[Peetwo]

World's best practice in CYA Aviation Accident Investigation -

K - If, you thought the Pel-Air epistle was an aberration; a one off, think again.  This latest abomination, following closely on the heels of the Mildura aberration speaks clearly of the total shambles ATSB has become under Dolan.

IMO there is no better example of how much damage Dolan has inflicted on the ATSB, in the 7 years he has been in charge, than in this 'interim report'.

To begin why after 847 days are we just now getting an interim report? Surely as a 'accident' investigation proper resources should have been allocated to progress this investigation beyond an interim report. Apparently this report was initiated because a 'safety issue' had only just been identified?

Although the investigation is not yet complete and covers a range of areas, a safety issue has been identified that, in the interests of safety, needs to be brought to the attention of the industry before the investigation is completed.

  
Yet if you refer to the 1st interim report issued 2 years ago (10 June 2014) even Blind Freddy can see that the 'safety issue' now identified...

Inadvertent activation of the elevator control system - pitch uncoupling mechanism

Inadvertent application of opposing pitch control inputs by flight crew can activate the pitch uncoupling mechanism which, in certain high-energy situations, can result in catastrophic damage to the aircraft structure before crews are able to react.
ATSB Safety Issue No: AO-2014-032-SI-01

 ...was also clearly identified back then:

...The flight crew of the earlier pitch‑disconnect flight and the engineers involved in the post-flight maintenance were interviewed and the damage to the aircraft was inspected at Albury. The ATSB downloaded data for the pitch-disconnect flight and subsequent flights from the flight data recorder and data for the pitch‑disconnect flight and last flight from the cockpit voice recorders that were installed in the aircraft for those flights.

Initial examination

An initial examination of the recorded data showed that when the airspeed approached 240 kt, at about 8,500 ft during the descent into Sydney on 20 February, the first officer used touch control steering and manually pitched the aircraft up. The airspeed increased again and then both the first officer and captain pulled on the control column. Shortly after, when the vertical load factor was increasing through 1.8 g, the first officer began to push the control column. The differential force on the control column that resulted from the captain and first officer applying an opposing force exceeded the differential force required to generate a pitch disconnect. Each pilot was then controlling the elevator on their side of the aircraft in opposite directions for a brief period before the first officer released his control column.

The aircraft manufacturer inspected the aircraft and found broken carbon plies, cracked joint sealant, and deformation in and around the area where the horizontal stabiliser attaches to the vertical stabiliser (Figures 2 and 3). There was also some minor damage to the rudder. The damage was assessed as being consistent with an overstress condition. Subject to further assessment and non-destructive testing, the aircraft manufacturer recommended replacement of the horizontal stabiliser, elevators, and vertical stabiliser...

 
IMO this is another blatant attempt to obfuscate a very serious causal chain of events that, if not for the luck of the gods, could have led to the worst recorded number of fatalities for any Australian aviation accident. We must remember that VH-FVR flew 13 more sectors with a severely bent horizontal stabiliser, before it was grounded in Albury after a suspected bird strike occurrence.

The other point to note is that the only reason this occurrence is listed as an 'accident' is due to the cabin crew member being seriously injured in the course of the event:

At some point the cabin crew called the cockpit and advised that the senior cabin crew member had injured her leg and that it might be broken. In the next contact with air traffic control the crew asked for an ambulance to be available after landing. The crew also made a PAN[4] call and requested runway 16 Right to minimise taxi time on the ground. Air traffic control agreed to that request.

   
{P2 comment: One wonders that if the unfortunate injury to the cabin crew member did not occur whether there would have even been a ASIR submitted to the ATSB}

Another indicator, that backs both the P7 & P9 summations, that this is another attempted ATSB whitewashed investigation is buried in the following text from the interim report:

..However, it shows that the aircraft was in a situation where inadvertent control inputs could lead to catastrophic failure of the horizontal stabiliser.

In normal operation, flight crew should not be making uncoordinated simultaneous control inputs. However this, and a number of other in-flight pitch disconnect occurrences, indicate that the pre‑existing procedural risk controls alone may not be sufficient to prevent this type of occurrence. Also, on this occasion, significant structural damage was done to the aircraft before the crew were alerted to, and able to react to the disconnection of the left and right pitch systems. Consequently, the ATSB is investigating whether the design of the pitch control and associated warning systems increases the likelihood of potentially catastrophic damage occurring when flight crew inadvertently make opposing pitch control inputs. The final report will contain a detailed assessment of this aspect of the investigation...

 
 And also from earlier in the report:

Although not shown in the previous figures, the yaw axis effort (pilot load applied to the rudder pedals), indicated that the applied load exceeded the value that would result in the automatic disconnection of the autopilot.[14] That load exceedance occurred at 05:40:51.9, about the time that the autopilot disconnected. However, due to the data resolution and lack of a parameter that monitored the pilot’s disconnect button, it could not be determined if the autopilot disconnection was due to the load exceedance or the manual disconnection reported by the captain.

 Now I know that this incident, if nothing else, proves ATR is obviously an extremely robust aircraft but the statements made in the above interim report text should IMO have automatically created a worldwide safety alert to this potential safety issue. Not a grounding as such but a heads up leading to a mandatory AD or safety notice. For history has proven over and over that if it can be done once the chances are it can be done again.
That important message should not be buried in the general context of an ATSB report (interim or otherwise) and left basically as a general comment for further investigation. What are we to wait another 847 days for the ATSB to tell us they've identified yet another safety issue -

Please someone(?), anyone(?) bring back sanity & veracity to the ATSB...  

MTF...P2

Ps  Q/ Why was there no 2nd interim report (update on investigation) on the 1st anniversary of the investigation?

[P7_TOM]

There is another scenario which could be worth considereing – the ‘turbulence’ event has not been defined, according to the scriptures.

According to the Aeronautical Information Manual (AIM) there are 4 major categories of turbulence: Light, Moderate, Severe and Extreme.

Intensity Reporting Term-Definitions.

Light Turbulence that momentarily causes slight erratic changes in ;altitude and/or attitude (pitch, roll, yaw). Report as Light Turbulence or Turbulence that causes slight, rapid and somewhat rhythmic bumpiness without appreciable changes in altitude or attitude. Report as Light Chop. Occupants may feel a slight strain against seat belts or shoulder straps. Unsecured objects may be displaced slightly. Food service may be conducted and little or no difficulty is encountered in walking. Occasional – Less than 1/3 of the time.  Intermittent – 1/3 to 2/3.  Continuous – More than 2/3.

Moderate Turbulence that is similar to Light Turbulence but of greater intensity. Changes in altitude and/or attitude occur but the aircraft remains in positive control at all times. It usually causes variations in indicated airspeed. Report as Moderate Turbulence; or Turbulence that is similar to Light Chop but of greater intensity. It causes rapid bumps or jolts without appreciable changes in aircraft altitude or attitude. Report as Moderate Chop.1  Occupants feel definite strains against seat belts or shoulder straps. Unsecured objects are dislodged. Food service and walking are difficult. NOTE

1. Pilots should report location(s), time (UTC), intensity, whether in or near clouds, altitude, type of aircraft and, when applicable, duration of turbulence. 2. Duration may be based on time between two locations or over a single location. All locations should be readily identifiable.
 
Severe Turbulence that causes large, abrupt changes in altitude and/or attitude. It usually causes large variations in indicated airspeed. Aircraft may be momentarily out of control. Report as Severe Turbulence. 1 Occupants are forced violently against seat belts or shoulder straps. Unsecured objects are tossed about. Food Service and walking are impossible

1.High level turbulence (normally above 15,000 feet ASL) not associated with cumuliform cloudiness, including thunderstorms, should be reported as CAT (clear air turbulence) preceded by the appropriate intensity, or light or moderate chop.

We do know that turbulence was encountered before the in flight abnormality, could this ‘event’ have affected the HS in some way which in turn led to the control problems being created by an AP response to maintain the protocol selected against a hard/bent/ point?  When does the AP call it quits and give up the struggle?

Chicken and egg situation, not assisted by the lack of clear detail and definition of ‘what’  level of turbulence was encountered.  What has become clear is that this is a mighty tough air-frame, but something, somehow bent one of the more vulnerable parts out of alignment and shape.  

The forces stated as opposite for the control channel disconnect are nowhere near close; then there is the rudder pedal force question (why use a 1inop amount in calm conditions).  It is all passing strange.

"When set correctly, the activation torque is equivalent to opposing forces of 50 to 55 daN (about 51 to 56 kg force) being simultaneously applied to each control column.”

•  in the seconds leading up to the occurrence, there were a number of rapid increases in the recorded airspeed

•  the FO made three nose up control inputs correlating with the use of the touch control steering
•  at about time 05:40:50.1, or about 2.5 seconds before the pitch disconnect, a small load (pitch axis effort) was registered on the captain’s pitch control

•  the captain started to make a nose up pitch input shortly before the FO made the third nose up input

•  when the FO started moving the control column forward (nose down) at about 05:40:52.3, the load on the captain’s control increased (nose up) at about the same rate that the first officer’s decreased

•  at 05:40:52.6 the elevators uncoupled. At that time: the load on the captain’s control column was 67 daN and on the FO’s -8.5 daN

I’ve seen “K’s” list of questions, a genuine four pages of serious, unanswered tough ones.  I can with some certainty answer one.  This aircraft did not run into a bird; it hit the bloody great big elephant.

[ventus45]

P7,

I think that the "elephant", which "caused" the initial speed excursions, was simply mountain wave.

In the image below, note the winds.
50 knots @ 10,000 ft (700hpa) and 30 knots at 5,000 ft (850hpa) out of the WNW over the average 3,500 to 4,000 foot high ranges west of Sydney = bumpy, with a capital "B".



PS: Is "K" going to publish his 4 page list of questions ?

And that tailplane does appear to be "twisted" ?

[thorn bird]

Personally I prefer the old coffee definition of turbulance, much simpler.
Light turbulence is defined as your coffee slopping around in your cup without actually spilling.
Moderate turbulence occurs when coffee slops out of your cup.
Severe trubulence is apparent if white caps appear on the surface of your coffe, and or you cant find the cup.

[Kharon]

Q, but no A : ala Estimates.

“V” - PS: Is "K" going to publish his 4 page list of questions?

In short, no mate.  Lots of reasons for that, but mostly because happily, no one else apart from the SFA, got hurt, which means there is no inquiry platform available, so no answers.  Apart from that, both ATR and VARA have some very competent folk and I am certain that the ‘questions’ have been properly addressed; and, whatever measures they have put in place to reduce the risk of a reoccurrence are properly promulgated and executed.  ‘Experts’ such as these have little use for the ATSB ‘conclusions’ or, indeed the time to waste waiting for ‘the’ report.  Which leaves ATSB with only the public and the politicians to deal with. QED – ‘the’ official report is published with the absolute certainty that few will actually read it and even fewer again will understand half of it, let alone question it.

But yes, it would be ‘bumpy’ coming into Sydney that day – but not too bad, the crew had a speed reduction on which seems sensible and proper, everyone strapped in by 10,000 is prudent.   But there are gaps in the Met analysis, I note that the 16 runways were in use, but cannot find the TAF or better the ATIS for the time which would provide some clues; was there an inversion?, was there a shear line? Had other crews reported speed excursions?  I get the impression from the ATSB that the aircraft was in ‘smooth’ conditions when the ‘speed’ event occurred. I’ve had this happen a number of times, it’s spooky, the aircraft gets a wriggle on without an immediately apparent reason. Happens around thunderstorms, wind shear lines, at the top of an inversion, when there is an air-frame problem (twice), when there has been a trim overrun or runaway (four off); and, just once, when an AP went rogue.  All dealt with as per; and never, ever, not once, did I need to use 67daN pull or push force to correct a 15-20 KIAS non scheduled speed increase.  Put it to a physical test; try at the gym, sitting; the math is simple enough, load the weights on then see just how much physical effort is required.  Try generating the published rudder loading against a torque meter:  have your Weetbix, then try it, then, while recovering - wonder at just WTF was going on.

Jumping past a few other interesting points, we arrive at the claim of things being ‘heavy’; this implies a force opposing the movement of both control and trim.  How would you address a speed excursion in normal conditions? Perhaps a squeeze of power off, a small suggestion of back stick and a handful of trim – job done; repeat as necessary.

Perhaps the above is all a bit vague, but then I don’t have to draft a report for my lords, masters and peers.  Something bent a serviceable aircraft, a tough, proven reliable air-frame.  Fact, there was a speed excursion – a minor one; fact, that excursion could not be corrected by normal means; fact, we have no idea why these events occurred, not really, and most certainly not from the ATSB rambling, conflicted dissemination they dare call a report.   Thank the gods that the real expertise resides firmly with industry; can you imagine the unholy mess we’d be in if all we had to rely on was the ATSB overdue and obfuscated reports.

We must either save the dollars and rely solely on industry; or get the ATSB back to taws; or contract the work to another agency. Why?  Well I’ll tell you, this incident was investigated because of an accident – the SFA busted undercarriage – why, how and what remedy has the ATSB suggested?   No “V”, no CF for guessing the answer; far too easy.

Aye well, that’s it from me on this subject, it makes me both sad and angry every time I read the wretched report thing.  So the great sobriquet ALT-FILE-DELETE is used, not satisfactory I know, but it’s not a fight I can win.  Out, out, brief candle!

Toot toot.

[Gobbledock]

Bloody hell. I spend 4 weeks in Montreal and upon returning I find that Australian aviation has plummeted to even newer lows than one thought possible!

Mildura incident - what a crock of shit. That is an infantile and poorly investigated (or should I say poorly covered over) event. ATSB = shame shame shame.

VARA incident - crock of shit number 2. A childish watered down report aimed at the Year 3 students at my grandsons school. ATSB = shame shame shame.

Dolan my friend, you truly depart the ATsB on an all time low. You are 'beyond embarressing'. Never in my aviation career have I come across such an incompetent, out of ones depth buffoon. You will go down in history amongst the likes of Roger Chambers, John McCormack, Warren Truss and Terry Farkwitson. Absolute fool.

As for Hoody, well don't hold onto your Toga's awaiting miracles folks. The chiselled one will tow the party line and do whatever his superiors ask of him. Pumpkin Head runs this ship and nobody else matters. Hoody will no doubt have robust intentions, and the bloke is pretty smart and well skilled. Potentially the right man for the job. But when you look at who his Master is (and might be) - the likes of perm boy Chester or the great white elephant Albanese, you can see how we are doomed. Unless ICAO head down under and slide this nation the pineapple of a lifetime, I fear nothing will change.

TICK TOCK

[Peetwo]

Hoodlum we may have a problem?

Irony of ironies, some 20 days ago we had the ATSBeaker (as it was then) release the bollocks 2nd interim report into investigation AO-2014-032 - see post: World's best practice in CYA Aviation Accident Investigation. This interim report was released because apparently after 847 days of ATSBeaker investigation a safety issue was identified... :

Inadvertent activation of the elevator control system - pitch uncoupling mechanism

Inadvertent application of opposing pitch control inputs by flight crew can activate the pitch uncoupling mechanism which, in certain high-energy situations, can result in catastrophic damage to the aircraft structure before crews are able to react.
ATSB Safety Issue No: AO-2014-032-SI-01

   
This interim report was apparently brought to the attention of the Indonesian AAI the NTSC who saw similarities to a reported incident involving an ATR-72 on the 27 June 2016, which they are now investigating:

Accredited representative to the Indonesian National Transportation Safety Committee investigation of the damage sustained by ATR 72 aircraft, registered PK-WG
 
Investigation number: AE-2016-069
Investigation status: Active
 

• Summary
  

On Monday 27 June 2016, the Indonesian National Transportation Safety Committee (NTSC) commenced an investigation into damage sustained by ATR 72 aircraft, registered PK-WGL. Initial examination of this damage suggested similarities with that found on an Australian-registered ATR 72, registered VH-FVR, which is being investigated by the ATSB (see ATSB investigation AO-2014-032 at ATSB website). On 29 June 2016, the NTSC requested the appointment of an ATSB accredited representative to the NTSC investigation in accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation Aircraft Accident and Incident Investigation. This was a result of the ATSB’s experience with the ATR during investigation AO-2014-032 and an accredited representative was appointed to the NTSC investigation that day. To facilitate this support, the ATSB initiated an investigation under the Australian Transport Safety Investigation Act 2003.

The NTSC is responsible for, and will administer the release of the final investigation report into the occurrence involving PK-WGL. Any enquiries regarding the NTSC investigation should, in the first instance, be directed to the:
Ministry of Transportation Fl. 3
Jalan Medan Merdeka Timur No.5
Jakarta  10110
INDONESIA 
Telephone:    +62 21 351 7606
Facsimile:  +62 21 351 7606
Email: knkt@dephub.go.id
Email: [email=knkt@dephub.go.id]knkt@dephub.go.id
[/email]Website: http://kemhubri.dephub.go.id/knkt
 
General details

Date: 27 Jun 2016
 
Investigation status: Active
 
Investigation type: External Investigation
 
Location   (show map): International
 
State: International
 
Occurrence class: Technical
 
Occurrence category: Technical Analysis
 
Report status: Pending 
 
 


Last update 01 July 2016

 
- I just love the irony of that NTSC request for an ATSB accredited rep, as per ICAO Annex 13 para 5.23:

Rights

5.23 Any State which on request provides information, facilities or experts to the State conducting the investigation shall be entitled to appoint an accredited representative to participate in the investigation.

Note.— Any State that provides an operational base for field investigations or is involved in search and rescue or wreckage recovery operations may also be entitled to appoint an accredited representative to participate in the investigation.

MTF...P2

[Gobbledock]

Shit I hope the Indo's listen to what the astute Alan Stray taught them and they don't follow the Beaker template for incident investigations. Otherwise there will be ATR's dropping from the sky over Indo waters!

Tick tock

[Peetwo]

Hoodlum we may have a problem?

Irony of ironies, some 20 days ago we had the ATSBeaker (as it was then) release the bollocks 2nd interim report into investigation AO-2014-032 - see post: World's best practice in CYA Aviation Accident Investigation. This interim report was released because apparently after 847 days of ATSBeaker investigation a safety issue was identified... :

Inadvertent activation of the elevator control system - pitch uncoupling mechanism

Inadvertent application of opposing pitch control inputs by flight crew can activate the pitch uncoupling mechanism which, in certain high-energy situations, can result in catastrophic damage to the aircraft structure before crews are able to react.
ATSB Safety Issue No: AO-2014-032-SI-01

   
This interim report was apparently brought to the attention of the Indonesian AAI the NTSC who saw similarities to a reported incident involving an ATR-72 on the 27 June 2016, which they are now investigating:

Accredited representative to the Indonesian National Transportation Safety Committee investigation of the damage sustained by ATR 72 aircraft, registered PK-WG
 
Investigation number: AE-2016-069
Investigation status: Active
 

• Summary
  

On Monday 27 June 2016, the Indonesian National Transportation Safety Committee (NTSC) commenced an investigation into damage sustained by ATR 72 aircraft, registered PK-WGL. Initial examination of this damage suggested similarities with that found on an Australian-registered ATR 72, registered VH-FVR, which is being investigated by the ATSB (see ATSB investigation AO-2014-032 at ATSB website). On 29 June 2016, the NTSC requested the appointment of an ATSB accredited representative to the NTSC investigation in accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation Aircraft Accident and Incident Investigation. This was a result of the ATSB’s experience with the ATR during investigation AO-2014-032 and an accredited representative was appointed to the NTSC investigation that day. To facilitate this support, the ATSB initiated an investigation under the Australian Transport Safety Investigation Act 2003.

The NTSC is responsible for, and will administer the release of the final investigation report into the occurrence involving PK-WGL. Any enquiries regarding the NTSC investigation should, in the first instance, be directed to the:
Ministry of Transportation Fl. 3
Jalan Medan Merdeka Timur No.5
Jakarta  10110
INDONESIA 
Telephone:    +62 21 351 7606
Facsimile:  +62 21 351 7606
Email: knkt@dephub.go.id
Email: [email=knkt@dephub.go.id]knkt@dephub.go.id
[/email]Website: http://kemhubri.dephub.go.id/knkt
 
General details

Date: 27 Jun 2016
 
Investigation status: Active
 
Investigation type: External Investigation
 
Location   (show map): International
 
State: International
 
Occurrence class: Technical
 
Occurrence category: Technical Analysis
 
Report status: Pending 
 
 


Last update 01 July 2016

 
- I just love the irony of that NTSC request for an ATSB accredited rep, as per ICAO Annex 13 para 5.23:

Rights

5.23 Any State which on request provides information, facilities or experts to the State conducting the investigation shall be entitled to appoint an accredited representative to participate in the investigation.

Note.— Any State that provides an operational base for field investigations or is involved in search and rescue or wreckage recovery operations may also be entitled to appoint an accredited representative to participate in the investigation.

Shit I hope the Indo's listen to what the astute Alan Stray taught them and they don't follow the Beaker template for incident investigations. Otherwise there will be ATR's dropping from the sky over Indo waters!

Tick tock

Update: Also now on the Planetalking blog, see my comment HERE:  

"...Damaged Virgin Australia turbo-prop risked crashing for five days
ATSB alerts the world to a safety issue that could have crashed a Virgin Australia turbo-prop..."

Ben Sandilands


Damage to the T-tail of the Virgin Australia ATR

MTF...P2  

[Peetwo]

Hoodlum we may have a problem?

Irony of ironies, some 20 days ago we had the ATSBeaker (as it was then) release the bollocks 2nd interim report into investigation AO-2014-032 - see post: World's best practice in CYA Aviation Accident Investigation. This interim report was released because apparently after 847 days of ATSBeaker investigation a safety issue was identified... :

Inadvertent activation of the elevator control system - pitch uncoupling mechanism

Inadvertent application of opposing pitch control inputs by flight crew can activate the pitch uncoupling mechanism which, in certain high-energy situations, can result in catastrophic damage to the aircraft structure before crews are able to react.
ATSB Safety Issue No: AO-2014-032-SI-01

   
This interim report was apparently brought to the attention of the Indonesian AAI the NTSC who saw similarities to a reported incident involving an ATR-72 on the 27 June 2016, which they are now investigating:

Accredited representative to the Indonesian National Transportation Safety Committee investigation of the damage sustained by ATR 72 aircraft, registered PK-WG
 
Investigation number: AE-2016-069
Investigation status: Active
 

• Summary
  

On Monday 27 June 2016, the Indonesian National Transportation Safety Committee (NTSC) commenced an investigation into damage sustained by ATR 72 aircraft, registered PK-WGL. Initial examination of this damage suggested similarities with that found on an Australian-registered ATR 72, registered VH-FVR, which is being investigated by the ATSB (see ATSB investigation AO-2014-032 at ATSB website). On 29 June 2016, the NTSC requested the appointment of an ATSB accredited representative to the NTSC investigation in accordance with clause 5.23 of Annex 13 to the Convention on International Civil Aviation Aircraft Accident and Incident Investigation. This was a result of the ATSB’s experience with the ATR during investigation AO-2014-032 and an accredited representative was appointed to the NTSC investigation that day. To facilitate this support, the ATSB initiated an investigation under the Australian Transport Safety Investigation Act 2003.

The NTSC is responsible for, and will administer the release of the final investigation report into the occurrence involving PK-WGL. Any enquiries regarding the NTSC investigation should, in the first instance, be directed to the:
Ministry of Transportation Fl. 3
Jalan Medan Merdeka Timur No.5
Jakarta  10110
INDONESIA 
Telephone:    +62 21 351 7606
Facsimile:  +62 21 351 7606
Email: knkt@dephub.go.id
Email: [email=knkt@dephub.go.id]knkt@dephub.go.id
[/email]Website: http://kemhubri.dephub.go.id/knkt
 
General details

Date: 27 Jun 2016
 
Investigation status: Active
 
Investigation type: External Investigation
 
Location   (show map): International
 
State: International
 
Occurrence class: Technical
 
Occurrence category: Technical Analysis
 
Report status: Pending 
 
 


Last update 01 July 2016

 
- I just love the irony of that NTSC request for an ATSB accredited rep, as per ICAO Annex 13 para 5.23:

Rights

5.23 Any State which on request provides information, facilities or experts to the State conducting the investigation shall be entitled to appoint an accredited representative to participate in the investigation.

Note.— Any State that provides an operational base for field investigations or is involved in search and rescue or wreckage recovery operations may also be entitled to appoint an accredited representative to participate in the investigation.

Shit I hope the Indo's listen to what the astute Alan Stray taught them and they don't follow the Beaker template for incident investigations. Otherwise there will be ATR's dropping from the sky over Indo waters!

Tick tock

Update: Also now on the Planetalking blog, see my comment HERE:  

"...Damaged Virgin Australia turbo-prop risked crashing for five days
ATSB alerts the world to a safety issue that could have crashed a Virgin Australia turbo-prop..."

Ben Sandilands


Damage to the T-tail of the Virgin Australia ATR

Update - via SMH today:

Plane lucky: an aviation escape
Date July 11, 2016 - 12:00AM

• 23 reading now
  
• (29)
  
• Read later
  

Martin Aubury

An ATR 72-600 aircraft operated by Virgin Australia prepares to land at Sydney Airport. Photo: Brendon Thorne

In February 2014 the crew of a small airliner flying from Canberra to Sydney mishandled their flight controls; one pilot pushed, the other pulled. The ATR 72 operated by Virgin entered such a violent manoeuvre that a flight attendant was seriously injured and the aircraft encountered loads far beyond what it was designed to sustain. Somehow it held together. Structural damage was so severe that the ATR 72 was visibly twisted, but nobody noticed and for the next five days the weakened airliner stayed in service.

Several months later, in December 2014, the pilots of an AirAsia Airbus A320 flying from Indonesia to Singapore made a similar mistake. They mishandled their joint response to a sudden deviation from steady flight; one pushed, the other pulled. The airliner did not recover. All 162 on board died. In due course Indonesian authorities published a timely and thorough accident report. AirAsia was vilified and Indonesian aviation in general denigrated.

It took a year longer for the Australian Transport Safety Bureau to tell us of the near-disaster here. ATSB's interim report, published last month, went largely unnoticed; perhaps we were too distracted by the election campaign. The report is sketchy and understates the seriousness of what went wrong. The report tells us what happened in the air but says little about why the damage was not found on the ground.

The captain and co-pilot of the ATR 72 each have a control column connected by cables and links to two moveable surfaces called elevators, hinged along the rear edge of the horizontal tail. Normally a pull on either control moves both elevators up; this exerts a down load on the tail and the aircraft pivots nose up.


Modern designs like the ATR 72 have an extra safety feature. The left and right systems are copies of each other, such that left control column connects directly to the left elevator and right control connects to right elevator. In normal operation, the left and right systems are connected together and move in unison. However, if either of the systems jams, a clutch between them opens and either the captain or co-pilot can safely fly the aircraft with the functioning system.

During descent to Sydney the ATR 72 increased speed unexpectedly. The co-pilot, who was flying the aircraft tried to slow it, by reducing power and by pulling back on his control column to raise the aircraft's nose. The captain was unsure if the co-pilot's response would be sufficient, so gently pulled on his own control to assist. With both pilots making simultaneous nose up inputs, the aircraft rapidly pitched up. The co-pilot responded immediately by reversing his control input, to nose down. Opposite control inputs from captain and co-pilot had the unintended consequence of left and right elevator control systems uncoupling from each other. This then caused left and right elevators to move in opposite directions; a configuration for which the aircraft was never designed.

As ATSB puts it ".....asymmetric elevator deflections resulted in a large asymmetric aerodynamic load being generated on the horizontal stabiliser. That load exceeded the design strength requirements for the stabiliser structure, resulting in significant damage. Such a large exceedance has the potential to result in catastrophic damage to the stabiliser and a subsequent loss of control."

Later analysis showed that much of the aircraft structure was overloaded, some by 47 per cent. Damage was extensive and when eventually found took months to repair. The whole of the tail structure, vertical and horizontal, had to be replaced.

ATSB coyly concedes pilots make mistakes. "Despite pre-existing, well-established and trained procedural risk controls to prevent dual control inputs in normal operation, the risk controls were readily, but inadvertently, bypassed by the crew on this occasion."
Much the same mistake contributed to the AirAsia crash. The A320 is a bigger airliner than the ATR 72 and its controls are more complicated, as was the accident scenario. Plus, we know from cockpit recordings that miscommunication compounded the confusion.

The Indonesian captain and French co-pilot spoke in English but it was not their native tongue. The captain needed the co-pilot to assist by pushing his control forward to make the aircraft pitch down. The captain should have instructed "Push Down" but repeatedly said "Pull Down, Pull Down". The co-pilot continued to pull, opposing the captain. The A320 crashed and reinforced the stereotype of unsafe aviation in Indonesia.

By contrast the Australian crew quickly regained control and avoided showering wreckage over outer Sydney. Point is, neither the crew nor Virgin's maintenance organisation realised that the ATR 72 was seriously weakened. It seems appalling that the damage was not found for five days and that ATSB's interim report does not explain how this came about. Suffice to say, all who flew in the damaged ATR 72 were in grave peril.
Sometimes luck alone keeps Australia's aviation reputation safe.

Martin Aubury is a retired aeronautical engineer who has been involved with aircraft design and regulation for more than 50 years.


Read more: http://www.smh.com.au/comment/plane-lucky-an-aviation-escape-20160708-gq1i4k.html#ixzz4E4Q4rObV

MTF...P2

[Peetwo]

Is this another sign?

Thought I'd file this one in O&O for future reference, so first a re-hash courtesy the Search For IP thread:

Q/ Will the ATSB now be investigating?

From the AAP courtesy SBS two days ago:

8 Aug 2016 - 5:57am
Jetstar Qld flight forced to land in Guam

P2 comment: Teagan with all due respect would you rather risk having to swim the rest of the way to the Gold Coast? - UDB

This line...

 "..The Australian Transport Safety Bureau says it's gathering more information on the unplanned landing but is yet to decide if it will investigate.."

Well after just reviewing the ATSB aviation investigation page - see HERE - it would appear that the ATSB is still pondering whether they will investigate??

Maybe Hoody is temporarily distracted with his teams, frankly shambolic, recent PR management of the MH370 SIO search, however after reading Binger's article (in the Oz today) on the Jetstar Guam occurrence, I think he made need to seriously consider opening an investigation:

Fault in new engine sets off Jetstar Guam emergency

Jetstar passengers arrive home from Guam yesterday. Picture: Regi Varghese

• Mitchell Bingemann
  
• The Australian
  
• 12:00AM August 9, 2016
  

Well...ho hum.. ..5 days later, with some subtle pressure from Binger at the Oz , finally the ATSB 'powers to be' decide to investigate... :

Aviation safety investigations & reports

Investigation title

Engine shut down involving Boeing 787, VH-VKK, about 370 km N of Guam, on 7 August 2016
 
Investigation number: AO-2016-095
Investigation status: Active
 

• Summary
  

The ATSB is investigating an engine shut down involving a Jetstar Airways Boeing 787, registered VH-VKK, about 370 km north of Guam, on 7 August 2016.

During cruise, the crew received low oil quantity and pressure warnings from the right engine. The engine was shut down and the crew diverted the aircraft to Guam. There were no injuries and the aircraft was not damaged.

As part of the investigation, the ATSB will interview the crew and gather additional information.

A report will be released within several months.
 
General details

General detailsDate: 07 Aug 2016
 
Investigation status: Active
 
Time: 01:00 EST
 
Investigation type: Occurrence Investigation
 
Location   (show map): Guam International Airport, N 370 km
 
Occurrence type: Engine failure or malfunction
 
State: International
 
Occurrence class: Infrastructure
 
Occurrence category: Incident
 
Report status: Pending
 
Highest injury level: None
 
Expected completion: Dec 2016 
 
Aircraft details

Aircraft manufacturer: The Boeing Company
 
Aircraft model: 787-8
 
Aircraft registration: VH-VKK
 
Serial number: 36237
 
Type of operation: Air Transport High Capacity
 
Sector: Jet
 
Damage to aircraft: Nil 
 
 


Last update 12 August 2016

   
And of course this development did not go unnoticed by Binger via the Oz... :

Jetstar probed over engine shutdown

Jetstar aircraft seen at Sydney International Airport, Sydney, Friday, Aug. 12, 2016.

• Mitchell Bingemann
  
• The Australian
  
• 6:11PM August 12, 2016
  

Reporter
Sydney
@Mitch_Hell
[img=0x0]http://pixel.tcog.cp1.news.com.au/track/component/author/4c134add4c3a9e4881f7841b69d9ac85/?esi=true&t_product=the-australian&t_template=s3/austemp-article_common/vertical/author/widget&td_bio=false[/img]
The Australian Transport Safety Bureau has opened an investigation into why a Jetstar flight from Tokyo to the Gold Coast was forced to shut down one of its two engines midflight and divert to the Pacific Island of Guam.

Flight JQ12 — a one-year-old Boeing 787-9 Dreamliner — was bound for the Gold Coast from Narita, Japan, with about 320 people on board when it was forced to divert to the US island territory last Sunday because of a suspected oil pressure problem with one of its General Electric-manufactured GEnx engines.

“During cruise, the crew received low oil quantity and pressure warnings from the right engine. The engine was shut down and the crew diverted the aircraft to Guam. There were no injuries and the aircraft was not damaged,” the ATSB said.

“As part of the investigation, the ATSB will interview the crew and gather additional information.”

The Jetstar Dreamliner remains grounded in Guam where it is being looked over by GE and the airline’s engineers.

“As the aircraft is in Guam it has presented a few challenges with getting the aircraft quickly back in operation,” said a Jetstar spokesman.

“Our engineers will be fitting another engine to the aircraft over the next few days and we expect the aircraft to depart Guam mid-next week.”

The opening of the official investigation comes after The Australian revealed the faulty engine was only three months old.

It had been fitted to the plane three months ago to replace a nine-month-old version of the same model in need of repair.

An investigation by The Australian found 22 incidents of in-flight engine failures with the General Electric-manufactured GEnx engine dating back to 2013, not long after the Boeing Dreamliner aircraft first took to the skies for commercial operations.

The incidences have affected international airlines including Jetstar, Air India, Qatar Airlines, Japan Airlines, Air Canada and United Airlines.

General Electric has defended the GEnx engine — used on about 270 Dreamliners and which has totalled close to four million flight hours — saying it has displayed “outstanding ­reliability” since being in service.

OK so ATSB 'team Hoody' reckon they can get this one done & dusted by December (this year)  ?? Hmm..we'll see -


MTF...P2

Ps Choc frog for Binger 

[Peetwo]

Jetstar probed over engine shutdown

Jetstar aircraft seen at Sydney International Airport, Sydney, Friday, Aug. 12, 2016.

• Mitchell Bingemann
  
• The Australian
  
• 6:11PM August 12, 2016
  

[/url]
Reporter
Sydney
[url=http://twitter.com/Mitch_Hell]@Mitch_Hell[img=0x0]http://pixel.tcog.cp1.news.com.au/track/component/author/4c134add4c3a9e4881f7841b69d9ac85/?esi=true&t_product=the-australian&t_template=s3/austemp-article_common/vertical/author/widget&td_bio=false[/img]

Update: In comments from the two short Binger articles on the Jetstar Guam incident, Mitchell has copped a bit of a pizzling from the likes of serial Australian Aviation section critic 'Mick', e.g.

Mick
5 days ago

@Mark  Haven't you been following this breaking story, Mark?!   It's an investigative effort of Watergate-like proportions.   Through his investigation Mitchell has managed to not only "uncover" widely available public domain safety information on the Dreamliner, he's also managed to invent a new word - incidences (having offered three separate corrections over four days, I swear on all that is holy and sacred that if he uses "incidences" again I will fair dinkum do my nut!).

It's riveting stuff. 

I am just a little miffed though that I haven't rated a by-line given I wrote this in Comments on the original news story 5 nights ago;
"On a more serious note, this would be the 19th or 20
th engine shut down inflight incident with the B787 Dreamliner in its relatively short in service history.   This is a very similar incident to Jetstar flight JQ25 from Cairns to Tokyo Narita back in December 2014 which was forced to divert to Guam due a decreasing engine oil quantity indication.  And no, it's not the same aircraft. 
...    Most of the engine problems with the B787 have been with the General Electric GEnx-1B engines and almost invariably related to either oil quantity or pressure indication issues.  In some respects the GEnx is a less complex engine than the other engine option for the 787, the Rolls Royce Trent 1000 (2 shaft low/high pressure V. 3 shaft low/intermediate/high pressure), but it seems to have an unhappy knack of throwing up these oil problems."

Some of this criticism is somewhat justified, as loose reporting in such a specialist area, full of many armchair experts & big egos, can very quickly lead to the demise of even the most seasoned of aviation journalists. However at this point in time I think Mick is being a little unfair and I do question ulterior (i.e. Troll) motives. Surely it would be just as easy for Mick to not even respond to what he obviously feels is substandard aviation reporting? 

I also would like to take to task this comment from Ian & Mick:

Ian - ..Are you trying to imply the ATSB only decided to investigate because of your article?

Mick
5 days ago

@Ian  I was thinking the same thing, Ian.   I doubt whether young Mitchell is familiar with either the Transport Safety Investigation Act 2003 or Transport Safety Investigation Regulations 2003, specifically Section 2.3 Immediately reportable matters 
(3) (k) a mechanical failure resulting in the shutdown of an engine; and
(3) (n) malfunction of an aircraft system that seriously affects the operation of the aircraft. 

Mick quotes the TSI Act & regs when it was never contended by Binger that this incident was not reported to the ATSB. What was in contention at the time (& ignored by Mick) was that it took more than five days for the ATSB to decide to investigate.

Okay now compare that response to this ATSB opened investigation yesterday:

Engine shut down involving Airbus A330, 9M-XXD, 445 km SE of Alice Springs Airport, SA, on 16 August 2016
 
Investigation number: AO-2016-101
Investigation status: Active
 

• Summary
  

The ATSB is investigating an engine shut down involving an AirAsia X Airbus A330, registered 9M-XXD, 445 km SE of Alice Springs Airport, South Australia, on 16 August 2016.

During cruise, the flight crew received a low oil pressure warning from the right engine.

The engine was shut down and the flight crew diverted the aircraft to Melbourne. There were no injuries and the aircraft was not damaged.

As part of the investigation, the ATSB will interview the captain and gather additional information.

A report will be released within several months.
 
General details

Date: 16 Aug 2016
 
Investigation status: Active
 
Time: 23:20 CST
 
Investigation type: Occurrence Investigation
 
Location   (show map): Alice Springs 445 km SE
 
Occurrence type: Engine failure or malfunction
 
State: South Australia
 
Occurrence category: Incident
 
Report status: Pending
 
Highest injury level: None
 
Expected completion: Dec 2016 
 
Aircraft details

Aircraft manufacturer: Airbus
 
Aircraft model: A330-343X
 
Aircraft registration: 9M-XXD
 
Serial number: 1066
 
Operator: AirAsia X
 
Type of operation: Air Transport High Capacity
 
Sector: Jet
 
Damage to aircraft: Nil
 
Departure point: Sydney, NSW
Destination: Kuala Lumpar, Malaysia
 
 
 


Last update 17 August 2016

 
Moving on: To Mitchell's credit he has not been deterred by the constant diatribe, by Mick and his fan club, that the Jetstar Guam incident is a non-event, & therefore a non-story. In the Oz today:

Engine shutdown risk for Jetstar Dreamliner fleet

• Mitchell Bingemann
  
• The Australian
  
• 12:00AM August 18, 2016
  @Mitch_Hell
  [img=0x0]http://pixel.tcog.cp1.news.com.au/track/component/author/4c134add4c3a9e4881f7841b69d9ac85/?esi=true&t_product=the-australian&t_template=s3/austemp-article_common/vertical/author/widget&td_bio=false[/img]
  

Planes in Jetstar’s Dreamliner fleet are flying with a known ­engine problem that could trigger a mid-flight engine shutdown such as the one that recently forced one of its Boeing-787s to divert to the Pacific island of Guam.

The Australian understands Jetstar has been working on the engine issue, which can lead to a loss of oil pressure, since March and has made repairs to 11 of its 24 General Electric-made GEnx ­engines, meaning about half the airline’s Dreamliner fleet could be operating with the problem.

A Jetstar spokesman said the figure of 11 repaired engines was “not correct”, but declined to ­reveal whether the airline had ­repaired more or less than the quoted number.
A service bulletin issued early this year by General Electric to operators of Dreamliners fitted with the GEnx engine said the issue related to a problem with the “transfer gearbox”.

It recommended operators of the Dreamliner modify a “dampened radial gearshaft” to prevent “induced resonance failures that have caused approximately eight in-flight engine shutdowns and oil loss events across the world.”

“A resonance-induced failure means a component of the ­aircraft engine developing an ­uncontrolled vibration,” said Marcus Diamond, a safety and technical consultant at the Australian Federation of Air ­Pilots.

Jetstar — which operates a fleet of 11 twin-engine Boeing 787-8s — confirmed the service bulletin had been issued to the airline but declined to share ­details of it with The Australian.

“Jetstar has been working closely with GE on the service bulletin,” the Jetstar spokesman said. “We are well progressed on our fleet and will have all aircraft engines completed months ahead of the recommended timeframe from GE.

“We are continuing our invest­igations into the cause of the engine issue with GE on the aircraft that diverted to Guam.”

Service bulletins alert operat­ors to known issues in aircraft components, but the instructions are optional and not as serious as “airworthiness directives” that mandate airlines to make modifications by a specific deadline.

The General Electric-issued service bulletin said modifi­cations to fix the known fault should be completed between November 30 this year and March 31 next year, depending on the model of engine. Jetstar is on track to complete the modifi­cations on the affected engines by the end of November.

The engine issue also affects Dreamliners operated by airlines such as Air Canada, Air India, China Southern, United Airlines and Etihad Airways that fly from Australian airports.
General Electric says it continually monitors and analyses the performance of the GEnx ­engine fleet. “Based on the engine fleet’s service history, we are not aware of operational issues that would hazard the continued safe flight of aircraft powered by these engines,” a spokeswoman said.

“As a relatively new engine in commercial airline service, the GEnx by any statistical measure (dispatch reliability, engine remov­als, in-flight shutdown rates) is exhibiting outstanding reliability powering the 787.”

Last week, Jetstar was forced to divert to Guam a one-year-old Dreamliner flying from Japan to the Gold Coast, because of an oil pressure problem with one of its GEnx engines. The Australian Transport Safety Bureau is invest­igating the incident.

And as is becoming routine, Mick is back and ironically he mentions the AirAsiaX inflight engine shutdown incident as a further attempt to discredit Binger:  

Gordon

1 hour ago

@Henry Read Mick's post above. I am an aircraft operations layman, but Mick sounds like he knows what he's talking about.   I'm betting this reporter from the Australian does not and the whole thing is a beat up designed to scare people unnecessarily.

Mick
42 minutes ago

@Gordon   It is a beat-up, a shameless beat-up.   Meanwhile, real aviation news, like the inflight shut-down of an engine on an AirAsia X A330 out of Sydney on Tuesday, goes unreported.

To put this in context this is the post chain, which includes the 'Mick' post to which Gordon refers Henry to:

arlys

3 hours ago

All aircraft who fly in this country, have to meet strict guidelines. A new aircraft like the B787, will always have shakedown problems, but having already flown close to a million miles, safely, its something the Engineers have decided needs attention, and will do so promptly, and efficiently, in this country. The B787 passes a ETOPS which allows it to fly 330 minutes from a landing field, suitable to its type, the normal ETOPS is 180 minutes, which means this aircraft can fly on one engine safely for a extended time officially.

---

Mick
2 hours ago

As Arlys points out, these engines are required to meet Extended-range Twin-engine Operational Performance Standards (ETOPS).   The ETOPS inflight shut-down (IFSD) requirement is no more than 0.02 IFSDs per 1000 engine hours, which is the same as 20 shutdowns per million hours.  To be clear, that means, on the average, one inflight engine shut-down every 50,000 engine hours.   The General Electric GEnx engine exceeds that reliability requirement by more than a factor of six.  Its reliability is at or about on a par with more "mature" engines such as the CFM CF6-80C2 (Airbus A300, Airbus A310, Boeing B767), the General Electric GE90 (Boeing B777) and the Pratt and Whitney PW4000 (Airbus A300, Airbus A310, Boeing B747). 

Service bulletins are issued by airplane and airplane engine manufacturers all of the time.   The fact that this matter is being dealt with via a service bulletin and not a directive indicates that it is not a time critical matter.   And some context for the "... failures that have caused approximately eight in-flight engine shutdowns and oil loss events across the world.", there are well over 1,000 GEnx engines currently in service around the world (it's one of the fastest selling airplane engines of all time) and it has accumulated around 7 million operating hours;  so the failure rate associated with the dampened radial gearshaft is about 0.0011 per 1,000 engine hours!

Regrettably while The Australian follows what seems to be becoming standard practice of flogging old stories to death, real aviation news just seems to pass by unobserved and unreported (well, by The Australian anyway). 

For those interested, on Tuesday, 16 August, the crew of an AirAsia X Airbus A330-300 operating as Flight D7-221 from Sydney to Kuala Lumpur was forced perform an inflight shutdown of the starboard Rolls Royce Trent 772 engine after receiving a low oil pressure warning.   The airplane was some 340 kilometres south east of Alice Springs at the time and diverted safely to Melbourne.   There have been four incidents involving RR Trent 772 engines on Airbus A330-300s in less than two months, on three occasions the engine has been shutdown in flight. 

Mick
52 minutes ago

A correction to my post above.   The requisite in-flight shut-down rate for ETOPS 330 is less than 0.01 IFSDs per 1000 engine hours, which is the same as 10 shutdowns per million hours (less than 0.02 IFSDs per 1000 engine hours as stated above is the ETOPS 180 requirement).   The General Electric GEnx is therefore more than three times more reliable than the requisite standard. 

 
So is this developing story worthy of MSM coverage; or (as Mick alludes) is it just another - 'nothing to see here, move along' - beat up incident that should not have been given oxygen? 

I agree that such stories should not be sensationalised, however the MSM has an important role to play within a State's aviation safety investigation & administration. For far too long Oz MSM has buried it's head in the sand on major airline aviation incidents & accidents all because it is simply too hard to tackle an area so heavily protected by obfuscating bureaucracy and enshrouded in 'mystique of aviation safety' issues.   

Therefore I applaud Mitchell for having a crack at this one, he is not always going to get it right but provided he sticks to the facts as presented he will begin to garner an informed industry readership while keeping the relevant authorities on their toes...
    

MTF...P2

Ps I know it is a different world in aero-engine technology and stringent requirements etc. but I cannot go past some strange parallels with the attempted embuggerance of Jabiru aircraft, over their thru-bolt fractures and subsequent in-flight engine failures - just saying...

[Gobbledock]

'Mick' is quite likely that stupid old tosser Lookleft, or his male lover Owen Meaney! Similar Troll like abuse.

[Peetwo]

"Nothing to see here, move along!" - What say you now Mick?

In a follow up to this Mick drono-logue :

@Gordon   It is a beat-up, a shameless beat-up.   Meanwhile, real aviation news, like the inflight shut-down of an engine on an AirAsia X A330 out of Sydney on Tuesday, goes unreported.

Binger has followed up with this addition in the Oz today:

AirAsia X engine shutdown, flight diversion probed


An AirAsia X Airbus A330 similar to the one forced to divert to Adelaide.

Mitchell Bingemann
The Australian
12:00AM August 19, 2016
@Mitch_Hell
[img=0x0]http://pixel.tcog.cp1.news.com.au/track/component/author/4c134add4c3a9e4881f7841b69d9ac85/?esi=true&t_product=the-australian&t_template=s3/austemp-article_common/vertical/author/widget&td_bio=false[/img]
The Australian Transport Safety Bureau has opened an investigation into why an AirAsia X flight from Sydney to Malaysia was forced to divert to Melbourne after an in-flight engine shutdown.

Flight D7 221 was flying from Sydney to Kuala Lumpur on Tuesday with 231 passengers on board when pilots were forced to shut down one of its Rolls-Royce Trent 772B-60 engines after receiving a low oil pressure warning.

The aeroplane, which departed Sydney airport at 9.25pm, was 445km southeast of Alice Springs when the engine was shut down and the plane diverted to Melbourne. It landed safely at Melbourne airport at 1.59am on Wednesday.

“The precautionary diversion was in compliance with all international aviation safety guidelines,” said a spokesman for AirAsia X.

“We sincerely apologise for any inconvenience caused. The safety and comfort of our guests are AirAsia X’s priority and we strive to provide as much assistance as possible in these circumstances.”

The affected Airbus A330 — registration 9M-XXD — has been in operation since 2009.
The ATSB is now investigating the incident and will release a report within several months. AirAsia X said it was fully co-operating with the ATSB on the investigation.

“During cruise, the flight crew received a low oil pressure warning from the right engine. The engine was shut down and the flight crew diverted the aircraft to Melbourne. There were no injuries and the aircraft was not damaged,” the ATSB said. “As part of the investigation, the ATSB will interview the captain and gather additional information.”
The AirAsia X engine shut-down is the second engine problem to hit a jet carrying Australian passengers in the past fortnight.

Last week Jetstar was forced to divert a one-year-old Boeing Dreamliner — flight JQ12, flying from Japan to the Gold Coast with 320 people on board — to the US island territory of Guam because of an oil pressure problem with one of its General Electric-manufactured GEnx engines.

The Australian Transport Safety Bureau has also opened an investigation into what caused that engine failure.

The Australian yesterday revealed that planes in Jetstar’s Dreamliner fleet are flying with a known ­engine problem that could trigger a mid-flight engine shutdown such as the one that forced its Dreamliner to divert to Guam.

So there you go Mick, now you can tell us all about the statistical chances of suffering a inflight engine shutdown on an Airbus A330-343X...
MTF...P2

[Gobbledock]

Perhaps 'Mick' the armchair critic can do the investigation into Air Asia's shutdown and provide the investigation report for us to critique.....in about 4 years time???

[Kharon]

Three strikes.

"The ATSB found that the dispatcher for YID could not visually confirm the position of VGR relative to gate D2 and assessed that because the aircraft hadn’t moved, it was on the gate. The pushback ground staff followed the normal practice for a pushback from bay E1. However, this practice did not allow for visual monitoring of the left side of the aircraft, such as by using a wing walker. This meant it was not possible for the dispatcher to identify the collision risk in time to prevent the collision."

The Sandilands article - HERE – begins by describing the ground collision between two aircraft as a super market car park bingle, then, after skipping several essential omissions in the ATSB report, takes a shotgun approach to the wide range of problems ATSB have, hitting the odd one or two, while the flock escapes. Missing an opportunity for a defining snap shot of where the ATSB is utterly failing the nations travellers.

ATSB – “This occurrence highlights the importance of ensuring that adequate clearance exists prior to commencing pushback. This includes using sufficient personnel to ensure visibility of each side of the aircraft at all times.”

The ATSB statement above, properly analysed, is terrifying.  It clearly defines the utter ineffectiveness of the agency, at all levels.  It also clearly defines the willing emasculation of the ATSB under Dolan.  I shall try, in my clumsy way, to make this simple for the politicians who need to get off their collective beam ends and make sure that either (a) this report is the tool used to close down the ATSB, disband it and save a fortune; or (b) return the ATSB to its proper role as the primary, independent arbiter of ‘safety’.  ATSB  cannot be allowed to wallow along as an ineffective, toothless, captive waste of time and money.  Australia is now so far away from true ICAO compliance that, if we were honest, a token ‘investigator’ parked in an office at the rear of the CASA building would suffice and be on a par with the other ‘token’ ICAO compliance requirements we need to be ‘seen’ to meet.

A good question; but not the first from ‘Dan Dair’ – “Now I think about it, I’d have probably asked what systems of assessment the airline or ground handler has in place before pushing-back an aircraft.”


Anyone who has suffered through a crowded shopping centre car park will understand what a busy air-side parking area – Ramp – is like when it is busy.  Arriving and departing a ramp (or gate) is probably one of the most dangerous parts of the entire journey.  Think on – a vehicle, about half the size of a football pitch, without rear view mirrors needs to be reversed about 100 meters into traffic.  The typical 737 is 12+/- meters high, wing span in the 30 meter range and some 35 meters long and weighs in somewhere between 65,000 and 85,000 kg.  I’ll leave the Kinetic energy calculation and the calorific potential in the fuel tanks to you; but it’s a big number.  

To get this aircraft ‘pushed-back’ onto a live taxi way requires the coordinated effort of every safety agency we have and the company ‘system’.  It is a massive effort; laws need to be in place through parliament; CASA must turn that law into a rule set which define responsibility, procedure and method. The company must transmogrify that rule into practical, workable solutions, develop a system which ensures legal and operational safety; train staff within that system and maintain the machinery which completes the act.  Flight crew need to be trained to comply with their end of the story and provide the essential link between traffic control and ground crew.  The ATCO managing the ‘ground control’ station has to coordinate traffic all over the aerodrome; from newly landed off the runway, those moving to designated parking areas and those pushing back to begin a journey.  Why is the fool rambling on about this? – well, consider the amount of links in that chain; the potential for an incident is huge.

The point I am labouring to make that somewhere, somehow a link in that safety chain failed and an incident occurred. But which link and why?  It is for this answer we must depend on an impartial ATSB.

Were the company procedures robust, did they comply?
Was the ATC sufficiently trained?
Did the CASA approval of the procedure comply with safety rules?
Did the tug driver make an error.
Were the sight lines obstructed?
Was fatigue an issue?
Was lighting a problem?
Were the push back lines clearly defined?
Who is to make the adjustments to procedure to prevent a reoccurrence?
Who is to approve those adjustments?
What new procedures have been initiated?

I could, if pushed, develop a page of questions which should have been answered.  I would bet a beer or even two, that the companies involved Safety Management Systems (SMS) asked and provided answers to those questions, and more.  I have no doubt of that; but I cannot prove it as fact.  The findings of the ‘internal’ investigations will, quite rightly, remain private.

The ATSB public findings will not assist in the prevention of a reoccurrence; why?  Well there ain’t any; well, not any that are worth a good god damn.

I have no quarrel with SMS.  What I object to is that there may have been a slackening of requirements which allow a company to legitimately reduce (for example) say the number of personnel required to effect a simple push-back; which increases the risk of a repeat.  We don’t know and no one else is telling the tale,

Perhaps it’s just my curiosity curse, I like to know what happened and what was done to prevent it happening again.  For this I rely on the ATSB; if the ATSB cannot provide those answers; then what is the purpose of them?

Long ramble over, but it seems to me there was a little more to consider than a simple ‘beg-your-pardon’ in a carpark.

"Just be careful crossing the road kids" - last words ever heard by young Jimmy as he chased the bouncing ball.

Toot – knitting? – toot.  Apologies to 737 type specialists.

[Gobbledock]

A puff of hot air

Kharon Kharon Kharon, stop it, just stop it. You have listed potential root causes, potential broken links in the chain. How dare you, that is NOT what the ATsB do!

The ATsB report in this instance is what I would describe as 'word masturbation using a wet lettuce leaf to perform the act'. It is an absolutely weak, soft, meaningless 'puff of air'. Lessons learned from this incident? Not one iota if you are going off the ATsB report. If this is what the ATsB do, if this is what they produce, if this is the standard then as I have said previously and to reiterate the Ferryman's thoughts - shut em down. They serve no useful purpose. Hoody's $700k cannot be justified, nor the department annual budget and staff salaries.

Sub-contract the ATsB's functions to the lower paid Indonesians who have been trained by the talented Alan Stray and who now have far superior capabilities compared to Australia's, at a third of the cost at least!
Dolan and MrDak the marionette have a hell of a lot to answer for. As for the master of hair products, Chester, he is another waste of breathable air and taxpayer money...

Tick tock goes the FAA audit clock!

#bringbackalan

[thorn bird]

Oh dear, despicable me master manipulator Mrdak's many malignant minions, mangle, mismanage, misappropriate. Meanwhile the minister magnificently misses malfecient manipulation.

[Peetwo]

Jetstar probed over engine shutdown

 
Moving on: To Mitchell's credit he has not been deterred by the constant diatribe, by Mick and his fan club, that the Jetstar Guam incident is a non-event, & therefore a non-story. In the Oz today:

Engine shutdown risk for Jetstar Dreamliner fleet

• Mitchell Bingemann
  
• The Australian
  
• 12:00AM August 18, 2016
  @Mitch_Hell
  [img=0x0]http://pixel.tcog.cp1.news.com.au/track/component/author/4c134add4c3a9e4881f7841b69d9ac85/?esi=true&t_product=the-australian&t_template=s3/austemp-article_common/vertical/author/widget&td_bio=false[/img]
  

Planes in Jetstar’s Dreamliner fleet are flying with a known ­engine problem that could trigger a mid-flight engine shutdown such as the one that recently forced one of its Boeing-787s to divert to the Pacific island of Guam.

The Australian understands Jetstar has been working on the engine issue, which can lead to a loss of oil pressure, since March and has made repairs to 11 of its 24 General Electric-made GEnx ­engines, meaning about half the airline’s Dreamliner fleet could be operating with the problem.

A Jetstar spokesman said the figure of 11 repaired engines was “not correct”, but declined to ­reveal whether the airline had ­repaired more or less than the quoted number.
A service bulletin issued early this year by General Electric to operators of Dreamliners fitted with the GEnx engine said the issue related to a problem with the “transfer gearbox”.

It recommended operators of the Dreamliner modify a “dampened radial gearshaft” to prevent “induced resonance failures that have caused approximately eight in-flight engine shutdowns and oil loss events across the world.”

“A resonance-induced failure means a component of the ­aircraft engine developing an ­uncontrolled vibration,” said Marcus Diamond, a safety and technical consultant at the Australian Federation of Air ­Pilots.

Jetstar — which operates a fleet of 11 twin-engine Boeing 787-8s — confirmed the service bulletin had been issued to the airline but declined to share ­details of it with The Australian.

“Jetstar has been working closely with GE on the service bulletin,” the Jetstar spokesman said. “We are well progressed on our fleet and will have all aircraft engines completed months ahead of the recommended timeframe from GE.

“We are continuing our invest­igations into the cause of the engine issue with GE on the aircraft that diverted to Guam.”

Service bulletins alert operat­ors to known issues in aircraft components, but the instructions are optional and not as serious as “airworthiness directives” that mandate airlines to make modifications by a specific deadline.

The General Electric-issued service bulletin said modifi­cations to fix the known fault should be completed between November 30 this year and March 31 next year, depending on the model of engine. Jetstar is on track to complete the modifi­cations on the affected engines by the end of November.

The engine issue also affects Dreamliners operated by airlines such as Air Canada, Air India, China Southern, United Airlines and Etihad Airways that fly from Australian airports.
General Electric says it continually monitors and analyses the performance of the GEnx ­engine fleet. “Based on the engine fleet’s service history, we are not aware of operational issues that would hazard the continued safe flight of aircraft powered by these engines,” a spokeswoman said.

“As a relatively new engine in commercial airline service, the GEnx by any statistical measure (dispatch reliability, engine remov­als, in-flight shutdown rates) is exhibiting outstanding reliability powering the 787.”

Last week, Jetstar was forced to divert to Guam a one-year-old Dreamliner flying from Japan to the Gold Coast, because of an oil pressure problem with one of its GEnx engines. The Australian Transport Safety Bureau is invest­igating the incident.

And as is becoming routine, Mick is back and ironically he mentions the AirAsiaX inflight engine shutdown incident as a further attempt to discredit Binger:  

Gordon

1 hour ago

@Henry Read Mick's post above. I am an aircraft operations layman, but Mick sounds like he knows what he's talking about.   I'm betting this reporter from the Australian does not and the whole thing is a beat up designed to scare people unnecessarily.

Mick
42 minutes ago

@Gordon   It is a beat-up, a shameless beat-up.   Meanwhile, real aviation news, like the inflight shut-down of an engine on an AirAsia X A330 out of Sydney on Tuesday, goes unreported.

To put this in context this is the post chain, which includes the 'Mick' post to which Gordon refers Henry to:

arlys

3 hours ago

All aircraft who fly in this country, have to meet strict guidelines. A new aircraft like the B787, will always have shakedown problems, but having already flown close to a million miles, safely, its something the Engineers have decided needs attention, and will do so promptly, and efficiently, in this country. The B787 passes a ETOPS which allows it to fly 330 minutes from a landing field, suitable to its type, the normal ETOPS is 180 minutes, which means this aircraft can fly on one engine safely for a extended time officially.

---

Mick
2 hours ago

As Arlys points out, these engines are required to meet Extended-range Twin-engine Operational Performance Standards (ETOPS).   The ETOPS inflight shut-down (IFSD) requirement is no more than 0.02 IFSDs per 1000 engine hours, which is the same as 20 shutdowns per million hours.  To be clear, that means, on the average, one inflight engine shut-down every 50,000 engine hours.   The General Electric GEnx engine exceeds that reliability requirement by more than a factor of six.  Its reliability is at or about on a par with more "mature" engines such as the CFM CF6-80C2 (Airbus A300, Airbus A310, Boeing B767), the General Electric GE90 (Boeing B777) and the Pratt and Whitney PW4000 (Airbus A300, Airbus A310, Boeing B747). 

Service bulletins are issued by airplane and airplane engine manufacturers all of the time.   The fact that this matter is being dealt with via a service bulletin and not a directive indicates that it is not a time critical matter.   And some context for the "... failures that have caused approximately eight in-flight engine shutdowns and oil loss events across the world.", there are well over 1,000 GEnx engines currently in service around the world (it's one of the fastest selling airplane engines of all time) and it has accumulated around 7 million operating hours;  so the failure rate associated with the dampened radial gearshaft is about 0.0011 per 1,000 engine hours!

Regrettably while The Australian follows what seems to be becoming standard practice of flogging old stories to death, real aviation news just seems to pass by unobserved and unreported (well, by The Australian anyway). 

For those interested, on Tuesday, 16 August, the crew of an AirAsia X Airbus A330-300 operating as Flight D7-221 from Sydney to Kuala Lumpur was forced perform an inflight shutdown of the starboard Rolls Royce Trent 772 engine after receiving a low oil pressure warning.   The airplane was some 340 kilometres south east of Alice Springs at the time and diverted safely to Melbourne.   There have been four incidents involving RR Trent 772 engines on Airbus A330-300s in less than two months, on three occasions the engine has been shutdown in flight. 

Mick
52 minutes ago

A correction to my post above.   The requisite in-flight shut-down rate for ETOPS 330 is less than 0.01 IFSDs per 1000 engine hours, which is the same as 10 shutdowns per million hours (less than 0.02 IFSDs per 1000 engine hours as stated above is the ETOPS 180 requirement).   The General Electric GEnx is therefore more than three times more reliable than the requisite standard. 

 
So is this developing story worthy of MSM coverage; or (as Mick alludes) is it just another - 'nothing to see here, move along' - beat up incident that should not have been given oxygen? 

I agree that such stories should not be sensationalised, however the MSM has an important role to play within a State's aviation safety investigation & administration. For far too long Oz MSM has buried it's head in the sand on major airline aviation incidents & accidents all because it is simply too hard to tackle an area so heavily protected by obfuscating bureaucracy and enshrouded in 'mystique of aviation safety' issues.   

Therefore I applaud Mitchell for having a crack at this one, he is not always going to get it right but provided he sticks to the facts as presented he will begin to garner an informed industry readership while keeping the relevant authorities on their toes...     

MTF...P2

Ps I know it is a different world in aero-engine technology and stringent requirements etc. but I cannot go past some strange parallels with the attempted embuggerance of Jabiru aircraft, over their thru-bolt fractures and subsequent in-flight engine failures - just saying...

Update 02/09/16: Binger in the Oz today.

Jetstar incident ‘a known issue’

• Mitchell Bingemann
  
• The Australian
  
• 12:00AM September 2, 2016
  

Jetstar has confirmed that the mid-flight engine shutdown that forced one of its Boeing Dream­liner jets to divert to Guam was caused by a known issue in one of the plane’s General Electric engines.

The Australian Transport Safety Bureau is investigating the incident but is still several months from releasing its official findings into why flight JQ12 — a one-year-old Boeing 787-9 Dreamliner with 320 on board — was forced to divert to the US island territory of Guam on August 6.

But The Australian has learned that the shutdown was caused by a known issue in the General Electric GEnx engine that has resulted in other identical engine shutdowns in the past few years.

“This is the same issue that other airlines with GEnx engines have encountered, so we’re confident that we understand what happened and how to prevent it from occurring,” a Jetstar spokesman told The Australian.

The issue relates to a problem with the transfer gearbox in the GEnx engines fitted to Boeing 787-8s.

In a service bulletin issued to airlines this year, GE advised operators of the Dreamliner to modify the “dampened radial gearshaft” to prevent “induced resonance failures that have caused approximately eight in-flight engine shutdowns and oil loss events across the world”.

Service bulletins alert operators to known issues in aircraft components, but the instructions are optional and not as serious as airworthiness directives that mandate airlines to make modifications by a specific deadline.

The fix for the engines comes as Jetstar’s Dreamliner fleet clocked up 100,000 hours of flying this week.

Jetstar — which operates a fleet of 11 Boeing 787-8s — has been modifying its 24 GEnx engines since March. The Australian understands Jetstar has made repairs to 11 of those GEnx engines, meaning that some flights continue to be powered by engines with the issue. Boeing Dreamliners, however, are able to fly with only one engine working.
“GE has been working with our engineering team on this and we will complete the modifications on the remaining engines around five months ahead of schedule in November this year,” the Jetstar spokesman said.

The engine issue also affects Dreamliners operated by airlines such as Air Canada, Air India, China Southern, United Airlines and Etihad Airways that fly from Australian airports.

General Electric has defended the GEnx engine, used on about 270 Dreamliners and which has close to four million flight hours, saying it continually analyses the performance of the GEnx engine fleet, which has displayed “outstanding “reliability”.

There have been more than 20 incidents of in-flight engine failures with the GEnx engine dating back to 2013, not long after the Boeing Dreamliner aircraft first took to the skies for commercial operations.

Of the 22 recorded incidents, 15 were severe enough that pilots in charge of the aircraft switched off the engine mid-flight and returned to their port of origin or diverted to a nearby airport.

So the ATSB are investigating, Jetstar are onto it and proactively addressing the identified issue, therefore Binger is wrapping the story up until such time as the ATSB issues the final report. That is kind of how the system is supposed to work, fully transparent, nothing to hide and now on the public record.

Still doesn't stop Binger's resident troll from having another crack, while big noting himself with another long winded passage on the ICAO standards for twin-engine ETOPs - FDS..

Roger
1 hour ago


Jetstar. The new gold standard for the Qantas group. There was a time when these aircraft would have been taken out of service until the problem was fixed. No longer. Now they play Russian roulette.


Mick
2 hours ago


"...  flight JQ12 — a one-year-old Boeing 787-9 Dreamliner..."

For the third or fourth time in as many weeks, Mitchell, Jetstar don't operate -9 Dreamliners.


TIMOTHY
2 hours ago

Not much fun if both have to be shut down at the same time.


Mick
2 hours ago


@TIMOTHY  Significantly less fun than winning Lotto.   Pick six numbers for tomorrow's Lotto draw before you board a Jetstar Dreamliner out of Melbourne for Tokyo - you're 725 times more likely to win division 1 than having a dual engine failure on that 10 hour flight.


TIMOTHY
1 hour ago


@Mick. Try telling that to the punters on the flight that had the engine out over water! And if it is not much of an issue why do we have restrictions on over water ops for two but not three or four engine aircraft?


Mick

31 minutes ago


@TIMOTHY   They had an inflight engine shut-down, the Dreamliner is certified to fly for five and a half hours on one engine.

ETOPS restrictions apply to passenger-carrying airplanes with more than two engines when flying a route that entails flying farther than 180 minutes flying time from an adequate airport at an approved one-engine inoperative cruise speed under standard conditions in still air.  In short, ETOPS does apply to 3 and 4 engine airplanes.

The requisite in-flight shut-down (IFSD) rate for ETOPS 330 is less than 0.01 IFSDs per 1000 engine hours, which is the same as 10 shutdowns per million hours.   The General Electric GEnx is more than three times more reliable than the requisite standard.

 

Mick mate your a wanker...



MTF...P2  

[thorn bird]

Hot off the presses of BCA magazine.

It would seem that International attention is focusing on the Adelaide foggy foggy du duck up.

The interesting things to read from the comments on this article from around the world.

Many were incredulous that a low vis approach and auto land was not conducted at Adelaide. Good question, but these were from peers from first world countries. Perhaps the question should be why does Australia, purporting to be a world leading first world country, not have CAT 111 facilities at its primary airports? I could stand corrected but only Melbourne has CAT 111 facilities, and that only recently installed. There could be many possible reasons for this situation, I was flying low Vis operations back in the early eighties and they were not new then.

Could it be that our RAAF infested regulator way back then considered Low Vis was too dangerous for Australia to adopt and therefore refused to allow it? Back then they had teams running around the world surveying airports used by Quaintass to set minima's for them to use, so I wouldn't be at all surprised.

Or maybe since our airports were delivered to entities who's kudos was maximising profits from huge turnovers, to be siphoned off into tax free havens, thus preferring to build car parks than investing in Aviation Infrastructure.

Or this strange government policy that the user must pay and be damned to public safety and convenience, putting the onus on airlines either they pay, or do without, with the obvious consequence.

Ahh the land of OZ, only third world country where you can drink the water.

Quote from BCA:

Two Boeing 737-800s Bust Minimums At Australian Airport In Bad Weather

When busting minimums is the only choice
Aug 31, 2016 Richard N. Aarons | Business & Commercial Aviation
Comments 45

A Tale of Two Boeings

[/url]At the end of a remarkable chain of inaccurate weather forecasts and missed communications opportunities, two [url=http://awin.aviationweek.com/ProgramProfileDetails.aspx?pgId=634&pgName=Boeing+737NG]Boeing 737-800s operated by different Australian airlines had to bust minimums within minutes of each other at Mildura Airport to prevent really bad outcomes.
                                                                       
It all happened on June 18, 2013. Boeing VH-YIR, operated by Virgin Australia Airlines as Velocity Flight 1384, and Boeing VH-VYK, operated by Qantas Airways Ltd. as Qantas Flight 735, were on scheduled passenger flights to Adelaide, South Australia.

The story of what happened to these airplanes, crews and passengers is best told by the investigators of the Australian Transport Safety Bureau (ATSB).

Velocity 1384 departed Brisbane, Queensland, at 0638 Eastern Standard Time (UTC +10) with six crewmembers and 85 passengers on board. The estimated time of arrival at Adelaide was 0920. The captain was the pilot flying and the first officer (FO) was the pilot monitoring. The fuel on board at takeoff from Brisbane was 8,800 kg (19,401 lb.)This comprised flight fuel to Adelaide of 6,410 kg (14,132 lb.), variable and fixed fuel reserves of 1,540 kg (3,395 lb.) and additional fuel of 940 kg (2,072 lb.).

Qantas 735 departed Sydney, New South Wales, at 0727 and had six crew and 146 passengers on board. The estimated arrival time at Adelaide was 0917. The captain was the pilot flying, with the FO as pilot monitoring. The fuel on board at takeoff from Sydney was 7,900 kg (17,416 lb.). This comprised flight fuel to Adelaide of 5,000 kg (11,023 lb.), variable and fixed fuel reserves of 1,600 kg (3,527 lb.) and additional contingency fuel of 1,300 kg (2,866 lb.).

At 0700, the Bureau of Meteorology (BoM) issued an updated airport forecast (TAF) for Adelaide calling for a 30% probability of fog developing. At 0800, the BoM issued an updated trend forecast (TTF) that showed that fog had reduced visibility at Adelaide and was expected to clear by 0900.

At this stage, the crewmembers of Qantas 735 were aware of the changes to the TTF and continued to Adelaide on the basis that the fog would clear prior to their arrival. In addition, they had sufficient fuel to hold for about 45 min. should the fog last longer than forecast and land with required fuel reserves.

The pilots of Velocity 1384 were not aware of the changes to the forecast. They were advised of fog at Adelaide by ATC at 0844, once they changed to the en route sector frequency immediately prior to reaching the Adelaide terminal area airspace.

The crew of Qantas 735 elected to hold at waypoint Black, about 48 nm from Adelaide, rather than continue their descent to the airport, which was still affected by fog.

The crew of Velocity 1384 had commenced their descent to Adelaide and gathered further information about the conditions from the Adelaide tower controller. Based on the report from the Adelaide tower controller that conditions were not suitable for landing, and that there had been no successful landing attempts, the crew of Velocity 1384 elected to divert to Mildura, Victoria, at 0904.

The observation reports issued by the BoM at that time indicated that the conditions at Mildura were above the alternate minima for the aircraft, despite the TAF for Mildura indicating a temporary deterioration during the forecast period. The crew’s estimated arrival time at Mildura was 0932.

The crew of Qantas 735 heard Velocity 1384 broadcast their decision to divert to Mildura. On being informed by ATC that the latest trend forecast for Adelaide predicted a 30-min. delay in the fog clearing, and after gathering observation reports for Mildura, the crew of Qantas 735 also elected to divert there at 0913. Their estimated arrival time at Mildura was 0942.

In making the decision to divert to Mildura, the captain of Qantas 735 reported that they were aware that they had the capability to conduct an autoland at Adelaide Airport.

However, based on the reports of significantly better weather at Mildura, a diversion to that airport was assessed as preferable to continuing to Adelaide.

The captain of Velocity 1384 similarly reported that they considered the option of an autoland at Adelaide. However, given the observations of the better weather at Mildura, they also concluded a diversion was a better option at that time.

Arrival at Mildura
At 0916, the pilot of an air ambulance flight departing Mildura made a call to ATC that conditions were deteriorating. He reported the cloud base was at 400 ft. MSL. At the time, neither Velocity 1384 nor Qantas 735 were on this frequency and therefore did not hear this transmission.

At 0918, just after Velocity 1384 transferred to this frequency, the controller for this sector informed them of four other aircraft due to arrive at Mildura around their arrival time. This included Qantas 735. At 0922, Qantas 735 transferred to the same frequency and was advised of the arriving traffic.

Also at 0918, the BoM issued a SPECI (special weather report) for Mildura, showing clouds at 200 ft. AGL but visibility in excess of 10 km (6.2 mi). The Mildura RNAV GNSS instrument approach to Runway 27 required pilots to be clear of cloud at a minimum of 660 ft. (493 ft. AGL), reducing to 560 ft. (393 ft. AGL) using an actual airport QNH (altimeter setting that shows airport ASL elevation when the airplane is on the ground). As the conditions had deteriorated below these minima, the RNAV GNSS approach could not be conducted in normal operations. The airport forecast for Mildura, valid at that time, contained a temporary deterioration with cloud at 600 ft. AGL.

Between 0928 and 0932, three further SPECIs were issued for Mildura, indicating that visibility was decreasing in mist. As the Automatic Weather Information Service (AWIS) for Mildura was out of service, the inbound aircraft could not obtain this information from the AWIS.

At 0936, the controller made a broadcast on the area frequency to traffic at Mildura, informing them of the details of the 0932 SPECI. This SPECI indicated broken cloud at 200 ft. and visibility of 2,100 meters (6,890 ft.) in mist. A review of data from the cockpit voice recorder of Velocity 1384 identified that, for the duration of the controller’s broadcast of the SPECI, the crews of Qantas 735 and Velocity 1384 were busy communicating on the Mildura common traffic advisory frequency.

At 0937, the crew of Qantas 735 contacted the crew of Velocity 1384 to discuss the arrival and the crew of Velocity 1384 stated that they were tracking to the initial waypoint to commence the RNAV GNSS approach to Runway 27.

At 0939, the crew of a QantasLink Bombardier DHC-8 (Dash-8) aircraft broadcast to traffic at Mildura that they were conducting a go around. The crew of Velocity 1384 asked for an assessment of the weather and were told by the Dash-8 crew that at the minima, they “couldn’t see anything.”

At 0940, the crew of Qantas 735 contacted Velocity 1384 to advise that they were commencing the RNAV GNSS approach “due fuel.” The Velocity 1384 FO replied that they were “in the same boat,” but, after discussion between the captain and FO of Velocity 1384, they elected to hold and allow Qantas 735 to continue with the approach. This decision was passed on to the crew of Qantas 735.

The crew of Qantas 735 applied a revised minimum to the approach that was 200 ft. lower than that published. This was based on the knowledge that the cloud base would preclude becoming visual via a normal approach. The crew reported that as they descended toward the revised minimum, the extent of the cloud reduced and they gained sufficient visual reference of the runway environment to continue the approach. At 0946, the crew of Qantas 735 broadcast that they had landed at Mildura. The aircraft landed on Runway 27 with the required fuel reserves intact, and the crew reported that the runway was visible once they descended below the cloud.

At 0948, the crew of the Dash-8 asked Qantas 735 for their assessment of the weather.

The crew replied that the cloud base was at 150 ft. AGL and that they had landed off the approach “due fuel.” At this time, a SPECI was issued for Mildura, showing visibility was now 900 meters (2,953 ft.) in fog and that the cloud was overcast at 100 ft. AGL.

At 0950, Velocity 1384 sought an update on the weather from the Qantas 735 crew, who stated that the fog had appeared to be getting thicker but was now clearing, although the cloud was still below minima.

At 0952, Velocity 1384 updated ATC that they were still holding due to the low cloud at Mildura. ATC asked them to nominate a latest divert time to proceed to a suitable airport.

The FO replied that they did not have the fuel to proceed anywhere else. After obtaining further information from the crew, ATC initiated an alert phase and at 0958, after contacting the crew again, ATC activated the Mildura Airport emergency procedures.

At 0954, the controller made another “all stations” broadcast with the latest TAF issued for Mildura, valid from 1000. This forecast predicted:

Visibility of 3 km (1.9 mi.) in mist;

Scattered cloud at 300 ft. AGL;

An improvement in both visibility and cloud base in the hour from 1000;

A 30% probability of the visibility reducing to 500 meters (1,640 ft.) in fog for the period between 1000 and 1200.

Given their available fuel, the crew of Velocity 1384 determined that they needed to commence an approach just after 1000 to allow for a second approach if needed. They discussed conducting a “sighting” approach to ensure the aircraft was aligned with the runway from the RNAV GNSS approach. The captain was still the pilot flying; however, they briefed that if at any time during the approach the FO sighted the runway, then the FO was to take control and land.

At 1002, Velocity 1384 transmitted that they were on a 4 nm (7 km) final for the RNAV GNSS approach. At 1004, as they were not visual with the runway, the crew initiated a missed approach from 132 ft. AGL. The FO reported that as they commenced the missed approach, it was possible to confirm that they were aligned with the runway by looking directly down. At 1012, ATC initiated a distress phase.

The aircraft was positioned for a second approach, during which the cabin crew were briefed and prepared for an emergency landing, briefing the passengers to brace accordingly. At 1014, Velocity 1384 landed at Mildura in foggy conditions with fuel below the required reserves. As they taxied in, the captain told the cabin crew to stand down and normal arrival procedures resumed.

The Investigators’ Analysis
Following months of investigation, the ATSB observed that the Australian aviation weather reporting, forecasting and distribution systems are world-class but could use improvement. Company flight watch services at both air carriers are usually reserved for long-haul flights, leaving short-haul flight crews with the responsibility to pursue weather updates on their own once they are dispatched. In this situation, the observations and forecasts were changing quickly and information on Adelaide weather (and later Mildura’s weather) just didn’t form a picture for the crews in time to avoid the below-minimums approaches. The ATSB is suggesting further studies by Australian aviation civil and government agencies to see if improvements can be made.

The Safety Bureau looked at decision-making in each cockpit and ultimately found that the pilots made reasonable decisions including the decision to bust minimums.

ATSB Safety Issues
Ultimately, the ATSB identified a series of “safety issues.” Also, as a result of this investigation, the Safety Bureau initiated a research investigation that will “initially examine the reliability of the airport forecasts for Mildura and Adelaide, before expanding to cover other major Australian airports.” The idea is just to see where the system can be improved.

According to the ATSB, 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 organization or a system, rather than a characteristic of a specific individual, or characteristic of an operating environment at a specific point in time. Here are the safety issues that arise from this event.

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 airport 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.
For many non major 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 conditions.

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 airport weather reports at Mildura over the airport 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 inflight 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 inflight weather report given by the air ambulance pilot was not passed on to the flight crews of Velocity 1384 and Qantas 735 by the controller when they changed frequency in bound 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 recognize and actively disseminate special weather reports (SPECI) to pilots, thus not meeting the intent of the SPECI alerting function provided by the controller-initiated flight information service.

Last Thought
These crews were led into a subtle trap when all tolerances added up unidirectionally, leaving only their exceptional airmanship to save the situation. However, the investigation does make the point well that pilot skills must include a high degree of skepticism when evaluating weather information and forecasts when marginal weather is forecast. 

This article was originally published on July 29, 2016