[Peetwo]

Twenty five years; four tails; 478 funerals; a birdstrike; and a broken leg - Part III

Reference previous:

Find the time; listen, learn and think.

You might want to consider the flight forecast for the ATR flight in question.

The wind in the area was forecast to be from the west to north-west and increase with altitude from 30 kt at 7,000 ft to 60 kt at 14,000 ft. South of Canberra, the winds above 10,000 ft were expected to be up to 20 kt stronger. Turbulence was forecast to be moderate in cumulus cloud and moderate otherwise at all levels throughout the forecast area
 
At 1506, while the crew was en route to Canberra, another area forecast was issued. There was little substantive change to the weather outlook; however, winds were forecast to ease by 5-10 kt and turbulence moderate now above 10,000 ft rather than at all levels.
 
The aerodrome forecast (TAF)20 for Sydney Airport, which was valid from 1100 until 1700,indicated that the winds were 10 kt from the south-east. There was no mention of turbulence in the area.The TAF for Canberra Airport that was in effect for the flight from Sydney to Canberra and the departure from Canberra, indicated that the forecast winds were from the west at 16 kt. There was no mention of turbulence.At the time that the aircraft departed Sydney, the Canberra Airport aerodrome meteorological report (METAR), which had a trend type forecast (TTF) current from 1430, indicated that the winds were 15 kts, gusting to 26 kt from the west-north-west with no significant weather. However, at 1500, 6 minutes after take-off, a revised METAR/TTF for Canberra Airport was issued noting that there was moderate turbulence forecast below 5,000 ft.
 
However, the bureau went on to advise that the balloon flight suggested a relatively strong inversion was developing during the day of the occurrence. The aircraft would have been traversing from a warmer stable atmosphere into a relatively cooler and unstable layer between 7,000 and 10,000 ft. This could account for any reported moderate turbulence.
 
Take a look at Fig.16 in the report. -  05:40:42 to 05:40:57 = 15 seconds with a 22 knots to 8 knots ‘drop’ in wind – 14 knots – for 15 seconds. Hardly 'dramatic'. Anyone ever skipped off the top of inversion - at Red line:?  How many FO's have been advised to back off the speed a bit?  - to be sure - to be sure.

Excellent points you make "K", I would also question why the FDR and associated flight wx forecasts, sig wx reports etc. weren't analysed for the 13 sectors that followed and any recorded data leftover from the flights before the accident flight. This data would surely be invaluable in the analysis of whether the CRM breakdown and flying at VMO (redline fever) in or in the vicinity of forecast and recognised high risk mechanical turbulence areas, was a normalised operating deficiency; and I believe would have helped with the analysis that went into this part of the report:

 

Operator’s history of VMO exceedances


A search of the VARA occurrence database for overspeed events from 2012 to 2014 identified seven occasions where an ATR 72 crew reported a VMO overspeed event on descent. In these events, six of which were before the occurrence, the crew cited turbulence and/or distraction as contributing factors. Where target speed was reported, it was 230 or 235 kt and where details were provided about recovery actions, the reported crew actions were reduction of power, disconnection of autopilot, and manual nose-up input. The ATSB noted that there was no significant geographical pattern to the occurrences and that there were 14 reported flap overspeed events during the same period.

A search of the ATSB database also identified one report of a VMO exceedance in an ATR 72, while they were under the Skywest operation in June 2012. In that occurrence, the aircraft was on descent at about 240 kt, when the airspeed rapidly increased due to an atmospheric disturbance. At the time, the pilot monitoring was distracted by another operational task.

VARA also supplied a copy of all incident reports lodged by the flight crew involved in the VH‑FVR occurrence. Neither of those flight crew had lodged reports to the operator of an overspeed event, including flap, gear and maximum operating speed. - (P2#: refer pg 20-21 of the report for crew personnel details and experience  ) 

Extract from ATSB FR 'Safety Message' section:

...From an operational perspective, the event shows how a flight crew whose intention was to keep the aircraft within the prescribed limitations, can inadvertently expose the aircraft to a higher level of risk. When taking action to address potential aircraft exceedances, flight crew should consider the serious consequence of applying aggressive or large control inputs at high speed relative to the risk posed by the exceedance. Flight crew should also adhere to sterile cockpit procedures to optimise their performance in the higher risk phases of flight and apply the handover/takeover procedures to ensure dual control inputs are avoided or coordinated to maintain effective control.

In terms of continuing airworthiness, the conduct of an inspection may be the sole opportunity to detect aircraft damage. As such, to avoid a single point failure it is imperative that the form of the inspection be fit-for-purpose and for inspections to be effectively coordinated and certified.

For aircraft manufacturers and airworthiness authorities, there can be unforeseen consequences of aircraft design characteristics. It is important that when identified, these are recognised and addressed during operational service of the aircraft type..

   
  From the report under 'safety issues and actions' it states that:

Proactive safety action by Virgin Australia Regional Airlines and Virgin Australia Airlines 

Action number: AO-2014-032-NSA-051 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 on-going training and checking
• full induction for ex-VARA crew into the VAA safety management system
• updated maintenance requirements following a pitch disconnect
• compliance with all relevant points in the ATR All Operators Messages with respect to this event. 

 
The date on the proactive action is the 15 June 2016. In reality VARA (now VAA) had probably actioned through their SMS the identified operational safety issues within weeks of the occurrence happening.

However the proof is always in the pudding...  

https://www.flightglobal.com/news/articles/hard-landing-in-turbulence-damaged-virgin-australia-445098/

A hard landing in turbulence on 19 November 2017 resulted in substantial damage to a Virgin Australia ATR 72-600, say investigators in a preliminary report.

---

https://www.pprune.org/australia-new-zea...rra-2.html

&..

https://the-riotact.com/probe-launched-i...out/279335

The Australian Transport Safety Bureau said the incident involved an ATR-72-flight from Sydney on 13 December at 7 pm.

The aircraft was descending through heavy rain when the right engine flamed out, automatically re-starting within five seconds as it is designed to do. As the descent continued the left engine also flamed out, automatically relighting as before with the right engine.

But for the remainder of the flight and the landing, the crew opted for manual engine ignition.

The ATSB has deemed the incident as serious and has downloaded the flight data recorder and is gathering other information.

Now from a completely left field OBS - in relation to the CBR hard landing occurrence - I noted the following very disturbing update from ASN on the Moscow Superjet accident (my bold): AIOS - & the 21st Century??

Superjet in fatal Moscow crash had windshear warning on approach and bounced twice on landing
26 May 2019


The Russian Ministry of Transport released initial findings on the May 5 accident of a Sukhoi Superjet at Moscow’s Sheremetyevo Airport in Russia.

Aeroflot flight 1492 took off from Sheremetyevo Airport’s runway 24C at 18:03 hours local time on a scheduled service to Murmansk, Russia. Visibility was fine but there were some Cumulonimbus clouds near the airfield at 6000 feet.

The flight crew engaged the autopilot as the aircraft climbed through a height of 700 ft (215 m). At 18:08, as the aircraft was climbing through an altitude of about 8900 ft (2700 m), a failure occurred in the electrical system. At this point, the aircraft was 30 km west-northwest of the airport in an area of thunderstorm activity.

The captain assumed manual control of the aircraft and the crew managed to establish radio contact using UHF. The flight was not able to contact the approach controller and subsequently selected the emergency transponder code 7600 (loss of radio communication).

About 18:17 the aircraft overshot the runway centreline after turning to runway heading. Altitude at that time was about 2400 feet. The aircraft continued the right-hand turn, completed a circle and proceeded on the final approach for runway 24L. Flaps were selected at 25°, which was the recommended setting for landing above maximum landing weight.

At 18:26 the flight crew selected the emergency transponder code 7700 (emergency).

When descending from 335 to 275 m (1100-900 ft) the windshear warning system sounded five times: “Go around. Windshear ahead”.

From a height of 80 m (260 ft) above ground level, the aircraft descended below the glide path and at a height of 55 m (180 ft) the TAWS warning sounded: “Glide Slope.” From that moment on the airspeed increased to 170 knots.

At 18:30 the aircraft overflew the runway threshold and touched down at a distance of 900 m past the threshold at a speed of 158 knots. Touchdown occurred at a g-force of at least 2.55g with a subsequent bounce to a height of about 2 m. After two seconds the aircraft landed again on the nose landing gear with a vertical load 5.85g, and bounced to a height of 6 m. The third landing of the aircraft occurred at a speed of 140 knots with a vertical overload of at least 5g. This caused a rupture of the wing structure and fuel lines. Flames erupted and engulfed the rear of the aircraft. The aircraft slid to a stop on the grass between runway 24L and two taxiways. An emergency evacuation was then carried out while flames quickly engulfed the rear fuselage.

  
 Hmm...no comment but there will be definitely more to follow...   

In the meantime here is an extract from a 2015 Ventus AP post: 

My dear Gobbles:

The problem, simply put, is one of discombobulation.


In a crisis, the respones of modern systems, the changing displays, the cavalcade of warnings, and the lack of "familiar cues", completely discombobulate the crews.

The fact is, regardless of the howls of protest from the techno-nerds that design them, and those who love them "on paper" when in their arm chairs, in the "real world" the systems are actually discombobulating, ( ie, they throw the crew into a state of mental uncertainty ) and as a result, in a crisis situation, the crews quickly become completely discombobulated.

The result, is needless disaster, after needless disaster.

The "industry" will however, never admit to this truth.  

The industry has "acquired institutionalised ostrichitis syndrome" (AIOS).


So, stand by for regular repeats of AF-447 and QZ8501.


Clues:
confusion, befuddlement, bewilderment, puzzlement, perplexity, disconcertment, discomposure, daze, fog, muddle, etc ........

Five years, 3 months and five days to perfectly obfuscate and PC the bejeezus out of what could have been Australia's worst ever aviation disaster - UDB? Nope OPS normal in Oz Aviation's safety circus:



&..

 

TBC...P2 

Ps I stand corrected on the media coverage of this bollocks report, yesterday Airline Ratings published this by Steve Creedy:
https://www.airlineratings.com/news/auss...atr-upset/