[Peetwo]

O&O investigation: AO-2015-108 1029 days to completion - UDB! 

Via the ATSB website today:

• Final Report
  

Final Report
Download final report
[DownloadPDF: 3.16MB]
 
 
Listen to this PDF[img=10x0]https://www.atsb.gov.au/Assets/readspeaker_small_blue.png[/img]
Alternate: [DownloadDOCX: 5.74MB]
 
What happened
On 3 September 2015, several multi-engine turboprop aircraft converged on the airspace above Mount Hotham Airport, Victoria, as part of a multi-day charter involving several operators. While conducting a number of area navigation (RNAV) Global Navigation Satellite System (GNSS) approaches, the pilot of a participating Beech Aircraft Corp B200 (King Air) aircraft, registered VH‑OWN, descended the aircraft below the minimum altitude and exceeded the tracking tolerance of the approach after experiencing GPS/autopilot difficulties. The pilot twice climbed the aircraft without following the prescribed missed approach procedure and manoeuvred in the Mount Hotham area. During this manoeuvring, the aircraft came into close proximity to another King Air, registered VH‑LQR, which had commenced the same approach. Both aircraft were in instrument meteorological conditions and unable to sight each other. Significant manoeuvring was also observed as VH‑OWN was on final approach to the Mount Hotham runway. All aircraft landed safely at Mount Hotham without injury to passengers or crew.

What the ATSB found
Difficulties in operating the GPS/autopilot resulted in the pilot of VH‑OWN experiencing an unexpected reduction in the level of supporting flight automation, and a significant increase in workload, while attempting to conduct RNAV (GNSS) approaches into Mount Hotham Airport. This increased workload affected both the pilot’s ability to follow established tracks such as the published approach and missed approach, and his ability to communicate his position accurately to other aircraft and the air traffic controller.

Although radar coverage in the area was limited, there were opportunities for the air traffic controller to identify when VH‑OWN was having tracking difficulties during all three approaches, and when VH‑OWN tracked towards the expected position of VH‑LQR. However, this position information was not effectively communicated, resulting in a missed opportunity to prevent a potential controlled flight into terrain and/or collision with VH‑LQR.

What's been done as a result
The pilot of VH‑OWN underwent flight testing by both a delegate of the Civil Aviation Safety Authority (CASA), and by a flying operations inspector employed by CASA, who recommended remedial training. Independent of this investigation, in February 2017 it became mandatory for all aircraft operating under instrument flight rules to be fitted with Automatic Dependence Surveillance – Broadcast, further increasing surveillance capability nationally, including in the Mount Hotham area.

Additionally, and independent of this investigation, the Department of Defence radar system, capable of surveillance in the Mount Hotham area, is scheduled for upgrade in late 2018. The radar system upgrade is likely to enhance the national air traffic system through the increased compatibility between that radar and the Airservices Australia surveillance system.

Safety message
Maintaining the pilot skill of operating an aircraft without the use of automation is essential in providing redundancy should the available automation be unexpectedly reduced. Additionally, as the responsibility for separation from other airspace users and terrain in Class G airspace lies with aircrew, it is imperative that pilots maintain the skills to navigate accurately, and interpret and utilise traffic information to maintain safe separation. From an air traffic control perspective, the occurrence highlights the safety benefit of communicating any apparent tracking anomalies and/or conflicts to the involved pilots.

Mount Hotham runway
[img=382x0]https://www.atsb.gov.au/media/5774582/ao2015108_picture-4.jpg?width=382&height=286&sharpen=2[/img]

Source: Mount Hotham Airport and Resort

P2 comment: IMO parts of the following extract rings some alarm bells...

The following day, the pilot of OWN, along with a Civil Aviation Safety Authority (CASA)‑approved testing officer, conducted a test flight in OWN which included a practice area navigation RNAV (GNSS) approach in daylight visual meteorological conditions. While the aircraft reportedly did demonstrate a minor tracking anomaly when approaching the final approach fix, this did not replicate the situation of the previous day. Further opportunity to test-fly the aircraft and/or the GPS was hampered when the pilot of OWN destroyed the GPS removable data card before the ATSB had commenced an investigation, making it impossible to replicate the conditions of the occurrence flight. This action was taken after the pilot was reportedly told the data card was likely corrupted.

The pilot of OWN voluntarily suspended RNAV (GNSS) operations until he could undergo independent flight testing by CASA. This testing by CASA then resulted in a recommendation that the pilot complete remedial training before undergoing a further flight test. Following the second flight test, the pilot was deemed proficient and competent to resume operations. At no time during the two test flights were any anomalies with the GPS and/or autopilot recorded by either the occurrence pilot or the CASA-approved testing officers. CASA, however, advised that no formal testing of the aircraft or its equipment was conducted during those two flights beyond observation of functionality.

Also coming out of HVH HQ today...

Via the ATCB twitter guy/gal:

The ATSB is requesting your feedback on the effectiveness of its engagement and communication.   Help us improve transport safety.  Visit the ATSB website to start our stakeholder survey:  http://www.atsb.gov.au/newsroom/news-items/feature-news-items/survey-2018/ …

10:47 AM - 27 Jun 2018

Err...no comments - they're all in the survey...


MTF...P2