(09-02-2016, 01:35 PM)thorn bird Wrote: Hot off the presses of BCA magazine.
It would seem that International attention is focusing on the Adelaide foggy foggy du duck up.
The interesting things to read from the comments on this article from around the world.
Many were incredulous that a low vis approach and auto land was not conducted at Adelaide. Good question, but these were from peers from first world countries. Perhaps the question should be why does Australia, purporting to be a world leading first world country, not have CAT 111 facilities at its primary airports? I could stand corrected but only Melbourne has CAT 111 facilities, and that only recently installed. There could be many possible reasons for this situation, I was flying low Vis operations back in the early eighties and they were not new then.
Could it be that our RAAF infested regulator way back then considered Low Vis was too dangerous for Australia to adopt and therefore refused to allow it? Back then they had teams running around the world surveying airports used by Quaintass to set minima's for them to use, so I wouldn't be at all surprised.
Or maybe since our airports were delivered to entities who's kudos was maximising profits from huge turnovers, to be siphoned off into tax free havens, thus preferring to build car parks than investing in Aviation Infrastructure.
Or this strange government policy that the user must pay and be damned to public safety and convenience, putting the onus on airlines either they pay, or do without, with the obvious consequence.
Ahh the land of OZ, only third world country where you can drink the water.
Quote from BCA:
Quote:Two Boeing 737-800s Bust Minimums At Australian Airport In Bad Weather
When busting minimums is the only choice
Aug 31, 2016 Richard N. Aarons | Business & Commercial Aviation
Comments 45
A Tale of Two Boeings
[/url]At the end of a remarkable chain of inaccurate weather forecasts and missed communications opportunities, two Boeing 737-800s operated by different Australian airlines had to bust minimums within minutes of each other at Mildura Airport to prevent really bad outcomes.
It all happened on June 18, 2013. Boeing VH-YIR, operated by Virgin Australia Airlines as Velocity Flight 1384, and Boeing VH-VYK, operated by Qantas Airways Ltd. as Qantas Flight 735, were on scheduled passenger flights to Adelaide, South Australia.
The story of what happened to these airplanes, crews and passengers is best told by the investigators of the Australian Transport Safety Bureau (ATSB).
Velocity 1384 departed Brisbane, Queensland, at 0638 Eastern Standard Time (UTC +10) with six crewmembers and 85 passengers on board. The estimated time of arrival at Adelaide was 0920. The captain was the pilot flying and the first officer (FO) was the pilot monitoring. The fuel on board at takeoff from Brisbane was 8,800 kg (19,401 lb.)This comprised flight fuel to Adelaide of 6,410 kg (14,132 lb.), variable and fixed fuel reserves of 1,540 kg (3,395 lb.) and additional fuel of 940 kg (2,072 lb.).
Qantas 735 departed Sydney, New South Wales, at 0727 and had six crew and 146 passengers on board. The estimated arrival time at Adelaide was 0917. The captain was the pilot flying, with the FO as pilot monitoring. The fuel on board at takeoff from Sydney was 7,900 kg (17,416 lb.). This comprised flight fuel to Adelaide of 5,000 kg (11,023 lb.), variable and fixed fuel reserves of 1,600 kg (3,527 lb.) and additional contingency fuel of 1,300 kg (2,866 lb.).
At 0700, the Bureau of Meteorology (BoM) issued an updated airport forecast (TAF) for Adelaide calling for a 30% probability of fog developing. At 0800, the BoM issued an updated trend forecast (TTF) that showed that fog had reduced visibility at Adelaide and was expected to clear by 0900.
At this stage, the crewmembers of Qantas 735 were aware of the changes to the TTF and continued to Adelaide on the basis that the fog would clear prior to their arrival. In addition, they had sufficient fuel to hold for about 45 min. should the fog last longer than forecast and land with required fuel reserves.
The pilots of Velocity 1384 were not aware of the changes to the forecast. They were advised of fog at Adelaide by ATC at 0844, once they changed to the en route sector frequency immediately prior to reaching the Adelaide terminal area airspace.
The crew of Qantas 735 elected to hold at waypoint Black, about 48 nm from Adelaide, rather than continue their descent to the airport, which was still affected by fog.
The crew of Velocity 1384 had commenced their descent to Adelaide and gathered further information about the conditions from the Adelaide tower controller. Based on the report from the Adelaide tower controller that conditions were not suitable for landing, and that there had been no successful landing attempts, the crew of Velocity 1384 elected to divert to Mildura, Victoria, at 0904.
The observation reports issued by the BoM at that time indicated that the conditions at Mildura were above the alternate minima for the aircraft, despite the TAF for Mildura indicating a temporary deterioration during the forecast period. The crew’s estimated arrival time at Mildura was 0932.
The crew of Qantas 735 heard Velocity 1384 broadcast their decision to divert to Mildura. On being informed by ATC that the latest trend forecast for Adelaide predicted a 30-min. delay in the fog clearing, and after gathering observation reports for Mildura, the crew of Qantas 735 also elected to divert there at 0913. Their estimated arrival time at Mildura was 0942.
In making the decision to divert to Mildura, the captain of Qantas 735 reported that they were aware that they had the capability to conduct an autoland at Adelaide Airport.
However, based on the reports of significantly better weather at Mildura, a diversion to that airport was assessed as preferable to continuing to Adelaide.
The captain of Velocity 1384 similarly reported that they considered the option of an autoland at Adelaide. However, given the observations of the better weather at Mildura, they also concluded a diversion was a better option at that time.
Arrival at Mildura
At 0916, the pilot of an air ambulance flight departing Mildura made a call to ATC that conditions were deteriorating. He reported the cloud base was at 400 ft. MSL. At the time, neither Velocity 1384 nor Qantas 735 were on this frequency and therefore did not hear this transmission.
At 0918, just after Velocity 1384 transferred to this frequency, the controller for this sector informed them of four other aircraft due to arrive at Mildura around their arrival time. This included Qantas 735. At 0922, Qantas 735 transferred to the same frequency and was advised of the arriving traffic.
Also at 0918, the BoM issued a SPECI (special weather report) for Mildura, showing clouds at 200 ft. AGL but visibility in excess of 10 km (6.2 mi). The Mildura RNAV GNSS instrument approach to Runway 27 required pilots to be clear of cloud at a minimum of 660 ft. (493 ft. AGL), reducing to 560 ft. (393 ft. AGL) using an actual airport QNH (altimeter setting that shows airport ASL elevation when the airplane is on the ground). As the conditions had deteriorated below these minima, the RNAV GNSS approach could not be conducted in normal operations. The airport forecast for Mildura, valid at that time, contained a temporary deterioration with cloud at 600 ft. AGL.
Between 0928 and 0932, three further SPECIs were issued for Mildura, indicating that visibility was decreasing in mist. As the Automatic Weather Information Service (AWIS) for Mildura was out of service, the inbound aircraft could not obtain this information from the AWIS.
At 0936, the controller made a broadcast on the area frequency to traffic at Mildura, informing them of the details of the 0932 SPECI. This SPECI indicated broken cloud at 200 ft. and visibility of 2,100 meters (6,890 ft.) in mist. A review of data from the cockpit voice recorder of Velocity 1384 identified that, for the duration of the controller’s broadcast of the SPECI, the crews of Qantas 735 and Velocity 1384 were busy communicating on the Mildura common traffic advisory frequency.
At 0937, the crew of Qantas 735 contacted the crew of Velocity 1384 to discuss the arrival and the crew of Velocity 1384 stated that they were tracking to the initial waypoint to commence the RNAV GNSS approach to Runway 27.
At 0939, the crew of a QantasLink Bombardier DHC-8 (Dash-8) aircraft broadcast to traffic at Mildura that they were conducting a go around. The crew of Velocity 1384 asked for an assessment of the weather and were told by the Dash-8 crew that at the minima, they “couldn’t see anything.”
At 0940, the crew of Qantas 735 contacted Velocity 1384 to advise that they were commencing the RNAV GNSS approach “due fuel.” The Velocity 1384 FO replied that they were “in the same boat,” but, after discussion between the captain and FO of Velocity 1384, they elected to hold and allow Qantas 735 to continue with the approach. This decision was passed on to the crew of Qantas 735.
The crew of Qantas 735 applied a revised minimum to the approach that was 200 ft. lower than that published. This was based on the knowledge that the cloud base would preclude becoming visual via a normal approach. The crew reported that as they descended toward the revised minimum, the extent of the cloud reduced and they gained sufficient visual reference of the runway environment to continue the approach. At 0946, the crew of Qantas 735 broadcast that they had landed at Mildura. The aircraft landed on Runway 27 with the required fuel reserves intact, and the crew reported that the runway was visible once they descended below the cloud.
At 0948, the crew of the Dash-8 asked Qantas 735 for their assessment of the weather.
The crew replied that the cloud base was at 150 ft. AGL and that they had landed off the approach “due fuel.” At this time, a SPECI was issued for Mildura, showing visibility was now 900 meters (2,953 ft.) in fog and that the cloud was overcast at 100 ft. AGL.
At 0950, Velocity 1384 sought an update on the weather from the Qantas 735 crew, who stated that the fog had appeared to be getting thicker but was now clearing, although the cloud was still below minima.
At 0952, Velocity 1384 updated ATC that they were still holding due to the low cloud at Mildura. ATC asked them to nominate a latest divert time to proceed to a suitable airport.
The FO replied that they did not have the fuel to proceed anywhere else. After obtaining further information from the crew, ATC initiated an alert phase and at 0958, after contacting the crew again, ATC activated the Mildura Airport emergency procedures.
At 0954, the controller made another “all stations” broadcast with the latest TAF issued for Mildura, valid from 1000. This forecast predicted:
Visibility of 3 km (1.9 mi.) in mist;
Scattered cloud at 300 ft. AGL;
An improvement in both visibility and cloud base in the hour from 1000;
A 30% probability of the visibility reducing to 500 meters (1,640 ft.) in fog for the period between 1000 and 1200.
Given their available fuel, the crew of Velocity 1384 determined that they needed to commence an approach just after 1000 to allow for a second approach if needed. They discussed conducting a “sighting” approach to ensure the aircraft was aligned with the runway from the RNAV GNSS approach. The captain was still the pilot flying; however, they briefed that if at any time during the approach the FO sighted the runway, then the FO was to take control and land.
At 1002, Velocity 1384 transmitted that they were on a 4 nm (7 km) final for the RNAV GNSS approach. At 1004, as they were not visual with the runway, the crew initiated a missed approach from 132 ft. AGL. The FO reported that as they commenced the missed approach, it was possible to confirm that they were aligned with the runway by looking directly down. At 1012, ATC initiated a distress phase.
The aircraft was positioned for a second approach, during which the cabin crew were briefed and prepared for an emergency landing, briefing the passengers to brace accordingly. At 1014, Velocity 1384 landed at Mildura in foggy conditions with fuel below the required reserves. As they taxied in, the captain told the cabin crew to stand down and normal arrival procedures resumed.
The Investigators’ Analysis
Following months of investigation, the ATSB observed that the Australian aviation weather reporting, forecasting and distribution systems are world-class but could use improvement. Company flight watch services at both air carriers are usually reserved for long-haul flights, leaving short-haul flight crews with the responsibility to pursue weather updates on their own once they are dispatched. In this situation, the observations and forecasts were changing quickly and information on Adelaide weather (and later Mildura’s weather) just didn’t form a picture for the crews in time to avoid the below-minimums approaches. The ATSB is suggesting further studies by Australian aviation civil and government agencies to see if improvements can be made.
The Safety Bureau looked at decision-making in each cockpit and ultimately found that the pilots made reasonable decisions including the decision to bust minimums.
ATSB Safety Issues
Ultimately, the ATSB identified a series of “safety issues.” Also, as a result of this investigation, the Safety Bureau initiated a research investigation that will “initially examine the reliability of the airport forecasts for Mildura and Adelaide, before expanding to cover other major Australian airports.” The idea is just to see where the system can be improved.
According to the ATSB, a “safety issue” is an event or condition that increases safety risk and (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organization or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time. Here are the safety issues that arise from this event.
The meteorological conditions at Adelaide Airport deteriorated below the landing minima while Velocity 1384 and Qantas 735 were en route to Adelaide.
The inaccuracy of the forecast clearance of the fog at Adelaide Airport compelled the flight crews of Velocity 1384 and Qantas 735 to either conduct an emergency landing at Adelaide or divert to Mildura Airport.
The actual weather conditions encountered by the flight crews of Velocity 1384 and Qantas 735 on arrival at Mildura were below landing minima and significantly worse than the airport forecast and weather reports used by both flight crews to assess its suitability as an alternate destination to Adelaide.
On arrival at Mildura, Velocity 1384 and Qantas 735 had insufficient fuel to divert to any other airport and were committed to a landing in conditions below their landing minima.
For many non major airports in Australia, flight crews of arriving aircraft can access current weather information using an Automatic Weather Information Service via very high frequency radio, which has range limitations. Where this service is available, air traffic services will generally not alert pilots to significant deteriorations in current conditions.
Other factors that increased risk:
The flight crew of Velocity 1384 did not obtain updated weather information for Adelaide while en route and were therefore unaware of the weather deterioration affecting the airport, limiting the options and time available to plan a diversion to an alternate destination airport.
The flight crews of Velocity 1384 and Qantas 735 gave precedence to the airport weather reports at Mildura over the airport forecast when deciding to divert.
Despite the Bureau of Meteorology (BoM) knowing of the deteriorating weather at Mildura from other sources, by not passing on the inflight weather report of deteriorating weather from the departing air ambulance pilot, the controller removed an important source of information for use by the BoM.
The inflight weather report given by the air ambulance pilot was not passed on to the flight crews of Velocity 1384 and Qantas 735 by the controller when they changed frequency in bound to Mildura Airport, removing an important source of information for flight crew planning and decision-making.
The automatic broadcast services did not have the capacity to recognize and actively disseminate special weather reports (SPECI) to pilots, thus not meeting the intent of the SPECI alerting function provided by the controller-initiated flight information service.
Last Thought
These crews were led into a subtle trap when all tolerances added up unidirectionally, leaving only their exceptional airmanship to save the situation. However, the investigation does make the point well that pilot skills must include a high degree of skepticism when evaluating weather information and forecasts when marginal weather is forecast.
This article was originally published on July 29, 2016
(09-03-2016, 11:56 AM)ventus45 Wrote: A "cheap" way of providing an instrument landing system at regional airports ?
http://web.archive.org/web/2010111912543...re2008.pdf
http://www.icasc.co/ifis-documents/12th-...is-papers/
(09-03-2016, 01:30 PM)thorn bird Wrote: Looks like a very cost effective solution Ventus....except!
By the time Australia's regulator got through with certification
the "Australian way" the thing would cost perhaps ten times what it
costs off the shelf and by the time they got it up and running there would
be something new in the market.
Our regulator is still back in the days when a guy stood at the end of the
runway with a table tennis bat in each hand.
Quote:CarmineRed
on Aug 31, 2016
Admaonfr
You do realize that Autoland systems themselves have minimum visibility requirements that can limit their usefulness, along with company/flightcrew certification issues that govern the decisions on its use ? I dont think these factors were adequately covered in this brief, so your jumping on their throats like that is unwarranted and your blind faith in autoland systems being able to recover any aircraft regardless of mitigating circumstances is naive.
What we have today in aviation is a strange dichotomy where often the passengers have nearly unlimited access to inane information via Internet connection and the flight crew up front is stuck with receiving updates on VHF just a few minutes prior to reaching their top of descent point (that was the case with Velocity 1384, anyway).
In both cases, the crews acted reasonably well given that most "decisions" in flying are actually educated guesses informed by inputs from myriad sources and coalescing into a plan of action in the minds of the Flight Crew.
Their decisions were arrived at after careful thought and colored by years of previous experience and training--a depth of data that you, Sir, do not possess in anywhere near their quantity.
To say nothing of the fact that they process all this under pressure of time and with the knowledge that stakes are high, with bad decisions easily snowballing into disasters. These pilots decided, to their credit, to err on the side of what they thought was caution...events proved otherwise, but through no fault of their own.
Technology has evolved to the point now where there should no longer be any reason for pilots to have to struggle with stale information obtained often times hours prior to departure and updated sparsely and randomly in hit or miss style, as we had happen here. Information relevant to the flight could be instantly and automatically presented without the need for query on anyone's part. Data on developing trends in visibility, TCUs, precipitation, runway conditions Alert areas and so on could be made easily accessible and digestible to optimize decision making.
Though we live in a wired world, I maintain that aviation is its last holdout and yet the place where connectivity would pay huge safety and even economic dividends.
If we are really serious about safety, a simple and inexpensive augment to all the approach aids and procedures now in place (ie: the final component that would seal completely the current safety gap in low-vis operations)--would be to have a FLIR image displayed on a basic, no nonsense HUD, essentially turning the worst conditions into just another Visual Landing.
Such systems are mature, inexpensive (trivial really, vs the cost of said inflight entertainment systems, for example) and would, in wide use, have the same revolutionary impact on safety that introduction of GPWS has had.
Finally, my hats off to both crews for a job well done.
yarbros@comcast.net
on Aug 31, 2016
As I read the first comments about the autoland capability I thought, "Don't these people know that autoland has minimums too?" If you are faced with minimums at your destination that are below your autoland limits then you are required to either hold there or go to an alternate airport. They chose, based on the data they were given, to go to an alternate. This is exactly the way it is supposed to work. The fault lies with the BOM and the controllers who did not pass onto the crews the updated weather report and the pilot report from the air ambulance. Some of you who are not pilots seem to jump to the conclusion that autoland is a zero/zero option which it is not. That is not to say that knowing the way it worked out the crews would have much preferred the autoland option at Adelaide than the non-precision approach at the final destination airport. In the real world, this is known as "Hindsight". These two crews did a magnificent job and should be highly praised for their professional skills.
Capt. Sterling
on Aug 31, 2016
carmine red -
I agree with you totally sir.
you said in words what my mind was thinking through the process.
my only other thought you didn't mention is my constant thinking that "Thank God ATC is NOT the PIC of an aircraft. (neither is the damnable FAA)".
.
thank you sir.
cjrp@att.net
on Aug 31, 2016
CarmineRed has put it in well. Kudos to both crews on a job done well.
I am sure some of both airline's SOPs have been changed after these incidents. It would be illuminating to find out what they are!!
Conrad
a small cargo pilot, check airman and instructor in the US
mack@solidthink...
on Aug 31, 2016
This could be a great case study of DQ (Decision Quality): "the quality of a decision at the moment the decision is made, regardless of its outcome." It gets into judgement, relative skill levels, what did they know and when did they know it, SOPs, and the trust of automation.
stoof59
on Aug 31, 2016
CarmineRed, totally agree with you. Just because their is autoland capability it does not mean that weather limits do not play in to it.
At my airline, our 737NG's are autoland CATII capable. Qualified crews can use it to 100 ft and RVR of 1300. Adelaide reported that there had been no successful landings. Autoland would not have helped.
user-2309032
on Aug 31, 2016
Carmine red has it the most correct. It was a perfect storm of bad and slow info that led them into this subtle trap but they were doing what they always do which is to error on the conservative side. The tower controller at Adelide said the landing was not possible and no one had made a successful landing. The decision to divert to an alternate RIGHT AWAY or holding for a short time to gauge the trend while you have safe fuel is a very understandable decision and expected. Not getting timely info from the pirep from the commuter plane and an updated forecast on the TREND was a contributing factor also. We do need IMMEDIATE weather info available to us by our own means as you can see that the handoff to different frequencies also allowed valuable info to be missed. As always, it is chain of events that leads to an incident/accident and there was certainly a long chain occurring here. That adage of "a superior pilot never puts himself in a situation where he HAS to use his superior skills to get himself/herself out of it" applies here but only to the required action to provide a safe result. The pilot made sound decisions to keep the thick margin of safety based on THE INFO THAT WAS AVAILABLE TO THEM AT THE TIME. I see this as more of a systemic issue rather than poor judgment on the aviators involved. JB Cap, B-787
xairbusdriver
on Aug 31, 2016
I flew for a very safety-aware company and never had to explain why I called for "extra" fuel (Internationally or Domestic). I suspect these crews will always have "extra" fuel from now on. Hopefully, this is one 'event' that didn't have to end in deaths for changes to be made. Thankfully, it appears that attention has been raised in the appropriate places!
DB
on Aug 31, 2016
Before you jump to criticise, have a look at the airfield charts, available from airserviceaustralia.com. The only ILS approach at Adelaide is on R/W 23 and has a DA of 270ft (250 AGL). So although approved for auto land it can only be used in Cat1 conditions. So these crews had the choice of flying an ILS, either manually or with auto land to land below limits at Adelaide, or diverting to their approved alternate where the weather was believed to be above limits for an RNAV approach. With 40 years experience I know where I would have gone, and it wouldn't be the Adelaide solution.
wayne.mccandles...
on Aug 31, 2016
This case (befalling 2 crews) suggests that fuel reserve criteria need to be revisited. Geography and weather might dictate that reserves can only be consumed in hopes of "waiting out" improvement in weather at the only airports you can reach. In the U.S. context, imagine a storm blanketing east coast airports from Washington DC to Boston. If you planned on landing at JFK, you'd have endurance to reach Boston, Washington, Philadelphia, etc., and maybe even some loiter time for a short hold, but eventually you'd eat your reserves and have to cme down ala Avianca flight 52 in 1990.
nfn21976@naples.net
on Aug 31, 2016
Two first world air carriers dispatched two modern aircraft to a foggy airport with 5400 and 6400 lbs. of alternate and reserve fuel when the alternate has only a 6000' runway, no precision approach and apparently no tower ( radar ) and had an obviously narrow temp-dew point spread. Captains you need to earn your money and say put another 10,000 lbs. on. The article doesn't say if the RNAV approaches were coupled. They were all skilled and lucky. If they'd each had another 5000 lbs. on they wouldn't have been lured into this. I flew the old DC-9 that at only two thirds the MGTOW had the same fuel burn. Five and 6,000 lb reserves were for day VFR arrivals.
Ingelsrw
on Sep 1, 2016
The decision to divert, in this case, is based on the fact that neither aircraft had enough fuel to make an approach at the destination, go "missed", and then proceed to the "alternate" and land with enough fuel remaining. Both crews reached the same decision: Better to divert early and land with a safe fuel reserve.
Just Watching
on Sep 1, 2016
Why were these supposedly 'modern' aircraft equipped with such low specification systems? Autoland should mean precisely that, the HS Trident could, and did, perform Cat 3C zero/zero landings 50 years ago (4th Nov '66). Any explanations as to why the step backwards in capability? Other than 'bean counters' 1 passengers and crew 0!
Rex Booth
on Sep 1, 2016
One needs to understand the Australian rules. Auto land is only certified on two runways in the whole country, Sydney and Melbourne. Of course it is available on a CAT 1 runway for training or in an emergency.
Australia does not require fuel planning to an alternate unless TAF at destination is below alternate minima.
[url=http://aviationweek.com/users/nfn21976naplesnet]nfn21976@naples.net
on Sep 2, 2016
That explains a lot. Maybe it's time to qualify more Cat III and look at the fuel rules. I never understood why there were any minimums for Cat III auto-land except enough to get off the runway. Infra-red camera's on the nose gear would suffice
Quote:Personally I think this could be applied across a much wider spectrum of the Federal bureaucracy and is systematic of more than a decade of successive poor governance and direction at an executive government level, Sandy dubs it the 'Canberra disease' and Ventus reckons it is a syndrome i.e. "acquired institutionalised ostrichitis syndrome" (AIOS).
Quote:Tail strike suspected
12:00amEAN HIGGINS
A Singapore Airlines plane flew on from Melbourne to Singapore despite being told it had struck its tail on takeoff..
Quote:Probe into ‘tail strike’ flight
12:00amEAN HIGGINS
The air crash watchdog has launched an investigation into a now confirmed ‘tail strike’ at Melbourne airport...
Quote:..In 2009 at Melbourne airport, an Emirates Airbus A340-500 struck its tail three times, and sustained $100 million damage as it barely cleared the airport boundary fence before returning to make an emergency landing...
- I too had recently referred to that accident in a Mount NCN post:Quote:Safety loops, trends & disconnections?
Quote: Wrote:Kharon: "..So to the 717 crew and their wee problems; how deep do we dig? Is the fix presented adequate to task? Has the ATSB done enough to cure the problem? Can this be classed as an ‘operational’ matter? The rational way to answer is to examine one factor only – can this happen again? The answer to that is a resounding absolutely. The loop remains open.."Nail on head "K" but this is not an isolated occurrence aberration, these are well documented repetitive operational safety issues. Yet the ATSB don't seem capable of even joining their own dots, which perhaps is best reflected in the fact that this occurrence was 'desktop' investigated and discretely hidden away in the latest ATSB SIB - WTD..
IMO if the ATSB had of join some of their own dots, they would have spotted a growing trend of similar incidents/accidents that potentially point to similar/identical contributory factors.
:Quote:Quote:ATSB jumped gun on MH370[img=0x0]http://pixel.tcog.cp1.news.com.au/track/component/author/0573acb566bb47c45e64e4c55a998aba/?esi=true&t_product=the-australian&t_template=s3/austemp-article_common/vertical/author/widget&td_bio=false[/img]
12:00amEAN HIGGINS
The Australian Transport Safety Bureau was wrong to say it had consensus on a “death dive” theory for flight MH370.
The Australian Transport Safety Bureau issued a bulletin falsely claiming it had “consensus” from a team of international experts for its “death dive” theory that Malaysia Airlines Flight MH370 went down fast in a pilotless crash, before two overseas agencies had a chance to express a view.
The ATSB made the claim as its chief commissioner Greg Hood joined the Malaysian government and Malaysia Airlines in a media campaign to hose down an alternative “rogue pilot” theory that Captain Zaharie Ahmad Shah hijacked his aircraft and flew it to the end outside the search area chosen by the ATSB.
Internal ATSB documents obtained by The Australian show that while a senior investigator drew the incorrect “consensus” statement to the attention of colleagues only minutes after the bulletin was released, the organisation never issued a correction and instead secretly deleted the claim from its website the next day, after it had been widely reported internationally.
The ATSB repeatedly refused to say why it had deleted the “consensus” claim, and falsely denied doing so in a subsequent post.
Internal ATSB emails obtained under Freedom of Information statutes by The Australian reveal the truth behind the organisation’s media manoeuvres.
The revelations come amid doubts expressed by independent experts about the reliability of the Inmarsat satellite data the ATSB uses for its rapid descent assumption, and claims the agency has, to avoid embarrassing Malaysia, steered away from the “rogue pilot” theory.
MH370 vanished on a scheduled flight from Kuala Lumpur to Beijing on March 8, 2014, with 239 people on board. Its radar transponder was turned off and radio contact was broken.
Radar and automatic satellite tracking data indicate the Boeing 777 reversed course early in the flight, and flew along the Malaysia-Thailand border and out over the Andaman Sea before making a sharp turn south to end up in the southern Indian Ocean.
The ATSB designed the search zone based on its “ghost flight” theory that the pilots were incapacitated, and that after flying on autopilot, the aircraft came down quickly after running out of fuel.
In July, two developments led to international debate about the ATSB’s strategy.
Reuters reported the project director of the underwater search, Paul Kennedy of Dutch survey group Fugro, said the rogue pilot theory might be right after all.
“You could glide it for further than our search area is, so I believe the logical conclusion will be, well, maybe, that is the other scenario,” Mr Kennedy told Reuters.
The same weekend, New York magazine revealed a Malaysian police report indicated the FBI had determined Zaharie had charted a similar route on his home flight simulator.
Days later, the ATSB issued a bulletin in the name of the federal government’s Joint Agency Co-ordination Centre for the MH370 search, downplaying the rogue pilot theory.
The ATSB claimed in its July 27 bulletin the satellite data showed MH370 came down “most likely in a high rate of descent”. As originally released, the bulletin said: “This is indeed the consensus of the Search Strategy Working Group,” referring to experts including from the US and British air crash investigation.
The documents obtained under FOI show that just a few minutes after the bulletin was issued, an ATSB senior investigator warned colleagues by email this was an “error” and that the sentence should be taken down.
“It is certainly not yet the consensus position of the SSWG … 2 parties are yet to make a formal response on the subject,” the investigator said.
The email chain shows another ATSB senior investigator agreed and gave instructions for the sentence with the “consensus” line to be removed from the ATSB’s and the JACC’s websites.
But the ATSB did not retract the sentence until the next day, by which time it had been reported internationally, including in Malaysian and Chinese publications.
As earlier revealed by The Australian, the deletion of the “consensus” line was discovered by British aerospace engineer Richard Godfrey, a member of the independent group of aviation experts who on their own initiative have been reviewing the MH370 scientific data.
When, at the time, The Australian rang the ATSB spokesman who had issued the July 27 bulletin to ask why the deletion had been made, the spokesman hung up and JACC director Annette Clark declined to respond.
Subsequently, ATSB MH370 spokesman Daniel O’Malley and JACC chief co-ordinator Judith Zielke would also not say why the “consensus” line had been secretly disappeared.
When The Australian reported the deletion of the sentence, the ATSB issued a denial on its website, saying the report “falsely accuses the ATSB of ‘secretly retracting’ information”.
In a statement after it had been made aware of the FOI material, the JACC said: “The information was retracted when it was learned not all working group members had, at that stage, provided formal responses. Subsequently a consensus view was reached.”
Quote:Updated: 13 October 2016
The collection and analysis of a large volume of evidence for this investigation has taken longer than originally foreseen. However, the ATSB now has sufficient evidence to establish findings across a number of lines of inquiry. The ATSB is in a position to finalise a draft report which is expected to be released to directly involved parties by the end of the year. Subject to comments made during the draft report review process, the final report should be released publicly in the first part of 2017.
(10-14-2016, 08:44 PM)Sandy Reith Wrote: I've just been reading the ATSB updates on the updates, the number of same does not matter. What is clear is that the expected date of release of the final report to the public is always a few months hence. The longer the better because people die, get dementia, become careless and forgetful and generally tire of the whole sustained obscurant process. Spin it out long enough and even some of the instigating Senators will retire. This is what to expect out of 400,000 Can'tberrans from the most stratified, socialistic and souless capital city in the developed world. This no freehold, perfectly planned black hole tax sucking vortex of deceit and obfuscation is completely at odds with free enterprise, honest and careful work or sense of duty to the greater good. I'm afraid it is not just our aviation 'corporates', but other departments and Commonwealth bodies that I have had the misfortune to deal with. Sorry to say. The good old days were not that good but were much better in many ways. As Arthur Caldwell, then leader of the Labor Party and an honourable man, said, in farewell to Menzies, that in the Commonwealth public service under Menzies there was never even a hint of corruption.
(10-15-2016, 06:34 AM)kharon Wrote: Hoody and the Safety Piñata.
You’ve all seen ‘em; those supposedly ‘funny’ video shorts of kids, blindfolded, given a big stick, spun around until dizzy, then trying to hit an ‘elusive’ target they cannot see. They remind me of Hoody, trying to manage the ATSB, not only blindfold and dizzy, with NFI where to hit and the target being remotely controlled, he’s also handicapped by either handcuffs or blinkers; possibly both. Just a series of wild air swings, vainly trying to hit something.
The Pel-Air ‘aberration’ was not a single handed affair, although Hood would have gotten some blood spots on his hands while adroitly side stepping the main outflow; it must be said that he did, eventually, wake up to the unmitigated Cambers bastardry. But he was there and if anyone in this misbegotten saga knows where the skeletons are buried – Hoody does.
But he’s buggered for all money; now the self imposed handcuffs are golden and the blinkers fur lined. It is a strange, highly conflicted paradox^. Now, ostensibly ‘in charge’ of a reinvestigation of a matter in which, even by default, he is deeply involved in. Continuing to allow Walker to run the ‘investigation’ and continuing to side-line the invisible ‘Manning’ simply add another layer of doubt to an already murky picture. When the ATSB come out with a statement like this:-
../ Updated: 13 October 2016 : The collection and analysis of a large volume of evidence for this investigation has taken longer than originally foreseen. However, the ATSB now has sufficient evidence to establish findings across a number of lines of inquiry. The ATSB is in a position to finalise a draft report which is expected to be released to directly involved parties by the end of the year. Subject to comments made during the draft report review process, the final report should be released publicly in the first part of 2017.
/..a DDDDD minister may get a warm fuzzy feeling; the public will swallow it no worries; but what about the rest of the world who know, through study of the Pel-Air ‘aberration’ that not only does it stink to the high heavens; but it is not an isolated aberration, but is, indeed the ‘norm’. The only difference is with Pel-Air, they all got caught out.
The Bollocks is clearly apparent “The collection and analysis of a large volume of evidence for this investigation etc.” Read the line again, then ask at least two pertinent questions.
1) Why is the ‘second’ investigation suddenly dealing with a ‘larger’ volume of evidence than the first? Shirley the volumetric difference between version 1 and version 2 would be minimal – had the first been done correctly.
2) Why does it take so long to ‘clarify’ and revisit evidence which must have been compiled to produce the first report? What can possibly be so new and so intricate that the second version is taking as long to complete as the first?
Its bollocks. If the differences are so vast and numerous then clearly, without doubt the first report was so grossly flawed and manipulated, that takes the actions of both CASA and ATSB into the realm of criminal investigation. IMO this is no longer a matter for the ATSB to investigate, but the Federal police. Never happen of course, far to many eggs will be broken, starting with the ministerial eggs and ending with the lowly FOI’s who were involved in the ‘audit’ process. Never happen – we cannot possibly have ‘organisational issues’ mentioned, certainly not the CASA ones.
No, this shambolic pantomime will continue to drag on, and on and on until as Sandy says Booze, bad living and Alzheimer’s wipe the shameful, disgusting event from human memory.
Aye; all’s well that ends well; ICAO remain bamboozled; the never empty trough overflows and things like Senate Inquiry, Forsyth reports, IOSA audits, NTSBC peer reviews and the protests of industry can all be managed; with a little ministerial help, under advisement from ‘the department’.
P2 – “Hmm...Coupled with MH370 questions, I reckon Hoodlum could be in for an uncomfortable (at least) half an hour ...
Dunno P2, the Senate inquiry into the Norfolk ditching failed to make anyone ‘uncomfortable’; just can’t see a thirty minute session, once every few months phasing any of those with dirty hands. I reckon the Senate crew questions will be the butt of 'in-house' jokes cracked at the ATSB/CASA favourite watering hole, thirty minutes after the ‘teams’ leave the parliament building.
Toot toot.
Quote:^[a] statement or proposition which, despite sound (or apparently sound) reasoning from acceptable premises, leads to a conclusion that seems logically unacceptable or self-contradictory.
Quote:ATSB hosts marine investigators forum
Australian Transport Safety Bureau (ATSB) Chief Commissioner Greg Hood today welcomed international visitors to the 19th Marine Accident Investigators Forum in Asia (MAIFA) conference in Canberra.
MAIFA is a non-profit organisation dedicated to promoting safety at sea and preventing marine pollution through the exchange of ideas, experiences and information acquired in marine accident investigations.
“I’m delighted to welcome participants to Canberra and I look forward to a fruitful exchange of ideas,” Mr Hood said.
“Australia’s reputation for high quality and rigorous investigations makes it uniquely placed to assist with transport safety in the Asia Pacific region.
“The ATSB has an active program of regional engagement with other transport safety agencies, over and above that required by our international obligations.”
As well as investigating marine accidents and incidents in Australia, the ATSB provides technical assistance to a range of countries in our region.
Nation’s participating in the MAIFA conference are Cambodia, the People’s Republic of China, Hong Kong, Japan, the Republic of Korea, Malaysia, New Zealand, Singapore, Thailand and Vietnam.
Last update 11 October 2016
(10-15-2016, 08:01 AM)Peetwo Wrote: Hoody moves on from AAI & MH370 -
(10-14-2016, 08:44 PM)Sandy Reith Wrote: I've just been reading the ATSB updates on the updates, the number of same does not matter. What is clear is that the expected date of release of the final report to the public is always a few months hence. The longer the better because people die, get dementia, become careless and forgetful and generally tire of the whole sustained obscurant process. Spin it out long enough and even some of the instigating Senators will retire. This is what to expect out of 400,000 Can'tberrans from the most stratified, socialistic and souless capital city in the developed world. This no freehold, perfectly planned black hole tax sucking vortex of deceit and obfuscation is completely at odds with free enterprise, honest and careful work or sense of duty to the greater good. I'm afraid it is not just our aviation 'corporates', but other departments and Commonwealth bodies that I have had the misfortune to deal with. Sorry to say. The good old days were not that good but were much better in many ways. As Arthur Caldwell, then leader of the Labor Party and an honourable man, said, in farewell to Menzies, that in the Commonwealth public service under Menzies there was never even a hint of corruption.
(10-15-2016, 06:34 AM)kharon Wrote: Hoody and the Safety Piñata.
You’ve all seen ‘em; those supposedly ‘funny’ video shorts of kids, blindfolded, given a big stick, spun around until dizzy, then trying to hit an ‘elusive’ target they cannot see. They remind me of Hoody, trying to manage the ATSB, not only blindfold and dizzy, with NFI where to hit and the target being remotely controlled, he’s also handicapped by either handcuffs or blinkers; possibly both. Just a series of wild air swings, vainly trying to hit something.
The Pel-Air ‘aberration’ was not a single handed affair, although Hood would have gotten some blood spots on his hands while adroitly side stepping the main outflow; it must be said that he did, eventually, wake up to the unmitigated Cambers bastardry. But he was there and if anyone in this misbegotten saga knows where the skeletons are buried – Hoody does.
But he’s buggered for all money; now the self imposed handcuffs are golden and the blinkers fur lined. It is a strange, highly conflicted paradox^. Now, ostensibly ‘in charge’ of a reinvestigation of a matter in which, even by default, he is deeply involved in. Continuing to allow Walker to run the ‘investigation’ and continuing to side-line the invisible ‘Manning’ simply add another layer of doubt to an already murky picture. When the ATSB come out with a statement like this:-
../ Updated: 13 October 2016 : The collection and analysis of a large volume of evidence for this investigation has taken longer than originally foreseen. However, the ATSB now has sufficient evidence to establish findings across a number of lines of inquiry. The ATSB is in a position to finalise a draft report which is expected to be released to directly involved parties by the end of the year. Subject to comments made during the draft report review process, the final report should be released publicly in the first part of 2017.
/..a DDDDD minister may get a warm fuzzy feeling; the public will swallow it no worries; but what about the rest of the world who know, through study of the Pel-Air ‘aberration’ that not only does it stink to the high heavens; but it is not an isolated aberration, but is, indeed the ‘norm’. The only difference is with Pel-Air, they all got caught out.
The Bollocks is clearly apparent “The collection and analysis of a large volume of evidence for this investigation etc.” Read the line again, then ask at least two pertinent questions.
1) Why is the ‘second’ investigation suddenly dealing with a ‘larger’ volume of evidence than the first? Shirley the volumetric difference between version 1 and version 2 would be minimal – had the first been done correctly.
2) Why does it take so long to ‘clarify’ and revisit evidence which must have been compiled to produce the first report? What can possibly be so new and so intricate that the second version is taking as long to complete as the first?
Its bollocks. If the differences are so vast and numerous then clearly, without doubt the first report was so grossly flawed and manipulated, that takes the actions of both CASA and ATSB into the realm of criminal investigation. IMO this is no longer a matter for the ATSB to investigate, but the Federal police. Never happen of course, far to many eggs will be broken, starting with the ministerial eggs and ending with the lowly FOI’s who were involved in the ‘audit’ process. Never happen – we cannot possibly have ‘organisational issues’ mentioned, certainly not the CASA ones.
No, this shambolic pantomime will continue to drag on, and on and on until as Sandy says Booze, bad living and Alzheimer’s wipe the shameful, disgusting event from human memory.
Aye; all’s well that ends well; ICAO remain bamboozled; the never empty trough overflows and things like Senate Inquiry, Forsyth reports, IOSA audits, NTSBC peer reviews and the protests of industry can all be managed; with a little ministerial help, under advisement from ‘the department’.
P2 – “Hmm...Coupled with MH370 questions, I reckon Hoodlum could be in for an uncomfortable (at least) half an hour ...
Dunno P2, the Senate inquiry into the Norfolk ditching failed to make anyone ‘uncomfortable’; just can’t see a thirty minute session, once every few months phasing any of those with dirty hands. I reckon the Senate crew questions will be the butt of 'in-house' jokes cracked at the ATSB/CASA favourite watering hole, thirty minutes after the ‘teams’ leave the parliament building.
Toot toot.
Quote:^[a] statement or proposition which, despite sound (or apparently sound) reasoning from acceptable premises, leads to a conclusion that seems logically unacceptable or self-contradictory.
Hoodlum a giant amongst his peers:Courtesy the ATSB
Quote:ATSB hosts marine investigators forum
Australian Transport Safety Bureau (ATSB) Chief Commissioner Greg Hood today welcomed international visitors to the 19th Marine Accident Investigators Forum in Asia (MAIFA) conference in Canberra.
MAIFA is a non-profit organisation dedicated to promoting safety at sea and preventing marine pollution through the exchange of ideas, experiences and information acquired in marine accident investigations.
“I’m delighted to welcome participants to Canberra and I look forward to a fruitful exchange of ideas,” Mr Hood said.
“Australia’s reputation for high quality and rigorous investigations makes it uniquely placed to assist with transport safety in the Asia Pacific region.
“The ATSB has an active program of regional engagement with other transport safety agencies, over and above that required by our international obligations.”
As well as investigating marine accidents and incidents in Australia, the ATSB provides technical assistance to a range of countries in our region.
Nation’s participating in the MAIFA conference are Cambodia, the People’s Republic of China, Hong Kong, Japan, the Republic of Korea, Malaysia, New Zealand, Singapore, Thailand and Vietnam.
Last update 11 October 2016
Quote:ATSB to Asia: “We Can Fix You”
Posted on October 14, 2016 by Mike Chillit — Leave a reply
I was a bit stunned a few days ago to see a photo of an Australian “Bwana” standing in front of a group of mostly Asian men with the caption “ATSB hosts marine investigators forum” (sic).
I admit that Americans have become perhaps too sensitized to appearances, and often try to avoid even a hint of paternalism when no one but a BuzzFeed editor would claim it exists. It’s the times we live in on the northern side of the equator. It has gone much too far and many of us try to find some middle ground. But it’s a slow process.
Try as I may, I just couldn’t get good vibes from the message as a whole as I took in that enormous photo that seemed more like a Stanley and Livingstone parody than anything else that came to mind. Yes, the big Anglo Bwana, front and center, is the one who chose the photo and wrote the self-adoring text that accompanies it.
What makes it almost farcical is that by any assessment outside of Australia, the Land Down Under is hardly in a position to school any nation on planet earth in responsible aircraft investigation technique. ATSB has monumentally failed one of the most basic of all investigative responsibilities: openness. It has more in common with Enver Hoxha’s Albania than with modern democratic traditions.
Australia’s ATSB is still reeling from two horrific aircraft investigation fiascos: Pel-Air, and MH370. Yet the agency had the chutzpah to make this claim:
Quote:..Australia’s reputation for high quality and rigorous investigations makes it uniquely placed to assist with transport safety in the Asia Pacific region...
Oh, really? Why did all of the Sonobuoys dropped in the MH370 search area in early April 2014 fail to operate? Why has your agency remained in the same place SW of Perth while ordinary citizens recover the plane’s debris in the Mascarene area? Why, why, why? A million whys about your agency’s abysmal performance.
But of course, perhaps I’m over-reacting. Perhaps all of those Asians need someone of British descent to look after them from Canberra. But I really doubt it.
[/url][url=http://www.atsb.gov.au/media/5771632/maifa-pic.jpg]
ATSB’s Greg Hood stands front and center with his little band of mostly Asian invitees. No Indonesian representative, and no representatives from Pacific Island nations, apparently.
Footnote:
Perhaps Australia’s ATSB is just trying too hard to pretend it hasn’t spent more than two years searching in the wrong place for the still-missing Malaysia Airlines MH370.
There are striking similarities to a US FEMA incident in 2005 that centered around an American named Michael DeWayne Brown. To a rather informal President George W. Bush in 2005, Brown was simply “Brownie” and he oversaw FEMA when Hurricane Katrina flooded the New Orleans area. Mr. Brown’s management of FEMA’s response to the Katrina tragedy was widely regarded as slow, bureaucratic, and inept. Mr. Brown had very little training or education relevant to his FEMA responsibilities, but that seldom counts for much when a lucrative employment opportunity presents itself.
What makes the Brownie incident analogous is that after Michael Brown resigned in disgrace, he attempted to form his own company to provide Disaster Training to US cities and counties, ostensibly replacing FEMA. It was a childish reaction to a bad experience, and didn’t succeed, but is remarkably similar to ATSB’s effort to now provide training for aircraft accident investigations throughout the region when, in fact, it can’t even complete two pending high profile investigations of its own.
The text of ATSB’s Bwana moment follows, and includes a link to the source article.
ATSB hosts marine investigators forum
Australian Transport Safety Bureau (ATSB) Chief Commissioner Greg Hood today welcomed international visitors to the 19th Marine Accident Investigators Forum in Asia (MAIFA) conference in Canberra.
MAIFA is a non-profit organisation dedicated to promoting safety at sea and preventing marine pollution through the exchange of ideas, experiences and information acquired in marine accident investigations.
“I’m delighted to welcome participants to Canberra and I look forward to a fruitful exchange of ideas,” Mr Hood said.
“Australia’s reputation for high quality and rigorous investigations makes it uniquely placed to assist with transport safety in the Asia Pacific region.
“The ATSB has an active program of regional engagement with other transport safety agencies, over and above that required by our international obligations.”
As well as investigating marine accidents and incidents in Australia, the ATSB provides technical assistance to a range of countries in our region.
Nation’s participating in the MAIFA conference are Cambodia, the People’s Republic of China, Hong Kong, Japan, the Republic of Korea, Malaysia, New Zealand, Singapore, Thailand and Vietnam
(01-06-2016, 11:39 AM)Peetwo Wrote:Quote:P9 - Speculation - Just looking at the paddock, gee whiz, it looks (at least in the photograph) to be as rough as the proverbial badgers whot’s it. Tough job, lots of wind, probably wind shadows and shear, rough paddock forced landing would be bad enough, but in a very light aircraft – Even if the aircraft speed was back to ‘safe slow’ even a small bounce in 20 kts of head wind (quartering crosswind a nightmare) would have the aircraft in a difficult place – even with a donkey to do the heavy lifting.
Quote:The future of Tiger Moth Joy Rides looks uncertain after fatal crash
January 4, 2016 1:00am
Lexie Cartwright Gold Coast Bulletin
The future of Tiger Moth Joyrides at Pimpama is uncertain after a fatal crash. Pic by Richard Gosling
Quote:Investigation number: AO-2015-150
Investigation status: Active
Summary
During the conduct of the flight with a pilot and passenger the aircraft collided with terrain. The passenger was fatally injured and the pilot received serious injuries.
A team of three investigators with expertise in aircraft maintenance, operations and human performance deployed to the accident site on 28 December 2015. Completion of the on-site phase of the investigation has been delayed due to the presence of asbestos within the engine compartment of the aircraft. Following specialist assessment and removal of the asbestos, it is expected that examination of the aircraft will be completed within the next few days.
General details
Date:
28 Dec 2015
Investigation status:
Active
Time:
09:30 EST
Investigation type:
Occurrence Investigation
Location (show map):
near Pimpama Airstrip
Occurrence type:
Collision with terrain
State:
QLD
Occurrence category:
Accident
Report status:
Pending
Highest injury level:
Fatal
Expected completion:
Nov 2016
Aircraft details
Aircraft manufacturer:
de Havilland Aircraft Pty Ltd
Aircraft model:
DH-82A
Aircraft registration:
VH-UZB
Serial number:
291
Type of operation:
General Aviation-Unknown
Sector:
Piston
Damage to aircraft:
Destroyed
Last update 05 January 2016
Quote:Investigation holdup into last year’s fatal plane crash at Pimpama on the Gold Coast&..via ATSB investigation page:
Kathleen Skene, Gold Coast Bulletin
November 11, 2016 1:00am
THREE Days after what would be his last Christmas, Gary Turnbull was flying high above Pimpama on a joy ride in a sunny yellow antique plane when its engine slowed dramatically.
Five seconds later, the 1930s de Havilland craft hit the ground, taking his life and shattering those of his beloved wife and daughters.
Investigations into the crash that killed Mr Turnbull, 58, and critically injured world record-breaking pilot Ryan Campbell, then 21, were due to finish this month, but have now been pushed back to May next year.
This week, the Australian Transport Safety Bureau revealed a Garmin camera retrieved from the wreckage contained footage that cut out 175m before the before the crash site, and that GPS data could not be retrieved.
What was recoverable in those fateful last moments showed engine speed began to decrease five seconds before the recording stopped, and that by the time the engine speed had decreased from its takeoff speed of 2010rpm to 1740rpm.
What caused the engine to slow remains unknown.
“The discontinuation of the recording prevented an understanding of the magnitude of the continuing rpm loss as reported by the pilot,” the ATSB said in a statement.
Quote:Updated: 8 November 2016
A Garmin VIRB Elite video camera capable of recording video, audio and GPS data was recovered from the accident site and downloaded by the Queensland Police with assistance from the ATSB. Video and audio data from the accident flight was recovered, however the video footage and audio ended shortly before the collision with terrain. GPS data from the accident flight could not be recovered.
Analysis of the recovered audio data indicated that engine speed began to decrease 5 seconds before the end of the recording. By the end of the recording, the take-off revolutions per minute (rpm) of 2,010 had reduced by 270 rpm. The discontinuation of the recording prevented an understanding of the magnitude of the continuing rpm loss as reported by the pilot. The final frame of the recovered video data indicated the aircraft was approximately 175 m from the accident site when the recording ended.
The aircraft's engine was recovered from site and examined at a Civil Aviation Safety Authority‑approved engine overhaul facility under the supervision of the ATSB. The examination did not reveal any conclusive reasons for the reduction in engine rpm. The ATSB has retained a number of engine components for further examination.
The investigation is continuing and will include further examination and analysis of evidence obtained during the investigation
![[Image: Norfolk_Island_0C55C330-9F98-11E4-B6E7020F57397571.jpg]](http://auntypru.com/wp-content/uploads/2015/02/Norfolk_Island_0C55C330-9F98-11E4-B6E7020F57397571.jpg)
Quote:QON 206./Australian Transport Safety Bureau/ Xenophon /Pel-Air
Please provide an update on the Pel-Air report.
Written 28/10/2016
Quote:EXECUTIVE SUMMARY
ATSB INVESTIGATION INTO THE DITCHING OF VH-NGA ON 18 NOVEMBER 2009.
Pelair agrees with the conclusion of the investigation that:
- The aircraft carried enough fuel at departure for normal operations as required under
the regulations;
- The essential cause of the ditching was the change of the weather enroute;
- Timely notification of the change of weather by ATC would have averted the accident;
Pelair feels that the role of ATC could be examined in this respect to see if any systemic
improvements can be made to provide an additional layer of safety buffer.
&..
The flight crew did not source the most recent Norfolk Island Airport forecast, or seek and apply other relevant weather and other information at the most relevant stage of the flight to fully inform their decision of whether to continue the flight to the island, or to divert to another destination.
The crew did request actual weather reports (either METARs or SPECIs).
WEATHER PROVIDED BY NADI:
The PIC requested a METAR from Nadi for Norfolk at 0756 and at 0801 was provided with an 0800 SPECI which indicated overcast (OVC) cloud at 1100 feet. This was the first indication to the crew that the weather at Norfolk Island was becoming marginal.
WEATHER PROVIDED BY AUCKLAND:
The aircraft transferred to Auckland at 0839 but did not request the latest Norfolk weather until 0904 when they were given the 0902 SPECI which showed broken (BKN) cloud at 1100 feet and OVC cloud at 1500 feet. This finally alerted them to the situation at Norfolk Island. However a much more severe SPECI was issued earlier at 0830 showing a marked deterioration of the weather with cloud BKN at 300 ft and OVC at 900 ft. This was well below the landing minima and if it had been passed to the aircraft on first contact with Auckland would have alerted the crew to the true situation with time enough to divert. At 0839 the aircraft was still around 32 min away from the last diversion point to Tontouta as shown in the timeline in the report. Additionally, if the Nadi controller had passed the 0830 SPECI to the aircraft when it was issued there would have been even more time for the crew to assimilate the changing weather and take appropriate action. As it was the critical 0830 SPECI was never passed to the crew.
While the obtaining of up to date weather information is ultimately the responsibility of the PIC, controllers are in a position to see weather changes as they happen and should always alert the crew to any new reports they see as significant. The report does not address the question as to whether the controllers could or should have passed on the 0830 SPECI to the crew other than to say they were not required to do so by international agreement.
The flight crew’s delayed awareness of the deteriorating weather at Norfolk Island combined with their incomplete flight planning to influence their decision to continue to the island, rather than divert to a suitable alternate.
Pel-Air agrees with the first part of the finding on delayed awareness but disagrees with the second part. As explained in the preceding section, the accident would have been averted if weather information was obtained in a timely manner as there was more than enough time and fuel to divert had the up-to-date information been communicated.
Quote:The operator’s procedures and flight planning guidance managed risk consistent with regulatory provisions but did not effectively minimise the risks associated with aeromedical operations to remote islands.
Pel-Air disagrees with the second part of this finding and maintains that its procedures, compliant with CASA regulations at the time, are effective for minimising risks for remote island operations.
Pel-Air supports the proposed rule changes by CASA to bring passenger carrying aerial work operations in line with regular public transport operations to remote islands including the requirement to always carry an alternate. (P2 comment: Although since actioned by CASA, I note that this amendment is way too little and way too late for Kaz Casey -
The available guidance on fuel planning and on seeking and applying en route weather updates was too general and increased the risk of inconsistent in-flight fuel management and decisions to divert.
Pel-Air agrees that more information can be provided in this area and notes that CASA is proposing a review of CAAP 234-1 and the relevant regulations to take into account amendments to ICAO Annex 6 with new Standards and Recommended Practices (SARPs) regarding to fuel planning, inflight fuel management and the selection of alternates becoming effective in November 2012. Pel-Air has also instituted a range of improvements to provide more guidance to pilots in this respect.
That having been said, by the nature of their profession the pilot-in-command is trained to exercise the ultimate authority with regard to the safety of their aircraft and the conduct of their flight . (P2 comment - Keep the above in mind when you consider the sanitised & Pc'd outcome of the Mildura Fog duck-up ATSB investigation final report - UFB!
Quote:ATSB seeks to be more data driven
November 23, 2016 By australianaviation.com.au
Australian Transport Safety Bureau (ATSB) chief commissioner Greg Hood says the greater use of data to identify trends will be a big focus in the…
“My goal is to utilise data to such an extent that we continue evolving from being a reactive organisation, to a proactive organisation and ultimately to being a predictive organisation.”
Quote:..One area of study currently underway that reflected the ATSB’s push to, in Hood’s words “interrogate the data more aggressively”, concerned weather forecasts and observations.
The ATSB study was looking at how the reliability of weather forecasts affected the ability of flight crews to conduct a safe landing.
There have been a number of “unforecast weather episodes” relating to flights into major Australian ports that have led to unforeseen diversions, holding and “in some cases landing below the published minima” in recent times, Hood said.
“By understanding the relationships between weather reliability and aircraft operations, we will be able to essentially predict higher risk time periods and locations and drive down the probability of an accident occurring,” Hood said.
“Our research is seeking to understand how the reliability of weather forecast affects the ability of the flight crew to conduct a safe landing.
“Compared to Europe and North America, weather in Australia is pretty good and the likelihood of an accident happening because of weather conditions unsuitable for landing is much lower but in making it even lower, the probability of a major accident happening reduces considerably.”
(10-18-2016, 08:05 PM)Peetwo Wrote: Finally some Reason in the ATSB nuthouse
[quote pid='5475' dateline='1476439660']
Now with all that in mind I was intrigued to find a very much related ATSB news item released today that almost (but not quite -
Quote:Ground-breaking aviation research to reduce unforecast weather risks
ATSB senior research analyst Dave Wilson is working on a research investigation that will raise awareness of potential weather-related risks among pilots and also examine the effectiveness of rules that have been in place for more than 30 years.
Weather planning rules in Australia are unique compared to countries in Europe and North America. Because weather in Australia is generally good, risks are very low. But when weather is unsuitable for landing, these differences can have a real world effect on aircraft operations. It is these effects that Dave’s research aims to quantify.
A number of unforecast weather episodes relating to flights into major Australian airports have led to unforeseen diversions, holding and, in some cases, landing below published safe limits. Dave’s research is seeking to understand how the reliability of weather forecasts affects the ability of flight crew to conduct safe landings.
“I want to help decrease the likelihood of pilots being exposed to unexpected and unsuitable conditions for landing,” Dave said. “The likelihood of an accident happening because of conditions unsuitable for landing is low. But in making it even lower, the probability of a major accident happening reduces considerably.
“Initially I’m looking at Mildura and Adelaide airports. At Mildura, 99 per cent of the time, the weather is suitable to land a large aircraft. But based on the data I’ve looked at, there is still a remote possibility you may have an unreliable forecast. With the volume of air traffic, this could affect up to four aircraft per year.
“If you look at Adelaide, the chances of a single flight crew being exposed to an unreliable forecast are lower. However, when you take into account fluctuations in weather reliability, and the aircraft traffic arrival patterns (around 50,000 per year), the potential to result in a catastrophic accident increases. That’s what we want to avoid.
“If you’re in the air and you get to the point of last safe diversion—where you’ll be committed to landing at the planned destination—if the current forecast predicts marginal conditions, questions are raised as to whether continuing to the planned destination or diverting to an alternate destination should be required. This scenario has been a particular focus of this research.”
Dave has a vested interest in his research. Several actually. He’s a pilot who first flew solo when he was a 15-year-old student at Caringbah High in Sydney—well before he could legally drive. The opportunity of subsidised flying with the Australian Air Force Cadets was too good to knock back. He has since flown aerobatics out of Bankstown Airport but has undertaken little flying over past two years while pursuing this research.
Dave also has degrees in Aeronautical Engineering and Physics from Sydney University. It was there he attended a guest lecture by Pierre Blais from the Directorate of Defence Aviation and Air Force Safety (DDAAFS), which set him on a path to the ATSB.
“It was then that I thought investigating aviation safety would provide the ultimate career path for me. I find it both meaningful and challenging,” Dave said.
The research was initially going to secure Dave a Master’s degree. But he is now upping the ante and aiming to pursue a Doctorate. A stumbling block is finding reviewers with sufficient expertise in a related field. When you’re breaking new ground, this is often the case.
After first working at the Department of Infrastructure as a vehicle compliance engineer, Dave came to the ATSB to embrace his love of aircraft, engineering and how things work. Now with six years under his belt, Dave is also considering his future. “I’m happy as long as I’m being challenged,” he said. “But after this research is completed, I wouldn’t mind also undertaking a broader range of transport safety investigations.”
Research on Adelaide and Mildura aerodromes is expected to be published by the end of 2016. Progressive reports for each major aerodrome in Australia and four of our remote island aerodromes (Norfolk, Cocos, Christmas and Lord Howe) will be progressively released over the next year or two.
Last update 18 October 2016
No direct criticism of Dave here, however I find it deeply disturbing that it has taken 16+ years with an identified (normalised deficiency) safety issue that has been causal to a number of min fuel occurrences & accidents, and we are just now exploring the regulatory and BOM contributory factors that are part of the causal chain to these incidents and accidents...
(11-28-2016, 06:09 AM)kharon Wrote: Bucket please - just read #
The cynical beast roars WTF in protest as I read the latest ‘puff piece’ from ATSB. The urge to vomit at the soft sell of ‘Dave the Saviour’ reads as though it was written to be inserted between recipes and advice on how best to remove stains from underwear in one of those journals for the mentally challenged, they leave lying about in waiting rooms (does anyone actually pay hard earned for that crap?).
Anywhere else on the planet the simple rule of 1, 2, 3 applies to your pre flight fuel planning (in broad terms)
IFR Alternate Airports (1-2-3 Rule).
When filing an IFR flight plan, you must include an alternate destination airport when the weather forecast at your original destination predicts conditions below those specified in CFR 91.169. To help remember those conditions, you can use the 1-2-3 rule.
1 - During the time 1 hour before to 1 hour after the estimated arrival time
2 - Ceiling less than 2,000 feet
3 - Visibility less than 3 miles
If the above conditions exist, an alternate airport must be filed.
The alternate airport also has requirements that it must meet.
• If the airport has an instrument approach published, the weather must be forecast to be (at the ETA) better than the alternate airport minima specified in that approach or the following standard conditions:
o Precision Approach: 600ft ceiling and 2SM visibility
o Non-Precision Approach: 800ft ceiling and 2SM visibility
Not in Australia – crew are hung out to dry, forced to make all decisions and be legally responsible for ‘getting it wrong’. The BoM factor something like 70% +/- error on their forecast conditions, let the computers do the modelling and waltz off, Scot free, whenever they get it wrong; or, the system fails to get the 'new' information delivered in time for that information to be of any value.
But no matter, our latest new best mate ‘Dave’ is going to do an ‘academic’ study for his degree and we must have the good manners and patience to wait for the results, until he has finished buggering about editing and refining his ‘thesis’, to impress other academics and further his own CV, while we pay him to do so. Bollocks - we don't have the time to fanny about, waiting on his pronouncements.
Pel-Air and the Mildura cock-up tell the tale of organizational and systematic errors very clearly. Only a degree in common or garden sense is required to see the gaping holes in not only the safety net, but in the lines of responsibility. No one has offered a solution, but all, except the flight crew, have gilt edged ‘get out of jail cards’. A company like Qantas have been operating a system of ‘cut out’ points for making diversion decisions for donkeys years now; all the expertise we will ever need is contained within the collective wisdom of their system. Why not ask them, politely, to share that ‘wisdom’ and adopt that advice into law?
I could, if I tried, care a little less about ‘Dave’s’ ambition and his aerobatic experience. This fluffy little bit of scripted bullshit typifies the standard approach to any and all ‘operational’ problems. Anything will do but address the problem head on and sort it out, quickly, effectively and properly.
I tire of the Hood ‘touchy- feely’, soft –softly, apologetic approach: that ducking ‘correcting the record’ thing they do is too pathetic to even be risible. Does he not realize that the organization he runs is a sad, sorry, failed, bloodless imitation, a sick parody of what it is meant to be.
"Ground-breaking aviation research to reduce incorrectly forecast weather risks".
Bollocks !
Quote:6.) Document titled 'Chief Commissioner Greg Hood Opening Remarks for Senate Estimates'. Tabled by Greg Hood, Chief Commissioner, Australian Transport Safety Bureau on 22 November 2016.
(PDF 2.27MB)
7.) Document titled 'ATSB Investigation Update'. Tabled by Patrick Hornby, Legal Services Manager, Australian Transport Safety Bureau on 22 November 2016.
(PDF 1.22MB)
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