likely to land within the 30/60 minute period.


Some interesting reading:
https://www.atsb.gov.au/media/32921/b20040246.pdf

 
 To which 'CurtainTwitcher' later responded and reposted:

Buzzbox, thank you for the link, I am making my way through it, and this section caught my eye:

The use of en-route weather reports for updating operational decisions as a potential risk mitigant was examined to assess their capacity to provide a timely en-route warning that the destination weather would prevent a safe landing from being assured, thereby enabling an early diversion to an alternate airport.

The comparisons in this study suggests that the use of Australian rule sets alone to assess the risk of deteriorated weather at a destination airport by themselves does not ensure a level of safety as described in the International Civil Aviation Organization Continuing Airworthiness Manual. The fact that there have been very few serious incidents or accidents associated with landing at a destination with unforecast deteriorated weather, suggests that one or more other factors are also reducing risk. From this it may be suggested that although other risk mitigants appear to be effective, they may not be known or consistently managed.

ATSB document: Destination Weather Assurance, Risk associated with the Australian Operational Rules for Weather Alternate Minima, page VIII

The assumption that "timely en-route warnings" will be passed on to crew(s) as a mitigator goes to the heart of this incident, I also note this document was published in 2006.

So yes, a decade ago this excellent paper was produced??  

From the executive summary:

...A comparison for these results was achieved from a survey of the Australian Transport Safety Bureau occurrence database, which found 62 occurrences in the nine years leading up to the end of 2004 where unforecast destination weather degradation had been a contributing factor to the occurrence. The occurrences were sorted by reference to defences that were appropriate to the occurrence.
 
The comparisons in this study suggests that the use of Australian rule sets alone to assess the risk of deteriorated weather at a destination airport by themselves does not ensure a level of safety as described in the International Civil Aviation Organization Continuing Airworthiness Manual. The fact that there have been very few serious incidents or accidents associated with landing at a destination with unforecast deteriorated weather, suggests that one or more other factors are also reducing risk. From this it may be suggested that although other risk mitigants appear to be effective, they may not be known or consistently managed.

200404385 Boeing 747-438

The aircraft landed with insufficient fuel due to unforecast fog at the destination. Prior to departure, weather forecasts had indicated that the carriage of extra fuel was not required.

ATSB Summary

Following an unforecast weather deterioration at the destination, the aircraft diverted to an alternate destination and landed in weather above the landing minima, but below the minimum fuel requirement.

And the conclusion:

...Aircraft accidents associated with IFR flight into unforecast deteriorated weather at the destination are very rare. The effectiveness of the procedures that exist to ensure that a pilot does not encounter unforecast deteriorated weather at the destination does not explain the associated lack of accidents, but other risk mitigators are probably proving effective. It is possible that conservative decision making by flight crews, consuming fuel reserves to reach an alternate and conducting successful instrument approaches in weather conditions that are below landing minima are some of the mitigators that have been effective. However, these mitigators have not been assessed in this study.
   

199906031 Boeing 737- 376

On the basis of the weather forecast that was available prior to departure from Perth, the crew of B737, VH-TAW had planned to arrive at Melbourne without extra fuel. The crew received weather reports during the flight indicating that the weather at the destination was worse than forecast. On arrival at Melbourne, the weather was found to be such that there was a requirement for the aircraft to be carrying extra fuel. The aircraft landed without incident at 11:34 eastern summer time.

The Bureau of Meteorology reported that at the time of the occurrence a high pressure system was located in the Great Australian Bight. This resulted in a moist southerly airstream being directed over Victoria. However the low cloud, showers and drizzle associated with the moist airstream were expected to clear by mid to late morning because of drier air moving into the area from the south. The arrival of the drier air was later than anticipated, and reduced visibility in drizzle fluctuated around the alternate minima until 13:00 hours. The forecaster, being aware of the operational impact of his decisions, considered that a trend of INTER was sufficient to cover these fluctuating conditions. However, between 11:00 and 13:00 conditions were below the special alternate minima. The timing of the arrival of the drier air was critical in the situation. Unfortunately, neither the data network nor the forecasting skills were adequate to facilitate forecasting of a cloud base to within a couple of hundred feet when the cloud base was fluctuating around the alternate minima. The Bureau of Meteorology advised that it would have been more prudent to trend alternate conditions until there was clear evidence that the drier air had reached the airport. Following the occurrence, the Bureau of Meteorology issued a recommended preventative action to prevent further recurrence

ATSB Summary

Following an unforecast weather deterioration at the destination, the aircraft landed in weather above the destination landing minima.

Since reading that report I have gone over my records and the Senate Pel-Air publicly available documents tabled/submissions webpage. There is no mention or copy of the ATSB 2006 that I can find; nor could I remember any Hansard mention made or reference since despite repeated historical reference to other related matters. Like for example the O&O'd 2000 ATSB safety recommendation to the BOM on the reliability of forecasts at Norfolk Island -  R20000040.

These ATSB research reports are painstakingly compiled in order to maximise the potential safety risk mitigation. From introduction of B2004/0246:

The aim of the Australian Transport Safety Bureau (ATSB) is to help maintain and improve transport safety. The ATSB investigates aircraft occurrences (accidents and incidents) in order to identify the factors that contributed to an occurrence and to seek to prevent a recurrence. The ATSB also conducts research into matters that affect or may affect safety.

Aviation safety can be enhanced by aiming to seek for a known and provable zero frequency of all factors of a flight that may compromise its safety. Such safety-critical aspects are sometimes independent (such as the reliability of power sources, wing structural integrity and navigational fidelity), and therefore the level of safety of the whole flight may be no more reliable than the least reliable safety-critical aspect of the flight. The safety of a flight may be only as strong as its weakest link.

Historically, transport aircraft operations have been demonstrably successful in identifying and controlling safety-critical risks. However, effective analysis can often be difficult because analysis of the probability of a specific risk is very low, therefore secondary indicators, such as the use of processes for protecting against risk, may be used to imply a relationship with risk.
 

A worthy objective and very much in line with the principles as outlined in ICAO Annex 13 (& now Annex 19). However six years later we get the PelAir report aberration and a decade later we now get the - total bollocks - Mildura duck-up report, neither report even references the 2006 research paper (although the Mildura FR did mention under tests & research some of the historical occurrences also covered by B2004/0246). And in light of those two examples (PelAir, Mildura), I would strenuously argue that we have not progressed in anyway in mitigating the related safety issues and if anything we have actually gone backwards.

One final coincidence/irony of the 2006 report, is that one of the co-authors is a M Watson, the IIC for VH-NGA was a Mike Watson - what are the chances that the ATSB had two TSIs that were called M Watson??

MTF...P2

[Kharon]

All’s well that ends well.

There, for mine. is the rub.  The Mildura episode, happily ended with not even a scuffed tyre or a band aid on a passenger.  It is a classic example of superior skill being required:

“A superior pilot uses his superior judgment to avoid situations that would require the use of his superior skills."

But the underlying implications are not considered by the ATSB non report; both aircraft should have had the infrastructure and approval to allow the use of low visibility training and equipment.  Had those elements been available, it would have been just a ‘routine’, albeit rare day where a low visibility landing was needed. However that facility was denied, so off they sail to Mildura to meet the daemon fog with even less fuel and less facilities, so it’s now a shit or bust situation, which ended well.  The ATSB do their thing and all is well, no one to blame, just a series of unfortunate holes in the cheese.  

Had the unthinkable happened; even a runway overrun, the airframe damaged, and passengers hurt do you think the ATSB report would have been so benign?  You know damn well it would not; 

Cover page - First safety message. Pilots are reminded of their responsibility for collecting all relevant information to support inflight decision making...

This ATSB report is quite Freudian in the way it exonerates each and every point of liability for the various ‘agencies’, BoM off the hook, CASA off the hook, airport off the hook, ATC off the hook, company off the hook etc. even the flight crew escaped.  But had there been a different outcome; then all but the flight crew would have wriggled away, off the hook.

IMO, when something as vital and as relied on as a weather forecast has a 70% chance of being inaccurate, the responsibility must be a joint one, blame shared between those who make the rules, offer the forecast, provide the infrastructure and pass timely advice to flight crew.  Had the crews involved been advised at any point during the holding time or before divert time, that Mildura was socked in there would be no need of this ATSB report. Had Adelaide provided first world facilities, same again. Had CASA approved low visibility as a routine practice for all, same applies.  

Broad strokes I know, but the point is this incident carries a shared, joint responsibility for all involved. It ended well, but had it not only the flight crew would be hung out to dry, even the FO has some wriggle room, but for PIC the full weight of agency self protection and the law would have been against.  I don’t reckon that is either fair or reasonable.

BS – “The full report is another matter. It will no doubt cause controversy in pilot ranks and more than a little concern as to whether Australia is actually capable of dealing with serious issues in air safety regulation and investigations at all, but it doesn’t on first reading on the other side of the world, do anything more offensive than trying to bury them from coming to the attention of inquiring minds.”

Aside, that 2006 report is a cracker, Watson on song.  I wonder what NX or Fawcett would have made of it; had both Watson and it been made available for the Pel-Air pantomime.

Aye, Hoody has his work cut out for him, let’s hope his first act is to acquire a sharp axe.  He knows which heads must roll, but will he swing it?  That boys and girls is the first and only question which matters.

Toot toot.

[Peetwo]

Hoody the ATSB & back to Reason? 

P9 - Aye, Hoody has his work cut out for him, let’s hope his first act is to acquire a sharp axe.  He knows which heads must roll, but will he swing it?  That boys and girls is the first and only question which matters.

 
Excellent rant "K", totally nailing the Hoody conundrum, if he doesn't act quickly and decisively on taking the Chief Commissioner role, I fear that the ATSB is inevitably doomed to irrelevance & eventual disbandment.

Quoting again from the UP, 'IsDon' pretty much mirrors a lot of the "K" sentiment and takes the dichotomy a step further by joining the dots with the PelAir debacle   :

IsDon - ..If you have experienced yet another display of incompetent forecasting by BoM and the field is below minima for longer than 60 minutes then, with nowhere else to go, you're committed to land regardless of the minima.


That said, expect the Monday morning quarterbacks (ATSB) to pillory whatever decision you make based upon airmanship and the best information you have available at the time. Especially if doing otherwise might actually find the route cause of the issue and that route cause may lay the blame squarely at the feet of Airservices Australia or BoM or some other government organisation that might be an embarrassment to some politician somewhere. How long has it taken for this report to come out, three years? How long did the pilots on these aircraft have to make their decisions? 15 mins? Maybe less.

The discussions here so far have missed the main point of this incident. I find a lot of similarities with the ATSBs handling of the disgraced Norfolk Is investigation and report on this incident. In both cases the ATSB has deliberately attempted to deflect any blame from BoM, CASA, Airsevices or any other government agency and has tried, and failed, to blame the crew.

It wasn't so long ago that the ATSB was formed. It was perceived, at the time, that CASA had a conflict of interest when it came to investigating accidents and incidents as it may seek to hide any blame possibly attributable to its own failings. Fair enough that an independent organisation should be tasked with that responsibility. This incident, and the Norfolk Is debacle, have demonstrated that the ATSB has a way too cosy relationship with other government entitities and will seek to deflect blame from them at all costs. Including destroying the reputations and careers of the crews involved.

Time for the ATSB to go.

And if anyone is of the misconception that Mildura & Pel-Air are merely a 'two off' aberration, please refer to O&O posts 61 to 63. In particular the P9 post - A Sunday rant. (My turn). - where "K" again makes a systematic 'nuts & bolts', no bollocks analysis of both the occurrence & the ATSB (top-cover) report:

P9 - The common threads are easily discerned, but even this latest pathetic report tries to hint at pilot error.  It is a good thing that the ATSB do not apportion blame; but they do hint at it.  Why?, well, another common factor is the sacred cow of the BoM, who only need to be within +/-70% accuracy of actual in their forecast (from memory) to be off the hook.  This level of accuracy has little intrinsic or practical value to a pilot.  In court the responsibility will all fall to the pilot, everyone else has wriggle room and bolt holes, all except the poor mutt in the dock...  

 
&..

..It’s a trend and ATSB should be screaming from the roof tops, demanding something be done to reverse that trend.  Do they? No sir, they do not.  We get presented with a snide, trite, puerile little report which tries to shift the spotlight off the piss poor service to the travelling public delivered by our expensive ‘safety watchdogs’.    

  
&..finally.. :

Routine, bog standard, sensible operating practice.  The rules and the BoM failed the public yet again, with everyone off the hook except those burned alive.  It is high time the ATSB started bringing this trend into focus instead of drafting a carefully prepared, prejudicial statement for prosecution use...

So back to the Hoody conundrum??

Q/Can Hoody drag the ATSB back to Reason? And/or has he even been tasked to do so?

From the government's point of view why would you persevere with a severely discredited, obviously not independent, government agency that is not fulfilling its primary purpose as a transport safety watchdog?

Might as well save the taxpayers $30 million +/- annual running cost of the ATSB, farm the ICAO Annex 13 AAI role to a private organisation, like a Flight Safety Foundation; or an ICAO approved regional (Asia/Pacific) AAI? 

It will be interesting to see which way Hoody jumps but for mine the Mildura Fog duck-up final report should provide the full stop to an era (more than a decade) where the ATSB severely lost their moral (Annex 13) compass - SOB?; or SOB? (sacrifice our bureau or save our bureau )   

P9 - "..The Beyond all Reason methodology and those that espouse it are not only becoming an international embarrassment, but part of the causal chain..."

The clock is ticking and the ATSB is still very much part of the causal chain...tick..tick..tick




MTF...P2

[Kharon]

The shell game.

You know the one; under which of the three shells is the pea hidden?  You also know, full well, if you are more than 5 y.o that you can’t win.  Trying to locate someone or a department which accepts any responsibility – for anything – is an even harder game to win.

"..The Beyond all Reason methodology and those that espouse it are not only becoming an international embarrassment, but part of the causal chain..."

"Those who do not learn history are doomed to repeat it." The quote is most likely due to George Santayana, and in its original form it read, 'Those who cannot remember the past are condemned to repeat it’.

[Kharon]

Right then. Steam – On.

P2 - "So back to the Hoody conundrum.  Q) - Can Hoody drag the ATSB back to Reason? And/or has he even been tasked to do so?"

I wonder what it would take to make the parliament and the travelling public realise the importance of the ATSB and the need to make it not only independent and impartial but unimpeachable? The world and it’s wife (including CASA) think CASA is the cornerstone of aviation safety.  The simple answer is, that it is not.  CASA is a regulator, not an investigator – unless you count persecution and prosecution as ‘accident investigation’.

When, as they do, ‘things’ go pear shaped, it is essential that industry fully and completely know why.  It has been demonstrated, so many times, that the bang heard at the end of a long chain of events is only the end part of the cause. Often the real reason, the James Reason if you like , if known could have prevented the 'Bang'.  So we now have the Mildura report; the airlines involved have undoubtedly ‘fixed’ things; or at very least buffed and patched their existing system to prevent a repeat. 

ATSB is no doubt delighted to have the airline not only remedy the ‘problem’ but remove the responsibility for ‘the fix’ from ATSB and CASA and ASA and the BoM.  It provides the perfect platform from which not only need nothing be done, but nothing more needs to be seen to be done.  Great init.

It’s a bollocks, an expensive, useless, farcical, wasteful, cynical, government supported, publicly funded bollocks.

ATSB need to be independent, need to have competent leadership and need to serve the needs of the Australian travelling public.  I, for one am heart sick of watching this illusion; this magic trick which deceives the gullible and robs the tax payer continue, unchecked.  

Words for Greg Hood: It won’t be a stylish marriage, we can’t afford a carriage, but you’ll look sweet, up on the seat. of a bicycle built for two.  Translation, we are out of patience, time and money the honeymoon period will be brief, after that it’s brutal reality; no holds barred.

[Peetwo]

O&O investigation No. AO-2014-032 

Today the VARA ATR Birdstrike/Pitch disconnect accident investigation was somewhat strangely updated with an interim report, the reason being that after 847 days the ATSB have identified a significant safety issue:

Inadvertent activation of the elevator control system - pitch uncoupling mechanism
Issue number:
AO-2014-032-SI-01
Who it affects:
All operators of ATR 42 and ATR 72 aircraft
Issue owner:
ATR
Operation affected:
Aviation: Air transport
Background:
Investigation Report AO-2014-032
Date:
15 June 2016
Safety issue description
Inadvertent application of opposing pitch control inputs by flight crew can activate the pitch uncoupling mechanism which, in certain high-energy situations, can result in catastrophic damage to the aircraft structure before crews are able to react.

Background to the safety issue

Initially, the ATSB was unaware of any other in-flight pitch disconnect occurrences on the ATR 42/72 series aircraft. As a result, the existing procedural risk controls were considered effective at maintaining a sufficiently low probability of a recurrence of the occurrence involving VH-FVR on 20 February 2014. As such, the ATSB did not initially consider that immediate safety action was necessary.

However, once aware of other in-flight pitch disconnect occurrences, none of which were because of a jammed system, it became apparent that the related procedural risk controls were not sufficiently effective. The likelihood of an inadvertent in-flight pitch disconnect has been demonstrated to be higher than the initial assessment suggested.

Proactive Action
Action organisation:
ATR-Gie Avions de Transport Régional
Date:
15 June 2016
Action status:

Released
Proactive safety action by ATR
As a result of this occurrence and a briefing from the ATSB on 5 February 2016 on the safety issue, ATR released an All Operators Message (AOM). The message informed operators of ATR 42/72 aircraft of revised maintenance and operational documentation relating to the pitch control system and pitch disconnect occurrences as follows:

Proactive Action
Action organisation:
Virgin Australia Regional Airlines and Virgin Australia Airlines
Date:
15 June 2016
Action status:
Released
Proactive safety action by Virgin Australia Regional Airlines and Virgin Australia Airlines[19]
Virgin Australia Airlines advised that, in response to this occurrence, they had taken action to reduce the potential for pitch disconnects and to manage the risk of adverse outcomes from such occurrences. These included:

• reviewing and revising (where necessary) policy and procedures associated with descent speeds, handover and takeover procedures, overspeed recovery and on ground pitch disconnects
  
• incorporation of a number of factors surrounding the event into training material and simulator checks
  
• improved pilot awareness through Flight Crew Operations Notices, manufacturer’s communications (All Operators Messages) and ongoing training and checking
  
• updated maintenance requirements following a pitch disconnect.
  

__________

1. Since the pitch disconnect occurrence, Virgin Australia Airlines had taken over operation of the ATR 72 fleet from VARA.
   

Proactive Action
Action organisation:
Toll Aviation and Toll Aviation Engineering
Date:
15 June 2016
Action status:
Released
Proactive safety action by Toll Aviation and Toll Aviation Engineering
Toll Aviation and Toll Aviation Engineering advised that, as a result of this occurrence, they issued a safety alert to their flight crew and aviation maintenance engineers. This alert advised that, in the event of a pitch disconnect, the aircraft was to be grounded until the appropriate checks had been carried out.
 


Last update 15 June 2016

Still trying to absorb & review the findings so far of this 
bizarre investigation, so definitely much, much MTF..

[P7_TOM]

Two bob’s worth, please!

This report is a real stinker.  The ATSB interim report, stand alone, is borderline -‘bizarre’ enough but; and it’s a big one, ATSB are only ‘focussing’ on the results stemming from the after the fact incidentals, i.e. the aircraft got broken, because the elevator channels became disconnected.  This is an easier escape route than analysing the true, radical of cause of why and how the aircraft became broken, in the first case. We knew that, without the 860 odd day delay to tell us so; honest, we did.   This is an easy, soft option for ATSB, through which ‘fault’ may be allocated ; i.e. to the crew.  But that is an after the event cop out, rather than an analysis of just what created a ‘sudden’, unsolicited speed increase. An increase which was beyond the ability of the FO to control, using ‘normal’ technique, i.e. power back and trim up.  Read the report – carefully.  The FO was in serious disagreement with an AP which was not, nor, perhaps would not be - disconnected; clear as day. Two hands, to correct a -4˚ pitch down to -2˚ down and a 10 knot speed reduction– gods spare me.  

So, apart from the easy option, the almost obvious crew ‘stuff-up’ (and some busted SOP), there is no service paid to, nor analysis to be made of the cleverly disguised pilot v autopilot arm wrestling competition, during which the very real, sinister damage was done.   Take a look at the ATSB picture provided, check the horizontal stabiliser – take a second, close look. The photo supplied says (under magnification) all that needs to be said.  Horizontal Stabiliser (HS) bent and twisted to buggery.  Compare it to the horizontal tail plane of the aircraft to the left (rear view) with that of the aircraft taxiing in.  One is level, the other clearly; and IMO, unmistakably ‘drooping’ below the horizontal.  Now who, you may well ask, would sign that aircraft out for more flight?  Probably a duty engineer, so what was he told?  Clearly, not too much.  But how could anyone miss ‘the droop’; and, what sort of crew would continue to operate an aircraft in such a condition – even if, after a cursory inspection, the engineer said it was fit; returned to service. The elevator channel ‘disconnect’ was an ‘accidental’ occurrence– a direct result of two pilots taking on an autopilot; which has not, as yet, been proven to have ever been actually ‘disconnected’.  Root cause, ala Reason, please; not the fluff and nonsense from ATSB telling us the bleeding obvious, not without offering realistic, believable resolution of the radical cause.    Cheers (and beers) the lad is paying his freight.

[Kharon]

Brass tacks.

It’s true, there was a honour debt to be paid having lost a bet.  Suitably lubricated and slightly alemazed, the ATR report became the topic of the evening.  Difficult to stay serious and focussed under those conditions, but we did manage to plough through the whole sorry thing.  One cannot trust notions formed in P7’s study, pint in one paw ATSB in the other, not safe; so as penance I have diligently revisited (as they say) this dreadful report.

There are on screen four pages of notes – which I intended to par down to questions for which I would like answers; questions which were not answered in the ATSB report.  Then I thought WTF – they’ll never be answered, so why bother. This ATSB report reminds me of the sort of thing a clever lawyer would do, when they wanted a thing that “may be relied on” brought in as evidence, but do not want the opposition to realise that it will be relied upon, heavily.

If you start at the very beginning of the report, the operational questions become immediately apparent.  Something created an unscheduled speed increase – what was it?  Then follow the actions taken and spot the errors; lots of – but no mention made. Think on, flight controls disconnected from the AP, good; power reduced a fraction, good; subtle pitch up, good; result, two hands needed to reef the nose up, without success – bad.  So what’s up? Solve that riddle and you can see where the merry pathway to ATSB duck shoving begins.

If, you thought the Pel-Air epistle was an aberration; a one off, think again.  This latest abomination, following closely on the heels of the Mildura aberration speaks clearly of the total shambles ATSB has become under Dolan.

Toot – toot.