[Peetwo]

Three years for this?? - FDS  

Today the ATSB Mildura fog duck-up report was finally released - hoorah! 

AO-2013-100 - Landing below minima due to fog involving Boeing 737s, VH-YIR and VH-VYK Mildura Airport, Victoria on 18 June 2013.

Final - 31 May 2016

Findings

From the evidence available, the following findings are made with respect to the landing below minima due to fog involving two Boeing 737s, registered VH-YIR and VH-VYK, which occurred at Mildura Airport, Victoria on 18 June 2013. These findings should not be read as apportioning blame or liability to any particular organisation or individual.

Safety issues, or system problems, are highlighted in bold to emphasise their importance. 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 organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time.

Contributing factors

• 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 aerodrome 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.
  

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 aerodrome weather reports at Mildura over the aerodrome 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 in-flight 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 in-flight weather report given by the air ambulance pilot was not passed to the flight crews of Velocity 1384 and Qantas 735 by the controller when they changed frequency inbound 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 recognise and actively disseminate special weather reports (SPECI) to pilots, thus not meeting the intent of the SPECI alerting function provided by controller-initiated flight information service. [Safety issue]
  
• For many nonmajor 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 weather conditions at such airports, increasing the risk of flight crew not being aware of the changes at an appropriate time to support their decision making. [Safety issue]
  

Other findings

• The flight crews of Velocity 1384 and Qantas 735 planned for, and uploaded, sufficient fuel for the forecast conditions at Adelaide Airport in accordance with the respective operator's fuel policies.
  
• The flight crew of Qantas 735 proactively sought weather information for various airports soon after departing Sydney.
  
• The meteorological information obtained from an Aerodrome Weather Information Service (AWIS) is operationally equivalent to that provided in routine (METAR)/special weather (SPECI) reports. However, as the AWIS broadcast doesn't contain the label 'SPECI', pilots are required to recognise and interpret its operational significance.
  
• Critical to the assurance of safe flight, all elements of the aviation system including weather services, air traffic services, aircraft operators and flight crews need to have a clear understanding of their roles and responsibilities in that system.
  

Safety issues and actions
The safety issue identified during this investigation is listed in the Findings and Safety issues and actions sections of this report. The ATSB expects that all safety issues identified by the investigation should be addressed by the relevant organisation(s). In addressing those issues, the ATSB prefers to encourage relevant organisation(s) to proactively initiate safety action, rather than to issue formal safety recommendations or safety advisory notices.

All of the directly involved parties were provided with a draft report and invited to provide submissions. As part of that process, each organisation was asked to communicate what safety actions, if any, they had carried out or were planning to carry out in relation to each safety issue relevant to their organisation.
The initial public version of these safety issues and actions are repeated separately on the ATSB website to facilitate monitoring by interested parties. Where relevant the safety issues and actions will be updated on the ATSB website as information comes to hand.

Limited provision of flight information service for some nonmajor airports
For many nonmajor 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 weather conditions at such airports, increasing the risk of pilots not being aware of the changes at an appropriate time to support their decision making.

ATSB Safety Issue No: AO-2013-100-SI-01
 
Alerting function of special weather reports (SPECI) is not met by the automatic broadcast services

The automatic broadcast services did not have the capacity to recognise and actively disseminate special weather reports (SPECI) to pilots, thus not meeting the intent of the SPECI alerting function provided by controller-initiated flight information service.

ATSB Safety Issue No: AO-2013-100-SI-02
ATSB Recommendation No: AO-2013-100-SR-057
 
Additional safety action

Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence.

Bureau of Meteorology
Although no safety issue was identified by the ATSB, the Bureau of Meteorology advised of the following safety action in response to this occurrence:

• A review of Trend Forecast services was undertaken through a consultative process with the aviation industry and the Australian Defence Force. The reasons for reviewing Trend Forecast services include:
  

The TTF format is unique to Australia.

Although the TTF and TAF are forecasts for the same aerodrome, they convey different information concerning the probability and timing of meteorological phenomena.

Perceived conflict information between TAF and TTF as TAF can mention probabilities of 30 and 40 per cent, whereas TTF is a forecast of the most likely outcome over the next three hours.

The report on the Review of the Trend Forecast was released for comment on the 29 September 2015. The closing date for feedback is 29 January 2016. At the time of release of this report, the BoM was progressing the action items from the report and will discuss the outcomes with CASA.

• Aviation Cameras for Forecasters (AvCam). For the 2015–16 financial year [FY] the BoM will install weather cameras at 15–20 locations at major capital city aerodromes, including Adelaide airport, and key regional aerodromes. The AvCam project [will] provide an additional tool for forecasters to assess current weather conditions, including fog, to supplement human observations or other automated present weather sensors and instrumentation.
  
• Trial Automation of Observations at Cairns and Canberra (TAOCC) Project. Information from the trial could be used to enhance observations and better define the capability requirement at all airports (completion expected 2017).
  
• Centralised Aerodrome Weather Information Service (C-AWIS) Project (completion expected 2015/16 FY). The Centralised-AWIS (C-AWIS) project aims to deliver a cost effective and reliable replacement to the current AWIB/AWIS that will centrally process AWS data.
  
• Aviation Verification System (AVS) 2 (due to be completed in 2017). The implementation of the next generations of TAF verification, AVS2, aims to:
  

- Improve the accuracy of forecasts in relation to predicting the onset and cessation times for thunderstorms and below minima conditions at airports;

- Result in developing a less conservative forecast approach for significant weather events (with below minima conditions);

- Improve forecaster responsiveness in amending forecasts after weather events have passed;

• Climatology Interface Development Project. This project aims to develop a new national climatological interface for the display and interpretation of climate information at aerodromes and key aviation locations (due to be completed in 2017).
  
• In September 2015 the BOM implementation of Himawari 8 satellite data. Himawari-8 provides observations that enable the Bureau to create true-colour images of the Australian region, every ten minutes, based on reflected visible light. These are useful, for example, for identifying fog and low cloud, which may not be visible in thermal infrared images because it has a similar temperature to the ground below.
  
• The BoM’s Aviation Weather Services already has a formal process in place to conduct regularly consultative meetings/workshops with key aviation stakeholders to identify improvements and current and future requirements.
  

Virgin Australia Airlines Pty. Ltd.
Although no safety issue was identified by the ATSB, Virgin Australia Airlines Pty. Ltd. (Virgin) advised of the following safety action in response to this occurrence:

• The flight following policy was rewritten. This included clarification of the minimum requirements of the service provided (i.e. definition of notifiable updates) and removal of the differentiation between passive and active flight following such that all flights are now flight followed.
  
• Amended flight planning policy to apply ‘worst case’ of TAF or TTF forecast conditions.
  
• Introduction of an adverse weather flight planning policy.
  
• Review of Flight Watch/Following activities across several carriers to obtain best practice for this activity – Virgin America and Westjet were visited.
  
• Central Flight Watch desk dissolved and Flight Following introduced mid 2014 with desks split up into regions and Flight Following assigned to individual desks.
  
• Pilot weather updating requirements have been clarified and enhanced and ACARS [aircraft communications addressing and reporting system] equipment continues to be rolled out across the Virgin fleet.
  

Alerting function of special weather reports (SPECI) is not met by the automatic broadcast services

Issue number: AO-2013-100-SI-02

Who it affects: All pilots operating into non-major airports accessing an automatic broadcast service

Issue owner: Airservices Australia in consultation with the Bureau of Meteorology

Operation affected: Aviation: Air transport

Background: Investigation Report AO-2013-100

Date: 31 May 2016

Safety issue description

The automatic broadcast services did not have the capacity to recognise and actively disseminate special weather reports (SPECI) to pilots, thus not meeting the intent of the SPECI alerting function provided by controller-initiated flight information service.

Proactive Action

Action organisation: Airservices Australia
Date: 31 May 2016
Action status: Released

In response to this safety issue, Airservices advised the following:
Airservices appreciates the opportunity to provide comment on the additional safety issue and supporting documentation in relation to ATSB Investigation A0-2013-100 provided on 26 April 2016.

Airservices agrees with the safety issue and acknowledges that automatically generated SPECls from Automatic Broadcast Service (ABS), while operating as designed, may not be readily apparent to crew in situations where weather conditions change rapidly and differ from forecast conditions.

As discussed with the ATSB and Bureau of Meteorology (BoM) on 16 April 2016, just as it is not practical for pilots to continuously monitor SPECls whilst within one hour flight time of destination, it is also not practical for ATC to continuously monitor and disseminate SPECls. This is due to the volume and frequency of automatically generated SPECI data at locations with ABS, particularly in recent times where more sensors are available at unmanned weather stations. There is currently no mechanism as part of the ABS to filter the SPECI data to delineate that which is operationally significant to a flight.

To address the safety issue Airservices considers that a meteorological system-based solution is likely to be required, and Airservices is available to support the BoM to progress the feasibility assessment work and identify suitable design and implementation options. This work could potentially be progressed in the form of a BoM-led working group including the aviation industry.

ATSB response:

The ATSB notes Airservices agreement with the issue and intention to work with the Bureau of Meteorology to establish a solution. However the ATSB is concerned that Airservices, as the agency that provides flight information service in Australia, has not taken responsibility for the resolution of this safety issue. In addition, the indefinite nature of the proposed activity does not provide a high degree of confidence that the safety issue will be adequately addressed.

As a result, the ATSB has issued the following safety recommendation.

Recommendation

Action organisation:Airservices Australia
Action number: AO-2013-100-SR-057
Date: 31 May 2016
Action status: Released

The ATSB recommends that Airservices Australia as the safety issue owner works in collaboration with the Bureau of Meteorology to instigate a system change to reinstate the alerting function of SPECI reports currently not available through an automatic broadcast service

On my first run through I have to say WTH was the hold up

Update: Before it gets muzzled on the UP, there is currently a thread running commenting on that bollocks report with some worthy posts:

Ozbiggles - 3 years later The Mildura report

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3 years later the ATSB final report finally appears.
Cover page - First safety message. Pilots are reminded of their responsibility for collecting all relevant information to support inflight decision making...
Qantas did that and ended up in the situation they did.
The report says the forecast was inaccurate in terms of significance and length of the fog at Adelaide and the Mildura met wasn't accurate either.
I have a feeling this report will make the Norfolk report look like a Shakespearian classic.

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Nothing to see here.

Quote: This occurrence has highlighted the effect of various factors coming together to create and influence a rare event.

The VA 737 landed with less than 15 mins of fuel and essentially no one stuffed up (not BOM, not ATC, not Crew, not Ops Control/Dispatch). - and if it wasn't for the QF skipper taking extra fuel they would have been in the same boat...

What is wrong with the ATSB?!!



When will we be like the rest of real world and carry technical alternates.

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framer - From the report:

Quote: The availability of a code grey forecast is unique to Australia, and is used to highlight the possibility of weather conditions that airline operators may wish to consider in terms of flight planning.

How are code grey forecasts promulgated?
Can a crew look at them on the internet or is it only available to Airlines?

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ozbiggles - 3 years to tell us what the aircraft did, nothing new from the interim report.

This was an opportunity for a top down dissection of how business Is done in this country. Two aircraft from different companies ended up on a country airstrip conducting emergency landings and the conclusion is they should have been getting more regular updates on inaccurate forecasts?

What about the infrastructure? All modern jet aircraft can auto land, in fact the report mentions when emergency autolands have saved us in the past. No recommendation to mandate it at capital airports at least? The bean counters will tell you it's not statiscally significant to warrant the expense but how many times has it saved the day already?

The NOC, National Operations Centre. What the hell does it do, it seems to have got involved right about the time both aircraft were in the circuit area at Mildura. Shouldn't the NOC be the centre of knowledge and information for these types of unfolding events or is it just somewhere in Canberra to sit and drink coffee? Surely we should have a central point for ASA,BOM, major airlines to co-ordinate unfolding scenarios so all the missed opportunities that occured here don't happen?if not why not?

ASA who the hell decided that not passing on SPECIs wasn't going to cause any real problems? That if they can only get that information within visual range it wouldn't be an issue. What the hell is going on there with risk mangement and what other chocolate eggs are hidden?

How did it happen the AIP didn't reflect the intent of the change at ASA? Where else is this a problem. How come the majority of the pilot group didn't know this was the intent?

This just on the first read, I'm sure there is more

How did it happen they had to ask CASA for an interpretation of inflight fuel requirements? Haven't we sorted that out in 100 years of flying.

Nothing on if current fuel policy is appropriate or what other countries might use.

We did cover the big issue that the air ambulance pilot didn't start his radio call with Airep, glad that made it in.

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Quote:When will we be like the rest of real world and carry technical alternates.

Probably when parasitic corporate bean counters stop running flt ops. I would advise not to hold your breath.

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ozbiggles - This report should have been a good chance to begin a move to mandate it. But it didn't touch that elephant in the room. That would have been a bit bold. Unless it's mandated the inmates will continue to run the asylum charging $1 tickets....checked baggage not included. Surely fuel policy and facilities should have been the main thrust of this report. Forecasting is a black art, getting lost in the aviation world. It will never be 100% therefore the risk controls would be fuel, facilities and timely supply of bad news...but we did find out the air ambulance pilot didn't say Airep....

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P2 - And for a possible candidate for QOTM...

hotnhigh - Quote: When will we be like the rest of real world and carry technical alternates

They did.....Mildura

  

MTF...P2