[Peetwo]

More pointless Spin'n'bollocks Investigation Report Media Releases??- 

This week's Popinjay DTS is Dr Godlike and apparently he is attributable for this bollocks press release...

 

Near collision highlights how line of sight limitations make non-mandatory radio calls essential



The pilots of two aircraft had incorrect mental models of local traffic when their aircraft took off from intersecting runways at the same time, an ATSB final report details.

During the 6 June 2023 incident at Mildura Airport, a Piper PA-28 Cherokee was conducting a solo private flight to Broken Hill, while a QantasLink Dash 8 with 3 crew and 33 passengers was departing on a scheduled service to Sydney.

The Cherokee had taxied to the threshold of runway 36, while the Dash 8 had taxied to the threshold of runway 09.

Both aircraft had made the required mandatory calls on the local common traffic advisory frequency (CTAF), used by pilots to coordinate and self-separate at non-controlled aerodromes, such as Mildura. 

However, ATSB Director Transport Safety Dr Stuart Godley said, during their calls, the pilot of the Cherokee had incorrectly identified Mildura’s runway 36 as ‘runway 35’.

“This occurred while the Dash 8’s pilots were obtaining their pre-departure information from air traffic control, and had the volume turned down on the CTAF radio,” Dr Godley explained.

“In addition, the Dash 8 crew only received certain elements of the Cherokee’s calls due to an over transmission from air traffic control.”

The incorrect runway identification compounded with these factors to create an incomplete comprehension of local traffic in the Dash 8 crew’s mental models – specifically, both Dash 8 pilots did not believe that the Cherokee was at Mildura, given that the nearby Wentworth Airport also uses the same CTAF.

Additionally, when the Cherokee was ready for its take-off roll on runway 36, its pilot believed the Dash 8 would still be backtracking on runway 09 – but the Dash 8 was in fact also about to begin its own take-off roll. 

“Subsequently, both aircraft began take-off rolls towards the intersection of their respective runways, and the Dash 8 passed about 600 m in front of the Cherokee,” Dr Godley outlined.

The report notes the pilot of the Cherokee gave a rolling call on the CTAF at the start of their roll, while the Dash 8 crew did not – but that rolling calls are not mandatory.

“However, due to terrain and buildings at Mildura Airport, aircraft are not directly visible to each other on the thresholds of runways 09, 27 and 36,” Dr Godley said.

“With the inability to see another aircraft when each aircraft is at the threshold at Mildura Airport, the lack of a requirement for mandatory rolling calls increased the risk of aircraft not being aware of each other immediately prior to take-off.”

Since the incident, Mildura Airport established a permanent requirement for Mildura Airport operations as of 4 April 2024 for mandatory rolling calls from all aircraft immediately prior to take-off due to the increased risk of aircraft not being aware of each other. 

In addition, QantasLink has made rolling calls part of the minimum requirements for operations at CTAF aerodromes.

“Communication and self-separation in non-controlled airspace is one of the ATSB’s SafetyWatch priorities,” Dr Godley said.

“Pilots can guard against occurrences like this one by making the recommended broadcasts when in the vicinity of a non-controlled aerodrome, actively monitoring the CTAF while maintaining a visual lookout for other aircraft and constructively organising separation through direct contact with other aircraft, and ensuring transponders, where fitted, are selected to transmit altitude information.”

While the ATSB did not identify radio interference or shielding as contributing to this occurrence, another ongoing investigation into a similar event that occurred at Mildura later in 2023 (AO-2023-050), is considering these factors.

As part of that investigation, the ATSB is continuing to work with Qantas Safety, Mildura Airport, the Australian Communications and Media Authority, the Civil Aviation Safety Authority and Airservices Australia.

Read the report: Near collision involving Piper PA-28-161, VH-ENL, and Bombardier DHC-8-315, VH-TQH, at Mildura Aerodrome, Victoria, on 6 June 2023

Listed as a 'Short' desktop investigation, this report took 344 days to complete and included a 'safety issue' that was apparently only publicly released 3 days ago.. : AO-2023-025-SI-01

Date issue released: 14/05/2024

Safety Issue Description

Due to topography and buildings at Mildura Airport, aircraft are not directly visible to each other on the threshold of runway 09, 27 and 36. The lack of a requirement for mandatory rolling calls increased the risk of aircraft not being aware of each other immediately prior to take-off.

However Mildura has already acted on and notified action on this safety issue:

Action description

Mildura Airport has advised that it has been successful in establishing a permanent NOTAM for Mildura Airport operations as of 4 April 2024.

The NOTAM includes the advice that aircraft are not directly visible to each other on the thresholds of Runway 09, 27 and 36 and that mandatory rolling calls are required from all aircraft immediately prior to take-off due to the increased risk of aircraft not being aware of each other. This permanent NOTAM is to be subsumed into the ERSA publication for Mildura Airport in the 2406 amendment cycle on 13 June 2024.

There is some interesting commentary on a UP thread currently running on this report.. : Mildura 2023 near miss final report out

Checklist Charlie

The occurrence

In the early afternoon of 6 June 2023, a Piper PA-28-161 (PA‑28), registered VH-ENL taxied for runway 36[1] at Mildura, New South Wales, for a private flight to Broken Hill

Ooooops, proof reading not a strong point there ATSB

CC

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SIUYA

Geez C.Charlie.......

Give the poor buggers a break.

At least they got this report out in less than the stock-standard 2 (maybe 3?) years.

Next, Godlike with another 'Short' investigation report bullshit presser...

Increased pilot workload during Parafield descent below minimum safe altitude incident



A Beech Baron’s descent below minimum altitude on approach to Adelaide’s Parafield Airport highlights to pilots the importance of vigilance of their aircraft’s altitude and workload management, an ATSB investigation report details.

On 12 August 2022, the twin-engined Baron was being repositioned from Port Augusta to Parafield, with weather conditions necessitating an instrument approach (using the RNAV GNSS RWY 21R instrument approach procedure).

“While in cloud on the approach segment between the initial approach fix and intermediate fix, the aircraft descended below the 3000 ft segment minimum safe altitude,” ATSB Director Transport Safety Dr Stuart Godley explained.

“The aircraft continued to descend and entered the next segment at 2000 ft, below that segment’s minimum safe altitude of 2200 ft.”

The approach controller then received an automated warning, and contacted Parafield tower, who alerted the pilot. The pilot subsequently climbed the aircraft back above the minimum altitude.

“The pilot was experiencing an increased workload from conducting an instrument approach in cloud and turbulence and did not detect their flight below the segment minimum safe altitude.

“This incident is a good reminder to pilots of the importance of close monitoring of the aircraft’s vertical and lateral navigation, in particular during high workload phases of flight.”

The investigation report notes that once the pilot returned above minimum safe altitude, they continued the climb. The aircraft was about 7 NM from the runway and 850 ft above the recommended profile, when the pilot elected to continue the approach.

“Continuing the approach from that position, above the recommended profile, required a higher-than-normal descent rate, and had the potential to increase the pilot’s workload,” Dr Godley added.

The pilot established visual reference with the runway about 4 NM from the threshold, and landed without further incident.

The ATSB report notes the pilot was referring to a hand-held paper copy of the instrument approach procedure, but that the aircraft’s control yoke did not have a chart holder, nor did the pilot have a document holder or kneeboard available.

This increased the difficulty monitoring the check altitudes and segment minimum safe altitudes.

“Continuous monitoring of the aircraft’s altitude relevant to the various segment minimum safe altitudes, and having the instrument approach procedure available in a suitable location, are both key to minimising workload and conducting an instrument approach safely,” Dr Godley said.

“Pilots also need to remain vigilant about the relationship between the procedure commencement altitude and the constant descent final approach path, including that the correct waypoint has been identified for managing the descent profile and ensuring the distance-based check altitudes are correctly interpreted.”

Read the report: Flight below minimum altitude involving Beech Aircraft Corp 95-B55, VH-ALR, 20km north-north-east of Parafield Airport, South Australia, on 12 August 2022

Publication Date: 15/05/2024

This time there was apparently no safety issues identified but the report did take a more normalised 643 days to produce...

MTF...P2