[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.


ATSB Safety Issue No: AO-2013-100-SI-01
 
ATSB Safety Issue No: AO-2013-100-SI-02

ATSB Recommendation No: AO-2013-100-SR-057 

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

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....

  

Further update 01/06/16:

Virgin jet forced to land at fog-bound airport after 'inaccurate forecasts'
Date May 31, 2016 - 6:18PM

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Matt O'Sullivan
Transport Reporter

A Virgin 737-800 similar to the one pictured had no choice but to land at Mildura because it was close to running out of fuel. Photo: Brendon Thorne

Inaccurate forecasts were partly to blame for a Virgin Australia jet making a last-ditch attempt at an emergency landing as it nearly ran out of fuel, air-safety investigators have found.

Passengers on board the Boeing 737-800 endured a terrifying ordeal as they were told to "brace, brace, brace" and keep their heads down as the plane was forced to land at a fog-bound Mildura Airport on June 18, 2013.

The Virgin jet, which had 85 passengers and six crew on board and was on route from Brisbane, had earlier diverted from landing at Adelaide Airport due to fog.

Location of the fuel quantity indication on the upper display unit (circled in yellow). Photo: Australian Safety Transport Bureau

A Qantas 737 carrying 152 people bound for Adelaide from Sydney had also re-routed to Mildura, only to find fog and cloud had enveloped the Victorian town's airport.
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Once circling above Mildura, the two planes had no choice but to land because they did not have enough fuel left in their tanks to divert to other airports.

In one exchange between the two planes, the Qantas pilots told their counterparts on the Virgin 737 that they were going to land at Mildura "due [to] fuel".

The Virgin pilots replied that they were "in the same boat" but decided to let the Qantas plane land first, which it managed to do safely.

Shortly afterwards, the Virgin plane made a "missed approach" during which the pilots were able to confirm that they were aligned with the runway as they looked directly down.

The Virgin pilots then briefed cabin crew to prepare for an emergency landing, and passengers were told to "brace". The plane eventually landed safely at Mildura.

In a final report released on Tuesday, the Australian Safety Transport Bureau found the deterioration in weather at Adelaide did not appear on the forecast when the two planes took off.

An updated forecast also predicted that the fog would lift at Adelaide sooner than it actually did.

It led to the Qantas jet flying on to Adelaide because the crew had reasoned that the fog would clear by the time they had reached South Australia's capital.

Investigators said the forecasting also influenced the decision making of Virgin's flight watch staff who did not pass the amended weather report onto the pilots of the airline's 737 en route.

By the time the planes reached Mildura, the weather was "significantly worse" than originally forecast, and they were forced to land in conditions below the level usually allowed for planes do so.

In response to the incident, the manager of the country's airspace, Airservices Australia, said it will look at "feasible options" to provide information about significant deteriorations in weather to solve limitations of automated broadcast services.

The Bureau of Meteorology has also said it has made "various system changes".

The final report from the ATSB comes two years after it was scheduled to be released


Read more: http://www.smh.com.au/national/virgin-jet-forced-to-land-at-fogbound-airport-after-inaccurate-forecasts-20160531-gp82j8.html#ixzz4AH1VkKC2
Follow us: @smh on Twitter | sydneymorningherald on Facebook

Next from Planetalking posting from OS yesterday... :

ATSB reports on two 737s blindsided by fog at Mildura ... in 2013

Virgin Australia and Qantas each found one of their 737s in peril three years when they were forced by inadequate fuel loads to divert to Mildura in a weather crisis that became much worse as they prepared to land at the country town


Ben Sandilands


Where the Virgin and Qantas 737s were when it all went pear shaped one foggy foggy morning

One of the most serious incidents ever involving Virgin Australia and Qantas when they landed 737s diverted to Mildura only to be blindsided by fog and carrying low fuel reserves, has finally been reported upon by the ATSB three years after it happened.

The safety agency’s report is as disappointing in its summary form as the incident, on June 18, 2013, is itself frightening.

It was brought about by a combination of factors described in detail in the full report, which Virgin Australia and Qantas may well hope no one in the flying public takes time to read.

As reported by Plane Talking last year and on many other occasions, both jets, a Virgin Australia flight to Adelaide from Brisbane, and a Qantas flight to Adelaide from  Sydney, couldn’t complete their journeys as they approached South Australia because of fog.

They diverted, as did a number of smaller regional flights, to Mildura, for which they were given incorrect meteorological data suggesting the Riverina town was clear, but it wasn’t.

It too lay under a deep blanket of fog.  The upshot of various missed approaches by the jets was that the Virgin 737 eventually had to land despite considerable uncertainty as to whether it would find the runway, with the cabin prepped for a crash landing, passengers in the brace position, and calls of ‘brace, brace,brace’ from the flight attendants.

There was about as much fuel left in the tanks of the Virgin jet as the body mass of five adults. There wasn’t enough fuel to perform another go around. It had to land, or crash.

This was a very confronting moment for air safety in Australia, raising troubling questions (as yet unanswered) as to why Australian airlines are allowed to skimp on inter city fuel compared to those in most of the developed and much of the undeveloped world. It highlighted the standard and quality and competency of our meteorological services for aviation.

And it brings out, now, in the craven language of the summary of that incident, the chronic evasiveness of our aviation safety guardian, the ATSB, when it comes to anything that might conceivably embarrass the airlines, or the authorities, or cause legitimate concerns among travellers.

The full report is another matter. It will no doubt cause controversy in pilot ranks and more than a little concern as to whether Australia is actually capable of dealing with serious issues in air safety regulation and investigations at all, but it doesn’t on first reading on the other side of the world, do anything more offensive than trying to bury them from coming to the attention of inquiring minds.

MTF...P2