[Peetwo]

Reference post -

Four incidents, a ditching & two cover-ups? - Safety risk mitigation Oz style.

Spot the disconnect - Part ??
Bizarrely even the ATSB twitter person missed this??? However last week the bureau put out the following presser (that was associated with this serious incident - report AO-2012-073):
  

Handling unexpected developments


A recent ATSB investigation shows how unexpected developments or confusion about procedures can contribute to decisions and actions that increase the safety risk to the aircraft.

In the incident, the crew of a Cobham Airline Services Boeing 717 aircraft, was conducting an instrument approach to land on runway 03 at Perth Airport.


The aircraft was conducting an approach in instrument meteorological conditions after a flight from Paraburdoo, Western Australia. When they reached the decision altitude, the crew initiated a missed approach procedure as they had not obtained visual reference with the runway.


Almost immediately, however, they obtained visual reference with the runway, discontinued the missed approach procedure and landed, despite the aircraft being in an unstable condition.


The ATSB found that the onset of fog at Perth Airport at the estimated time of arrival was not forecast until after the aircraft had passed the point in the flight when it had insufficient fuel remaining to divert to a suitable alternate aerodrome. Before that point, there had been no requirement for the aircraft to carry fuel to continue to a suitable alternate.


Under the circumstances, the flight crew considered that the better option was to discontinue the missed approach procedure and land, in spite of the aircraft being in an unstable condition due to the initiation of the missed approach.


This incident highlights the risk of an unstable approach from not following a missed approach through to its conclusion.


Unstable approaches are a frequent factor in approach and landing accidents, including controlled flight into terrain. The Flight Safety Foundation has developed an Approach and Landing Accident Reduction Tool Kit to reduce the risk of approach and landing accidents.


‘Handling approach to land’ is also a top safety concern in the ATSB’s SafetyWatch initiative. The ATSB has identified an increasing trend where pilots mishandle or mismanage their aircraft and flight profile when unexpected events arise during the approach to land.


The occurrence also highlights that during a flight, the forecast weather at the destination may change and it is advisable to obtain the most up-to-date weather forecasts.

However, pilots should be alert to the fact that the actual weather can differ significantly from forecasts.


Read the investigation report AO-2012-073
 








Last update 25 February 2016

This is an extract of the findings:

From the evidence available, the following findings are made with respect to the weather-related operational event involving a Boeing 717, registered VH-NXO, which occurred at Perth Airport on 1 June 2012. These findings should not be read as apportioning blame or liability to any particular organisation or individual.


Contributing factors

• The weather forecast for Perth Airport was amended to include the requirement to carry sufficient fuel to divert to a suitable alternate aerodrome when the aircraft no longer had that amount of fuel remaining.
  
  
• The captain, as the flying pilot, continued an approach to land after the approach had been destabilised by initiating a go-around procedure.
  
  
  

Other factors that increased risk

• The flight crew did not update the weather forecast for Perth Airport en route which, although in this instance did not indicate an operational requirement, was a missed opportunity to update pertinent operational information prior to the aircraft being committed to its destination.
  
  
  

Other findings

• Given the circumstances, when confronted by a choice between completing the missed approach with an indeterminate outcome and landing from a discontinued missed approach, the captain chose the option that was considered to represent lower risk.
  
  
• The operator’s procedures in the case of an unstabilised approach were unambiguous and reflected those promoted by the Flight Safety Foundation.
  
  

Now according to the investigation page the Final Report for AO-2012-073 was published on the 12 October 2015, i.e. 3 years 4 months & 12 days after the incident occurred; no surprises there I guess??

However what I do find absolutely unforgivable was this incident, with some very real comparisons to the Mildura Fog Duck-up..

"..The occurrence also highlights that during a flight, the forecast weather at the destination may change and it is advisable to obtain the most up-to-date weather forecasts.

However, pilots should be alert to the fact that the actual weather can differ significantly from forecasts..."

..was still being investigated after Mildura occurred and in parallel with that investigation and yet it does not even rate a mention - UFB!


MTF..P2