DTS Godlike back to DTS 'The Ghost Who Walks' in the space of two days - WTF? 
Via the Hooded Canary's aviary...
Sudden control input to prevent overspeed results in injuries to cabin crew
![[Image: virgin_b737.png?width=670&height=376.5222623345367]](https://www.atsb.gov.au/media/5778736/virgin_b737.png?width=670&height=376.5222623345367)
Key points:
The actions of the captain of a Boeing 737 in response to a sudden speed increase during a high speed descent resulted in sudden pitch changes and injuries to two cabin crew members, a new ATSB report details.
The Virgin Australia-operated Boeing 737-800 was at the top of the descent 136 nautical miles south-east of Adelaide Airport conducting a scheduled passenger flight from Melbourne on 13 September 2017, with the first officer acting as pilot flying.
Air traffic control instructed the crew to perform a high speed descent, which they commenced with the autopilot engaged with a target descent speed of 320 knots, which was higher than the normal descent speed of 280 knots.
During the descent, the first officer attempted to manage airspeed by using changes in the autopilot modes and reductions in the target airspeed. As the aircraft descended through around 17,000 feet, the tailwind affecting the aircraft decreased suddenly and significantly, which caused the indicated airspeed to increase and approach the maximum operating speed limit of 340 knots.
Highly concerned about overspeeding the aircraft, the captain responded by abruptly pulling back on the control column, causing the autopilot to disconnect. The resulting control forces caused sudden changes to the aircraft’s pitch attitude and vertical acceleration.
Two cabin crew members who were standing in the aircraft’s rear galley eating a meal received injuries during the upset, with one sustaining a broken leg.
ATSB Director Transport Safety Dr Stuart Godley said that during the occurrence, the aircraft only exceeded its maximum operating speed by one knot, which did not require any structural inspections to ensure the ongoing airworthiness of the aircraft. Instead, the safety implications associated with this event related to the actions of the captain in response to the sudden change in airspeed.
“Even though the autopilot was operating correctly, when the aircraft was approaching and exceeding the maximum operating speed, the captain’s perception was that the autopilot was not controlling the aircraft and that urgent intervention was necessary,” Dr Godley said.
“However, the captain did not follow the normal procedure for taking over control of pilot flying duties, and the large pitch control inputs made by the captain were probably influenced by a perception of urgency.”
Dr Godley said the investigation serves to remind pilots that they are entitled to decline air traffic control instructions where they do not perceive they can safely comply.
“Due to increased kinetic energy and reduced margins to placard speed limits, high-speed descents involve a higher level of risk, including increased risk of harm due to abrupt control input.”
The investigation also highlights the challenges pilots face when responding to sudden or unexpected situations, Dr Godley said.
“There will often be a reduction in safety when pilots perceive a situation is urgent and when they make decisions rapidly and reflexively. In these situations, pilots may not be able to effectively process information or make good decisions.”
The investigation also notes that it took over 90 minutes for the injured cabin crew member, who had sustained a badly-broken leg, to be removed from the aircraft after its arrival at Adelaide, while the operator’s ground operations supervisor, Aviation Rescue Fire Fighting Service (ARFFS) officers and SA Ambulence officers co-ordinated the extraction.
The injured cabin crew member was not able to walk or to sit in a wheelchair, and an ambulance stretcher would not fit down the aircraft aisle, however, the ground operations supervisor declined an ARFFS request to use a catering truck, the report notes.
Instead, emergency services personnel used a slide sheet to drag the injured cabin crew member along the aisle to the front of the aircraft, then placed the injured cabin crew member on a stretcher.
Virgin Australia has subsequently updated the training and information provided to pilots about overspeed and overspeed recovery. The airline has also changed procedures for ground handling staff when responding to requests from emergency services.
Read the investigation report AO-2017-092: Overspeed and pitch up resulting in cabin crew injury involving Boeing 737, VH‑VUE, 42 NM ESE Adelaide Airport, South Australia, on 13 September 2017
And then from Wanker Walker today:
Taxiway design, flight crew distraction and incorrect mental model, lead to Perth Airport runway incursion
![[Image: ao2018032_runwayincursion.jpg?width=670&...0000000005]](https://www.atsb.gov.au/media/5778739/ao2018032_runwayincursion.jpg?width=670&height=377.34400000000005)
Key points:
The crew of a Boeing 737 had to reject their take-off roll when a second 737 did not stop at a holding point and passed through an illuminated stop bar after landing at Perth Airport, an ATSB investigation report details.
On 28 April 2018, a Qantas Boeing 737, registered VH-XZM, landed on runway 03 at Perth, exiting the runway onto taxiway J2, which led to a holding point for crossing runway 06. The aircraft did not stop at the holding point and crossed an illuminated stop bar (a set of lights embedded across the taxiway surface) without an air traffic control clearance.
At that time, a second Qantas 737, VH-VZL, had commenced its take-off roll from runway 06. An automated warning within the Perth air traffic control tower alerted the aerodrome controller (ADC) of the stop bar violation and the controller issued an instruction for the departing 737 to ‘stop immediately’.
Soon after, the flight crew of VH‑XZM became aware of their position and stopped their aircraft just before crossing the edge of runway 06. VH-VZL’s wingtip passed about 15 metres from VH-XZM’s nose at low speed just before coming to a stop.
Among other findings, the ATSB found that the captain of VH-XZM was not expecting to cross runway 06, having developed an incorrect mental model of their location and thinking the aircraft was on taxiway J1 which led directly to the terminal area.
“Due to this incorrect mental model, and a combination of workload and distractions at key times, the flight crew did not detect the runway crossing issue until their aircraft had almost reached the edge of runway 06,” said ATSB Director Transport Safety Dr Mike Walker.
Taxiway J2 was the preferred runway exit for jet aircraft landing on runway 03, the ATSB’s investigation report notes.
“The location and design of the taxiway significantly increased the risk of a runway incursion onto runway 06/24,” Dr Walker said.
“The relatively shallow intersection angle with the runway and wide turn radius meant pilots were more likely to take the exit at a higher speed, and this combined with the short distance to the holding point gave pilots less time to see the illuminated stop bar lights at the runway holding point and stop.”
Although the junction around taxiway J2 was identified as a ‘hot spot’ on aerodrome charts, there was no detailed information about the reasons for it.
Also, Qantas did not specifically require pilots to brief hot spots during departure and approach briefings.
In response to the runway incursion, Airservices Australia made taxiway J2 unavailable for use, and Perth Airport subsequently removed taxiway J2 from aerodrome charts.
In addition, Airservices changed the settings of an alerting system to ensure tower controllers at Perth Airport performing multiple roles received appropriate aural and visual alerts at their workstation.
“Runway incursions are one of the most significant risks to safe aviation operations and a key global safety priority,” Dr Walker said.
“Airport operators and local runway safety teams are strongly encouraged to identify and mitigate the risk of hot spots, especially those that involve short distances between runways, complicated junctions, and the potential for higher taxi speeds.”
Since the incident, Qantas published a safety information notice to all pilots containing information about the background of runway incursions. The airline also updated its Flight Administration Manual to include a requirement for pilots to brief relevant airport hot spots and their contingency planning to mitigate against the possibility of collision or runway incursion.
“Pilots can help prevent incursions by identifying runway hot spots during departure and approach briefings, and discussing the actions they will take to reduce the risk of a runway incursion,” Dr Walker said.
“The ATSB also strongly encourages air traffic controllers to provide safety alerts and/or clear instructions – such as ‘stop immediately’ – to the flight crews of all aircraft involved in runway incursions and related occurrences.”
Dr Walker noted that the aerodrome controller and flight crew of VH-VZL exhibited a high level of situational awareness to respond to the incursion.
Read the investigation report AO-2018-032: Runway incursion involving Boeing 737, VH-XZM, and subsequent rejected take-off involving Boeing 737, VH-VZL, at Perth Airport, Western Australia, on 28 April 2018
MTF...P2
Via the Hooded Canary's aviary...
Sudden control input to prevent overspeed results in injuries to cabin crew
Key points:
- A sudden wind change during high-speed descent resulted in the airspeed suddenly increasing towards the aircraft maximum operating speed
- The captain responded by abruptly pulling back on the control column, causing autopilot to disconnect
- Subsequent sudden pitch attitude and vertical acceleration changes resulted in injuries to cabin crew members.
The actions of the captain of a Boeing 737 in response to a sudden speed increase during a high speed descent resulted in sudden pitch changes and injuries to two cabin crew members, a new ATSB report details.
The Virgin Australia-operated Boeing 737-800 was at the top of the descent 136 nautical miles south-east of Adelaide Airport conducting a scheduled passenger flight from Melbourne on 13 September 2017, with the first officer acting as pilot flying.
Air traffic control instructed the crew to perform a high speed descent, which they commenced with the autopilot engaged with a target descent speed of 320 knots, which was higher than the normal descent speed of 280 knots.
During the descent, the first officer attempted to manage airspeed by using changes in the autopilot modes and reductions in the target airspeed. As the aircraft descended through around 17,000 feet, the tailwind affecting the aircraft decreased suddenly and significantly, which caused the indicated airspeed to increase and approach the maximum operating speed limit of 340 knots.
Highly concerned about overspeeding the aircraft, the captain responded by abruptly pulling back on the control column, causing the autopilot to disconnect. The resulting control forces caused sudden changes to the aircraft’s pitch attitude and vertical acceleration.
Two cabin crew members who were standing in the aircraft’s rear galley eating a meal received injuries during the upset, with one sustaining a broken leg.
ATSB Director Transport Safety Dr Stuart Godley said that during the occurrence, the aircraft only exceeded its maximum operating speed by one knot, which did not require any structural inspections to ensure the ongoing airworthiness of the aircraft. Instead, the safety implications associated with this event related to the actions of the captain in response to the sudden change in airspeed.
“Even though the autopilot was operating correctly, when the aircraft was approaching and exceeding the maximum operating speed, the captain’s perception was that the autopilot was not controlling the aircraft and that urgent intervention was necessary,” Dr Godley said.
“However, the captain did not follow the normal procedure for taking over control of pilot flying duties, and the large pitch control inputs made by the captain were probably influenced by a perception of urgency.”
Dr Godley said the investigation serves to remind pilots that they are entitled to decline air traffic control instructions where they do not perceive they can safely comply.
“Due to increased kinetic energy and reduced margins to placard speed limits, high-speed descents involve a higher level of risk, including increased risk of harm due to abrupt control input.”
The investigation also highlights the challenges pilots face when responding to sudden or unexpected situations, Dr Godley said.
“There will often be a reduction in safety when pilots perceive a situation is urgent and when they make decisions rapidly and reflexively. In these situations, pilots may not be able to effectively process information or make good decisions.”
The investigation also notes that it took over 90 minutes for the injured cabin crew member, who had sustained a badly-broken leg, to be removed from the aircraft after its arrival at Adelaide, while the operator’s ground operations supervisor, Aviation Rescue Fire Fighting Service (ARFFS) officers and SA Ambulence officers co-ordinated the extraction.
The injured cabin crew member was not able to walk or to sit in a wheelchair, and an ambulance stretcher would not fit down the aircraft aisle, however, the ground operations supervisor declined an ARFFS request to use a catering truck, the report notes.
Instead, emergency services personnel used a slide sheet to drag the injured cabin crew member along the aisle to the front of the aircraft, then placed the injured cabin crew member on a stretcher.
Virgin Australia has subsequently updated the training and information provided to pilots about overspeed and overspeed recovery. The airline has also changed procedures for ground handling staff when responding to requests from emergency services.
Read the investigation report AO-2017-092: Overspeed and pitch up resulting in cabin crew injury involving Boeing 737, VH‑VUE, 42 NM ESE Adelaide Airport, South Australia, on 13 September 2017
And then from Wanker Walker today:
Taxiway design, flight crew distraction and incorrect mental model, lead to Perth Airport runway incursion
![[Image: ao2018032_runwayincursion.jpg?width=670&...0000000005]](https://www.atsb.gov.au/media/5778739/ao2018032_runwayincursion.jpg)
Key points:
- 737 taxied toward active runway; second 737 rejected take-off
- Taxiway location and design significantly increased the risk of a runway incursion
- Runway incursions are a significant risk to safe aviation operations and a key global safety priority
The crew of a Boeing 737 had to reject their take-off roll when a second 737 did not stop at a holding point and passed through an illuminated stop bar after landing at Perth Airport, an ATSB investigation report details.
On 28 April 2018, a Qantas Boeing 737, registered VH-XZM, landed on runway 03 at Perth, exiting the runway onto taxiway J2, which led to a holding point for crossing runway 06. The aircraft did not stop at the holding point and crossed an illuminated stop bar (a set of lights embedded across the taxiway surface) without an air traffic control clearance.
At that time, a second Qantas 737, VH-VZL, had commenced its take-off roll from runway 06. An automated warning within the Perth air traffic control tower alerted the aerodrome controller (ADC) of the stop bar violation and the controller issued an instruction for the departing 737 to ‘stop immediately’.
Soon after, the flight crew of VH‑XZM became aware of their position and stopped their aircraft just before crossing the edge of runway 06. VH-VZL’s wingtip passed about 15 metres from VH-XZM’s nose at low speed just before coming to a stop.
Among other findings, the ATSB found that the captain of VH-XZM was not expecting to cross runway 06, having developed an incorrect mental model of their location and thinking the aircraft was on taxiway J1 which led directly to the terminal area.
“Due to this incorrect mental model, and a combination of workload and distractions at key times, the flight crew did not detect the runway crossing issue until their aircraft had almost reached the edge of runway 06,” said ATSB Director Transport Safety Dr Mike Walker.
Taxiway J2 was the preferred runway exit for jet aircraft landing on runway 03, the ATSB’s investigation report notes.
“The location and design of the taxiway significantly increased the risk of a runway incursion onto runway 06/24,” Dr Walker said.
“The relatively shallow intersection angle with the runway and wide turn radius meant pilots were more likely to take the exit at a higher speed, and this combined with the short distance to the holding point gave pilots less time to see the illuminated stop bar lights at the runway holding point and stop.”
Although the junction around taxiway J2 was identified as a ‘hot spot’ on aerodrome charts, there was no detailed information about the reasons for it.
Also, Qantas did not specifically require pilots to brief hot spots during departure and approach briefings.
In response to the runway incursion, Airservices Australia made taxiway J2 unavailable for use, and Perth Airport subsequently removed taxiway J2 from aerodrome charts.
In addition, Airservices changed the settings of an alerting system to ensure tower controllers at Perth Airport performing multiple roles received appropriate aural and visual alerts at their workstation.
“Runway incursions are one of the most significant risks to safe aviation operations and a key global safety priority,” Dr Walker said.
“Airport operators and local runway safety teams are strongly encouraged to identify and mitigate the risk of hot spots, especially those that involve short distances between runways, complicated junctions, and the potential for higher taxi speeds.”
Since the incident, Qantas published a safety information notice to all pilots containing information about the background of runway incursions. The airline also updated its Flight Administration Manual to include a requirement for pilots to brief relevant airport hot spots and their contingency planning to mitigate against the possibility of collision or runway incursion.
“Pilots can help prevent incursions by identifying runway hot spots during departure and approach briefings, and discussing the actions they will take to reduce the risk of a runway incursion,” Dr Walker said.
“The ATSB also strongly encourages air traffic controllers to provide safety alerts and/or clear instructions – such as ‘stop immediately’ – to the flight crews of all aircraft involved in runway incursions and related occurrences.”
Dr Walker noted that the aerodrome controller and flight crew of VH-VZL exhibited a high level of situational awareness to respond to the incursion.
Read the investigation report AO-2018-032: Runway incursion involving Boeing 737, VH-XZM, and subsequent rejected take-off involving Boeing 737, VH-VZL, at Perth Airport, Western Australia, on 28 April 2018
MTF...P2