[Peetwo]

Road Kill.

When Beaker recovers from being thrown under the bus by An(g)us and Hoody, he may like to contemplate a piece offered by Ben Sandilands – HERE – on Plane Talking. Or, maybe this one which has been ignored by both Beaker and Sandilands. _HERE_ 

The ATSB has tweeted its media followers that the definition of a serious aviation incident is one in which an accident nearly occurred.

That means that it classed the Qantas too low approach to Melbourne Airport by an A330 in 2013 as an incident that could have ended in the crash of a 300 seat airliner on the Sydney-Melbourne route

The search for Investigative Probity continues with out a map or candle; with NX trying to strike a spark to kindle the flames while Beaker pisses on the flint.  

MTF?– watch this space.

ATSB BASR - Risk mitigation vs topcover?? 

Was kind of wondering when someone would mention this 'serious incident' & the strange disconnection with the one 'serious incident' (AO-2013-047) & one 'not so serious incident' (AO-2013-130)... - Why? Well because the correlation between those two aviation safety occurrences (especially the Virgin incident) and the ATLAS 747 'incident' is IMO quite remarkable:

Introduction


During approach into Melbourne Airport, Victoria on 9 September 2012, the Boeing 747 aircraft descended below the minimum permitted altitude for the final segment of a standard arrival route (STAR) prior to landing at Melbourne. A number of factors influenced this descent and are discussed in the following analysis.

The approach

The flight crew were initially issued with the STAR clearance involving a visual final segment by air traffic control (ATC) after they requested an approach to runway 34 instead of runway 27. During the descent, and prior to commencing the STAR, the flight crew requested an area navigation global navigation satellite system (RNAV GNSS) approach. ATC advised that this approach was not available unless it was an operational requirement. The captain related a concern about the prevailing visibility, to which ATC responded that the visibility should improve as they neared the airport. In response the flight crew decided to continue with the STAR and visual approach.

During this approach, ATC issued the clearance ‘from SHEED, cleared visual approach’. However the crew did not read back the full clearance, omitting the ‘from SHEED’ condition issued by ATC. This condition only allowed them to commence the visual approach once they passed the SHEED waypoint. The clearance was provided at the same time that the crew sighted the lead-in strobe lights, for which they had been actively searching to assist their turn onto final. It also occurred close to the point where a missed approach procedure would be required had the lights not been sighted. It is possible that the activity of searching for the lights, particularly in the reported hazy conditions, and the preparation for a potential missed approach drew the crew’s attention away from monitoring their vertical position on the approach.

Additionally, as the flight crew were United States (US)-certificated, they were used to the normal practice in US airspace of STAR clearances being cancelled implicitly by the provision of new clearances. In Australian airspace, an aircraft remains on a STAR until ATC transmits ‘Cancel STAR’ and provides further instructions, or until the aircraft reaches the end of the published STAR procedure. While the captain had flown into Australia ‘many times’ previously, this was the first time in Australian airspace for the first officer.

The first officer reported believing that any restrictions associated with a STAR no longer applied once cleared for a visual approach.

The flight crew’s shared mental model of the ability to descend on receipt of a new clearance (in this case for the visual approach) was inconsistent with that of the air traffic controller. The controller was not expecting the flight crew to descend below the minimum height before passing the SHEED waypoint, as stipulated in the STAR procedure. While the flight crew’s understanding was consistent with the procedures used in US airspace, these did not apply in Australia, leading to the descent below the minimum permitted altitude.

Air traffic control clearance procedures

The standard risk mitigation for ensuring that a clearance was understood by flight crews was for the flight crew to read back the clearance to the controller and for the controller to correct any errors. The flight crew’s read back of the clearance for the visual approach to runway 34 from the SHEED waypoint was incomplete. The controller did not detect the omission and the crew’s misunderstanding of the visual approach clearance remained undetected by the flight crew. Consequently, the flight crew followed their understanding of the clearance as it applied in the US, and descended below the cleared minimum of 2,500 ft before the SHEED waypoint.

If the controller had recognised and challenged the incomplete read back, it is likely that the flight crew would have been alerted to the need to maintain 2,500 ft until passing SHEED.

Approach design and approval

The design of the LIZZI FIVE RWY 34 VICTOR ARRIVAL necessitated a descent profile of 3.5° for the visual approach from SHEED to the runway 34 threshold. A review of exceedances at SHEED by other operators highlighted that this increased angle resulted in higher descent rates, often in excess of 1,000 ft/min. This is the recommended maximum rate of descent for a stabilised approach. A higher descent rate increases the likelihood of an unstable approach during the descent from overhead the SHEED waypoint.

During the approach, the aircraft was descended to about 1,900 ft over the SHEED waypoint, which was about 600 ft below the minimum altitude at that position. A review of similar occurrence events found that other aircraft had also overflown SHEED at about this altitude. This lower altitude was consistent with a 3° descent profile for a landing on runway 34 and with the first officer’s recollection of commencing a 3° descent profile once they believed they were cleared to descend.

There were a number of control practices restrictions in the Manual of Air Traffic Services (MATS) in relation to ATC issuing STAR clearances with a visual segment to foreign operators of heavy or super jet aircraft. These restrictions would have precluded this aircraft from conducting a STAR with a visual segment at other locations in Australia.

However, MATS allowed the SHEED visual approach by foreign operators if they were familiar with its conduct, and this operator was considered to meet this requirement.

Aside from an undocumented local control procedure for application to the SHEED visual approach by foreign operators of heavy or super jet aircraft, there were no alternative or additional defences to support this variation in control practice. In addition, the local control procedure required the flight crew to stop descending before SHEED, report sighting the lead-in strobe lights and then recommence the descent once the aircraft had passed SHEED. This resulted in the foreign crews conducting a step-down descent profile.

While this sequential clearance was a considered decision by ATC in order to minimise the risk of foreign flight crew misinterpreting the approach or descending prior to SHEED, it negated the inherent protections of a constant angle descent profile. The importance of constant-angle approaches was highlighted by the Flight Safety Foundation in their Approach and Landing Accident Reduction Tool Kit as a defence against unstable approaches and controlled flight into terrain.

 
The first paragraph under 'Approach design and approval' in bold is a critical part of the causal chain for this incident & the Virgin incident, because by a flawed design this approach introduces a stepped descent (duck'n'dive) sector (not below 2500' till past SHEED) which by design does not always meet the criteria for a stabilised approach (not > 1000' ROD). A standard (by the way) which is widely accepted and adhered to in approach design by most ICAO signatory States Worldwide.

Other glaring aberrations/observations with this investigation & final report.

1) The final report took just shy of three years to complete? - UFB...

2) So the ATSB investigators made the link/safety issue with the approach design (above). However the ATSB initially neglected to see the significance of this safety issue and subsequently did not promulgate a 'safety recommendation' or even a 'safety issue' until recently (i.e. nearly three years after the incident - AO-2012-120-SI-02)

Safety issue description

The LIZZI FIVE RWY 34 VICTOR ARRIVAL required a 3.5° descent profile after passing the SHEED waypoint for visual approach to runway 34 at Melbourne, increasing the risk of an unstable approach.

Proactive Action

Action organisation:
Civil Aviation Safety Authority
Action number:
AO-2012-120-NSA-051
Date:
01 September 2015
Action status:
Released

In response to this safety issue, the Civil Aviation safety Authority (CASA) advised that:

CASA acknowledges the Safety Issue identified by the ATSB in relation to the descent profile of the LIZZI FIVE RWY 34 VICTOR ARRIVAL. 3.5 is at the upper limit specified in Procedures for Air Navigation Services – Operations (PANS-OPS) Volume II for instrument flight procedures designed for Category D aircraft (including the Boeing 747). CASA intends to engage with Airservices to ensure the procedure meets instrument procedure design and ‘flyability’ standards.

 
3) There was also a safety issue sent to Airservices - AO-2012-120-SI-01  In light of the Virgin incident nearly a year later I find the ASA disconnection & proactive action quite bizarre...

Safety issue description

Unlike other Australian standard arrival routes that included a visual segment, the visual approach to runway 34 at Melbourne via the SHEED waypoint could be issued to super or heavy jet aircraft operated by foreign operators, despite there being more occurrences involving the SHEED waypoint than other comparable approaches.

Proactive Action
Action organisation:
Airservices Australia
Action number:
AO-2012-120-NSA-050
Date:
01 September 2015
Action status:
Released

In response to this safety issue, Airservices Australia (Airservices) advised of the following proactive safety action:

Airservices agrees with the safety issue identified in the report. Airservices has commenced action to remove the MATS [Manual of Air Traffic Services] provision which allows the use of SHEED visual segment for all International Heavy and Super Heavy aircraft, rather than just Australian and New Zealand operators as detailed in MOS [Manual of Standards] Part 172. The related operational documentation will be reviewed and amended accordingly in line with our standard safety change management process.

Airservices will aim to introduce the permanent change to the November 2015 MATS [Manual of Air Traffic Services] update and will issue a temporary local instruction in the interim. Airservices will advise the ATSB when the action has been completed.

 So again we have a situation where a latent safety risk, that could have been effectively mitigated back in 2012, is only now (3yrs later) being properly addressed - again UFB..

Next "K" said:

..The search for Investigative Probity continues with out a map or candle; with NX trying to strike a spark to kindle the flames while Beaker pisses on the flint...  

This was in reference to last night's special Senate ASA inquiry hearing and relevant to Farmer Joe's discovery that the ATSB website has no record of the 05 July YMML LAHSO BOS ''serious incident' - More Beaker Bullocks.

{Comment:From the  above we get further confirmation from Hoody that the ATSB indicated they would be investigating this serious incident- so where is the record... }


MTF?- You bet..P2