[Peetwo]

AA summary article of ATSB VH-OWN FR:

LACK OF ACCURATE POSITION REPORT BROADCASTS, INCORRECT MISSED APPROACH CONTRIBUTED TO KING AIR NEAR MISS – ATSB

written by Australianaviation.Com.Au June 29, 2018

Two Beech King Airs came within approximately 300ft vertically of each other on approach to Mount Hotham Airport as the pilot of one of the aircraft grappled with GPS and autopilot difficulties while flying in instrument meteorology conditions, an Australian Transport Safety Bureau (ATSB) final report has found.

In the September 3 2015 incident, King Air VH-OWN was found to have come within around 300ft vertically of another King Air, VH-LQR, that was also on approach to Mount Hotham Airport, which is located at 4,300ft above sea level in the Victorian alps.

The ATSB report found the pilot of VH-OWN, who was also the pilot of a King Air that crashed shortly after takeoff from Essendon Airport in February 2017, killing all five people on board, had descended the aircraft below the minimum altitude and exceeded the tracking tolerance of the approach to Mount Hotham after experiencing GPS and autopilot difficulties.

“The pilot twice climbed the aircraft without following the prescribed missed approach procedure and manoeuvred in the Mount Hotham area,” the ATSB report said.

“During this manoeuvring, the aircraft came into close proximity to another King Air, registered VH-LQR, which had commenced the same approach.”

The ATSB report said air traffic control had limited radar coverage of the area.

However, investigators sourced radar data from the Department of Defence (Defence controlled East Sale airspace lies to the south of Mount Hotham) which found VH-OWN passed 300ft below VH-LQR.

Further, the report said the actions of the pilot of VH-LQR, who stopped descent when confronted with inconsistent position information from VH-OWN, helped avoid a collision.

“After detecting inconsistencies in the position reports from the pilot of VH-OWN, the pilot of VH-LQR stopped his descent at 8,000ft,” the ATSB report said.

“As a result, the separation between the aircraft was around 300 ft, ± 150 ft, and a collision was likely avoided.”



ATSB SAYS VH-OWN PILOT EXPERIENCED HIGH WORKLOAD AND GPS/AUTOPILOT DIFFICULTIES

The ATSB report found the pilot of VH-OWN did not track via the prescribed missed approach and prescribed holding pattern when experiencing GPS/autopilot difficulties, and did not communicate this to the air traffic controller or other aircraft in the area.

“This increased the risk of a collision,” the ATSB report said.
“Due to high workload and difficulties with the operation of GPS/autopilot system, the pilot of VH-OWN did not broadcast accurate position reports, resulting in reduced separation, and a near-collision, with VH-LQR.

“The pilot’s ability to follow established tracks and accurately communicate the aircraft’s position was likely adversely affected by experiencing a high workload, due to factors including single-pilot IFR operations while conducting an area navigation (RNAV) global navigation satellite system (GNSS) approach, existing weather minimums and the reduced available flight automation.”

The ATSB report said the pilot of VH-OWN voluntarily suspended RNAV operations until he could undergo independent flight testing by the Civil Aviation Safety Authority (CASA).

“This testing by CASA then resulted in a recommendation that the pilot complete remedial training before undergoing a further flight test,” the report said.

“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.”

The ATSB said in its safety message on the incident that “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. “

While on the subject of O&O'd ATCB investigations and final reports, I note that yesterday HVH's minions released another 'bollocks' update to yet another Scair Asia occurrence investigation...   

The ATSB has released its preliminary investigation report into the operational non-compliance of an Airbus A320 at Perth Airport, in Western Australia, on 24 November 2017. Preliminary report:
https://www.atsb.gov.au/publications/inv...-2017-114/

---

Preliminary report published: 29 June 2018

Sequence of events

On 24 November 2017, at about 1200 Western Standard Time,[1] the crew of an Airbus A320 aircraft, registered PK-AZE and operated by AirAsia Indonesia, was being prepared to depart on a scheduled passenger service from Perth Airport, Western Australia for Denpasar (Bali) Airport, Indonesia. The captain was designated as the pilot monitoring and the first officer (FO) was designated as the pilot flying.[2]

While the captain was conducting the pre-flight walk around, the FO entered the flight plan into the flight management guidance computer (FMGC). Believing that they would be using runway 03 for take-off, as they had recently landed on this runway, he entered this into the FMGC. He then listened to the automatic terminal information service,[3] which indicated the runway-in-use was runway 21. When the captain returned to the fight deck, the FO completed the pre-flight and departures briefing using runway 03. At 1201, the crew received their clearance from air traffic control (ATC) to depart for Denpasar using the AVNEX TWO standard instrument departure (SID)[4] and to climb to 5,000 ft using the SID (Figure 1). At 1213, the crew commenced taxiing. The crew also received ATC clearances to taxi to, and line-up on runway 21, which was read back correctly by the crew.

Figure 1: AVNEX TWO standard instrument departure

Source: Naviga, modified by the ATSB

At 1220, the aircraft took off from runway 21. Shortly after take-off, the aircraft was turned left at 260 ft above mean sea level (AMSL) (Figure 2), which was contrary to the SID procedure and below the minimum safe altitude stipulated by the operator. The runway 21 SID required a right turn at or above 2,500 ft at waypoint[5] NAVEY (Figure 1) and the operator stipulated that turns should not be commenced below 400 ft above ground level.

After observing the aircraft turning left on radar, ATC re-cleared the crew onto an assigned radar heading. ATC later confirmed with the crew they were issued with the AVNEX TWO SID and asked if operations were normal. The crew reported operations normal and the aircraft was turned to intercept the flight planned route and continued to Denpasar without further incident.

Recorded data

The aircraft’s flight data recorder was downloaded and a copy was provided to the ATSB. A review of that recording found:

• 
  
• the waypoint MIDLA was the first selected waypoint in the flight management guidance computer, which was the first waypoint on the AVNEX TWO SID for runway 03 (Figure 1)
  
  
• when manually flown, the aircraft was turned left at 260 ft AMSL
  
  
• after multiple heading changes were made by the crew, waypoint SWANN was selected at 8,104 ft, which was the second waypoint on the runway 21 AVNEX TWO SID.
  

Ongoing investigation

The investigation is continuing and will consider the following:

• 
  
• operator pre-flight procedures and checklists
  
  
• crew training and qualifications
  
  
• aircraft systems.
  

This is clearly a 'something nothing' investigation, that by anyone's measure should have been discontinued (or possibly written up as a 'desktop' short investigation bulletin) well before now. 

The curious thing is this investigation update is listed as a 'preliminary report'. However we all know, that according to ICAO Annex 13, that a preliminary report should be completed and dispatched to ICAO and DIPs within 30 days of the occurrence (ref: Ch 7 para 7.4) not 7 months after the occurrence - 

Q/ Could it be we have a 'notified difference' to that requirement? 

Not according to the 11 page PDF on our NDs to Annex 13:  http://www.airservicesaustralia.com/aip/...gation.pdf

So again we have some unexplained aberration with yet another ATCB Scair Asia occurrence investigation. Coincidence? - Yeah right..  

TICK..TOCK miniscule, TICK..TOCK indeed...
        


MTF...P2