Quote:Partenavia P68B aircraft autopilot and trim systems
Prepared by Alan C Baskett
Introduction
On the 10th July 1978 the Partenavia P68B VH-PNW crashed at Essendon Airport. The Dept in their Special Investigation Report 79-1 of March 1979 list the cause as:
Quote:Cause
The cause of the accident was that the aircraft became grossly out of trim at a height, which did not permit time for the crew to affect recovery. The manner in which the out–of–trim condition occurred has not been determined and the possibility of a trim system malfunction cannot be eliminated, however the more likely explanation is that the command trim switch was activated unknowingly.
The coroner at the inquest because of the evidence could not accept the DEPT’s more likely explanation. The DEPT’s simplistic assessment of the cause of this accident is an easy way of minimizing the underlying design deficiencies which allowed the aircraft to “become grossly out-of-trim” and the DEPT’s mismanagement of its certification responsibilities by attempting to shift the cause of the accident to “pilot error”.
This report attempts to detail the history and modifications made to the trim tab travel range of the trim system and the auto- pilot/trim system and of the certification and approval of these modifications.
Quote:Summary of events
23-1-75 - First of Type Certification in Australia of P68b Air- craft (no autopilot fitted)
April/May - Two P68B arrive in Australia with 1975 Autopilots fitted and no certification.
23-5-75 - The Dept formally requests certification justification for Autopilot installation.
12-6-75 - R.A.I. Autopilot Approval - No 124-245-T 1-8-75 to Edo-Aire Flight tested Autopilot
12-9-75 - R.A.I. Autopilot Approval - No 124-245-T 1-8-75 installation.
15-9-75 - Edo-Aire issued S.T.C. no SA 3067SW-D for Auto- pilot/Electric Trim system installation.
Sept 75 - Australian approval of Autopilot/Electric trim system installation.
28-4-76 - Partenavia produce Autopilot flight tests BM 82 and BM 83.
20-7-76 - VH-PNW registered in Australia with TTTR Number 2 fitted.
23-11-76 - TTTR Number 2 certified by FAA type data sheet A31 EU Revision 3.
16-1-78 - R.A.I. Certify TTTR Number 3 in RAI Type Data Sheet SO / A151 Revision 5
10-7-78 - Date of the said Crash.
October 78 - S. B. 41 modification to TTTR Number 4.
March 79 - Special Investigation Report 79-1 published.
17-2-89 - The Dept. flight test P68B aircraft as per CAA document M131-515-4 and in doing so establish TTTR Number5.
NOTE:
FAA - Federal Aviation Authority (USA)
R.A.I - The Italian Aviation Authority
STC - FAA Modification certification i.e. Supplementary type Certificate
Partenavia P68B aircraft and autopilot electric trim installation history
The original P68 aircraft and the P68B aircraft were both certified originally with a Trim Tab Travel Range (TTTR ) of 36 degrees. In fact this was the only trim tab travel range approved in Australia until the requirement for S.B. 41 became a mandatory modification late in 1978 after the accident date.The first P68B aircraft arrived in Australia during 1974 after Forrestair entered into a distribution agreement with Partenavia. This aircraft received “First of Type” certification on 23-1-75 for Australian operation.
IT WAS NOT FITTED WITH AN AUTOPILOT/ELECTRIC TRIM SYSTEM
During April/early May 1975 two aircraft arrived at Essendon after ferry flight from Italy, both these aircraft were fitted with Edo-Aire Century 111 Autopilot / Electric Trim Systems. During the registration/certification process the Dept. noted the autopilot installation and requested under Reg.27 justification for these non-approved modifications. This justification was first sought verbally and then in writing from the Dept. to Partenavia on the 23-5-75.
In the mean- time Forrestair were required to disconnect and disable the autopilot installations in these aircraft, leaving Forrestair with two aircraft paid for by them but unable to deliver to their customer and receive payment for until completion of the autopilot installation. Partenavia obtained Italian certification from the RAI. for the Autopilot/Electric trim system installation, RAI approval # 124, 245 / T on the 12-6-75 more than a month after the two aircraft had arrived in Australia after the ferry flight from Italy.
I am unaware of any flight test data or any justification for the Italian certification of the Autopilot/Electric trim system being submitted to the RAI for this certification. Note: None was produced during legal discovery for the litigation by Partenavia to me and this was the process where Partenavia were legally required to produce all documents that we had requested.
Italian certification of the Autopilot/Electric trim system would have been a prerequisite for testing to obtain American STC approval of this modification.
I suspect that Edo-Aire were probably mislead into a false sense of security when conducting the flight tests for the STC issue as the aircraft had already obtained Italian certification. Partenavia may have led Edo-aire into believing that an aft C of G may have been the critical condition to be tested. It appears that this is the only condition where results appear to be satisfactory can obtained.
Edo-aire document A75-66SW-DAS is incomplete, inadequate, superficial and misleading for the following reasons:
1; The section of the FAA Flight Test Report Guide Form 811018(6.75) dated June 1975 on pages 69 and 70 referring to Electric Trim System including flight tests have not been reported on.
2; The only flight tests conducted at forward C of G position were function tests only
3; Autopilot malfunction and trim runaway tests were all conducted at aft C of G position only. This is not a normal operating condition for the P68B aircraft as even at all up weight the C of G position is normally towards the forward limit. Note: On the night of the accident VH-PNW operating weight was only 57 kg below the maximum allowable operating weight, at a C of G position only six percent aft of the forward position of the total allowable.
4; Trim runaway tests were not conducted hands free but “Stick force observations were made without allowing an aircraft or air- speed change to occur”
5; Trim runaway tests were not conducted in takeoff or climb configurations
6; Trim runaway tests were not conducted to determine if a temporary force of 50 pounds (22.65kg) on the elevator control was exceeded when corrective action is not initiated until the malfunction is detected by the pilot for the following time delays and conditions of flight:
Takeoff, climb, approach & landing - 2 seconds
Cruise - 4 seconds
7; The most critical weight and C of G condition was not determined and used for trim runaway tests. However the FAA- STC No SA 3067 SW-D was issued by Edo-aire on the 15-9-75.
The Australian Dept. then approved the Autopilot / Electric trim system modification to the P68B for use in Australia even though they did not then or even now receive any flight test data from Partenavia to justify this Australian certification as required by ANO 101-22-7.3(6)
They do not even have a copy of the S.T.C.
The Dept. did not require Partenavia to submit any evidence “relating to the design to which the application relates including evidence of the effect of the design on safety of an aircraft” as required by ANR.40 (1 )( 2 )
The Dept. had previously recognized that the possibilities of problems occurring with aircraft designed and manufactured in counties other than the USA or the UK as they had included in ANO 101-22.1.2:
“The Director-General may specify additional design standards, documents and other evidence for aircraft types other than those designed in the United Stares of America or the United Kingdom.”
I have not been able to discover any such additional require-ments being made for the certification of the P68B or its modification by installing the Autopilot / Electric trim system. In fact when one departmental officer suggested additional flight tests for the first of type certification, he was informed that under no circumstances would this be required (copy of departmental memo held) nor was any additional requirement made for the certification of the Autopilot/Electric trim system. In fact the reverse is the case as the Autopilot/Electric trim system was certified with the requirements being less than that required by the statuary standards.
So the Autopilot /Electric trim system was certified in Australia.
Partenavia produced flight tests numbered BM82 and BM83. These tests are dated 28-4-76 and are similar in nature to Edo-Aire flight tests
BM 82 and BM 83 and Edo-Aire document A75-66SW-DAS are all documents applicable to the Autopilot / Electric system installation certification none of which are in possession of the department.
During April 1976 Forrestair took delivery of VH PNW. This aircraft Partenavia claim and the wreckage reconstruction would support this claim, was fitted with trim tab travel range number two of 28°. This TTTR not certified in Australia and the change was not noticed during the certification process by the department, nor was it noted during subsequent maintenance by Forrestair or Phil White (Aircraft Maintenance Engineer). The only certification details of this change to TTTR 2 are included in FAA types certificate Data Sheet A31EU Revision 3 (dated 23/11/76) more than six months after installation in VH-PNW.
No justification have been discovered to myself or to the department and for this modification.
A further modification of the trim tab travel range (TTTR number three) was approved by the R.A.I. on the 16th of the first 1978 in R.A.I. type certification data sheet SO/A151 revision five. This reduced trim tab travel range to 24°.
Again this modification has no design justification or flight tests discovered by Partenavia to myself, nor were any submitted to the Department. Partenavia were either unaware; or are unable; or unwilling to notify certification authorities of changes to the P68B design status and obtaining approval before incorporation into production aircraft.
These modifications to the Trim Tab Travel range from 36° to 28° indicate that Partenavia were aware that a problems existed in the trim system.
Perhaps the events of the 10th of July 78 may have been averted at the modifications to 24° total travel had been incorporated into Australian aircraft as this reduced the nose-down trim capability by 54% from a total excess on over 140% to only 86% of excess capabilities.
After the crash of VH-PNW on the 10th July 1978, Partenavia issued Service Bulletin 41 during October 1978, which changed trim tab travel range (TTTR number four) to 14° and again Partenavia have not discovered to me any design justification or flight tests to support this modification. Neither have they provided any design justification or flight tests to the Department.The departments CAA report M131-515-4, I submit is the only fight test report that is available - even though it would not be produced until early 1989 - that is able to establish the actual trim tab travel required for the Partenavia. Even though its primary purpose was to determine the P68.B’s compliance - with F.A.A.23-689 (f) - by doing this the Department has established the trim tab travel requirements for the P68B. By logical conversion as detailed in TTTR number 5, it can be determined that only 7 ½ degrees of total trim travel is required for the aircrafts safe operation.
Quote:
Trim Trim Tab Travel Diagram
Trim tab travel range number one
0 degrees + / – 1 degree Down To 16 degrees + / – 1 degree UP
- This was the only range that was certified in Australia- This travel range has an excess nose down trim capability of 18.5 degrees or 246 %excess capability.
- This range is shown on the Trim Tab Travel Ranges drawing - colored RED .
- This travel range has an excess nose up trim capability of 10 degrees or 135 % excess capability.
- This excess capability has been calculated over that shown in Trim Tab Travel Range number 5
{Comment: No design justification for this trim tab travel range - by the Dept, or Partenavia - has been discovered by the author A Baskett.}
Trim tab travel range number two
20 Degrees + / – 1 Degree Down - To 8 Degrees + / – 1degree Up
- This range is shown on the Trim Tab Travel Ranges drawing as being coloured YELLOW.
- This is the range that was approved and certified by the F.A.A Type Certificate Data Sheet A31EU Revision 3 dated 23/11/76.
- This range was not approved in Australia.
- This is the range that Partenavia claim was fitted to VH-PNW.
- This appears to be the range fitted to VH-PNW as far as can be determined by the wreckage reconstruction.
- This travel range has an excess nose down capability of 10.5 or 140% excess capability.
- This excess capability has been calculated over that required in Trim tab travel range Number 5.
{Comment: No design justification for this trim tab travel range - by the Dept, or Partenavia - has been discovered by the author A Baskett.}
Trim tab travel range number 3
20 Degrees +/- 1 degree to 4degrees +/- 1 degree Down
- This range is shown on the Trim Tab Travel Range drawing as being coloured BLUE.
- This is the range that was approved and certified by the R.A.I. Type Certificate Data Sheet SO/A151 Revision 5 dated 16/1/78.
- This Range was not approved in Australia.
- This travel range has an excess nose down trim capability of 6.5 degrees or 86% excess capability.
- This travel range has an excess nose up trim capability of 10 degrees or 135% excess capability.
- This excess capability has been calculated over that required in Trim tab travel range Number 5.
{Comment: No design justification for this trim tab travel range - by the Dept, or Partenavia - has been discovered by the author A Baskett.}
Trim tab travel range number four
1 degree Down to 15 degrees Down
- This range is shown on the Trim Travel Range drawing as being coloured ORANGE
- This is the range that has been approved by the requirements to incorporate Partenavia Service Bulletin 41 in October 1978.
- This range is now approved in Australia.- This travel range has an excess nose down trim capability of 1.5 degrees or 22% excess capability.
-This travel range has an excess nose up capability of 5 degrees or 66% excess capability.
- This excess capability has been calculated over that required in trim tab travel range Number 5.{Comment: No design justification for this trim tab travel range - by the Dept, or Partenavia - has been discovered by the author A Baskett.}
Trim tab travel range number five
2.5 degrees Down to 10 degrees Down
- This range is shown on the Trim Tab Travel Ranges drawing as being coloured GREEN.
- This is the range discovered to A Baskett to be approved by the Dept. in C.A.A. document M-141-515-4 dated 17/2/89.- This range is NOT approved in Australia.
- This travel range was established by flight test procedures to confirm compliance with F.A. R. 23-689(f) by a correctly rigged P68B aircraft at both forward and aft loading conditions, in so doing the total trim tab travel range required was also established for the Partenavia P68B.
(Note: The method of determining the angular travel – was by dividing the 14 degrees of travel of a correctly rigged aircraft by the number of divisions of travel indicated by the trim indicator i.e. 8.5 degrees. Therefore 1 division of trim indicator equals 1.65 degrees trim indicator scale.of trim tab travel. It is assumed linier along the scale.)
{Comment: The M-131-515-4 document is the only document available that the author, A Baskett, has been able to discover that has any creditability to establish the actual trim tab travel requirement for the Partenavia P68B Aircraft.}
Special investigation report 79-1
This Accident Investigation Report prepared by the Dept while appearing to be extensive and detailed in its investigation of this accident is in fact deficient in its pursuit of the subject matter to its logical extension of the ramifications of the total assessment of all the facts.
The Dept have touched on the matter of pilot strength when they investigated control system failure caused by pilot input loads but chose to not detail in a similar manner the requirements of FAR 23-143© which limit the force required to be exerted by a pilot on a temporary basis not to exceed 75 pounds.
This report also omits to detail any reference to the fact that the position of the trim tab actuator was in a position that indicatedthat the trim tab travel was other than that certified in Australia.
This report omits to admit to the fact that the Dept failed to obtain flight test reports as required by ANO 101-22 prior to certifying the Autopilot/Electric Trim system.
This report omits to detail that the Trim Tab Travel Range was excessive to that required to comply with FAR23-689(f) which establishes total trim capacity required for an aircraft.
This report fails totally to address the fact that the Electric Trim Systemwas never flight tested correctly as required.
This report by not completely investigating all aspects of the ElectricTrim System was able to minimize the design and certification deficiencies to enable the claim of pilot error to be raised by stating - “However, the more likely explanation is that the command trim switch was activated unknowingly.”
This cannot be supported by any evidence as the coroner found at the inquest.
The CAUSE as listed in this report is incorrect and misleading and would be more accurate if listed similar to the following:
Cause
The cause of the accident was that the aircraft became grossly out of trim at a height which did not permit time for the crew to affect recovery. The trim system design allowed control forces to be generated that exceeded pilot control force limits to be exceeded by a substantial amount. The manner in which the out of trim condition occurred has not been determined and the possibility of a trim system malfunction cannot be eliminated.
Footnote.
I have no beef with the actual accident investigators Stewart or Jim, only the executive above them. At the time of the accident BASI were part of the Department and it appears that nothing has changed over 37 years. From what I can see, I am glad I am not involved in General Aviation in today’s environment.
Alan C Baskett
Quote:Stan van de Wiel wrote:P2 comment: I also find it interesting that the AAI was incorporated within the 'Department'. Interestingly it was rumoured that prior to - & sometime after - the PelAir cover-up that the Iron Ring were determined to absorb the ATSB back into CASA - hence the set up of the ALIU (Accident Investigation Liaison Unit).
Having first hand knowledge of Alan's experience I would like to contribute further in relation to the trim problem. Schutt's at YMMB operated a PN68B and experienced a similar runaway trim situation, after the VH-PNW accident. Conditions were daylight and aircraft was able to complete a circuit with great difficulty.
As I recall the trim settings were altered on at least two occasions restricting the total freedom of movement some 20 plus degrees. AD to this effect should still be on the system and it became a (more) important preflight check.
CAsA was known as DOT ASG at the time but the culture of self preservation was already past the embryo stage and as we witness it now.
Alan was lucky to survive but over the years individuals in CAsA made it difficult and virtually forced his retirement. [appears treatment is according to the internal MOS]
) with this endeavour, perhaps it is now nugatory because the ATSB has now been affectively neutered and any veracity in the ATSB statement of 'independence' & a so called 'unbiased' investigator is simply BOLLOCKS! 
Quote:What are the facts?
Again and again and again — what are the facts? Shun wishful thinking, ignore divine revelation, forget what "the stars foretell," avoid opinion, care not what the neighbors think, never mind the unguessable "verdict of history" — what are the facts, and to how many decimal places?
You pilot always into an unknown future; facts are your single clue. Get the facts!
Robert Heinlein (1978)
(11-15-2015, 10:09 PM)Peetwo Wrote:(11-15-2015, 09:20 AM)Peetwo Wrote:(11-11-2015, 06:45 PM)ventus45 Wrote:
Comet's comment , COTY??- “…the main casualty will be our democracy”
Combined with the "V" post (above) and in light of the atrocities in Paris, I thought the following chain of excellent commentary on Ben's blog piece - ATSB now has only one set of black boxes lost at sea; or here on AP - ending with perhaps a nomination for 'comment of the year' by comet was worth regurgitating..
The Pel-Air story is about government opaqueness.
We don’t know – and can only guess – why the governent safety investigator didn’t want to get to the truth, or why two government ministers (Albanese and Truss) took no interest in forcing the ATSB into line.
Unfortunately the atrocities in Paris will give governments around the world the cover they need to become more opaque and less open, while at the same time monitoring their citizens’ every move, and introducing harsher penalties for whistleblowers.
A bad event gives governments the excuse to start other bad events (eg Iraq wars). Aviation will suffer, but even worse, the main casualty will be our democracy.
Update - 25 November 2015: Courtesy of Planetalking..
Quote:Pel-Air 2nd final report now has data, and a stab at a date
Ben Sandilands | Nov 25, 2015 10:35AM |
The aft section of the ditched jet as seen early this year
The disgraceful saga of the ATSB inquiry into the ditching of a Pel-Air Westwind jet in 2009 now has black box data, and an indication of a date, for its second and forced final inquiry into the accident.
This update has been posted on the ATSB website:
Data from both the CVR and FDR from VH-NGA has been successfully downloaded at the ATSB’s technical facilities in Canberra. The CVR data is of just over 2 hours and 4 minutes duration, covering the period up to the aircraft’s ditching into the waters off Norfolk Island. The FDR contained 116 hours of data, which included the last four flights of VH-NGA, which were undertaken in the period between fitment of the particular recorder to the aircraft on 3 November 2009 and the date of the accident (including the accident flight). The evidence obtained from the recorders will be analysed as part of the ongoing investigation and relevant information will be included in the ATSB’s final report, which is expected to be released in the first quarter of 2016.
The previous post on Pel-Air can be read here.
Quote:"[and] relevant information will be included in the ATSB’s final report, which is expected to be released in the first quarter of 2016."
(11-26-2015, 05:36 AM)kharon Wrote: A Black box – for Beaker’s coffin?
Good news – and well done the Black box system, robust, serviceable and performs design function very well indeed. Of course the OBR are designed and specified to survive just about anything, the information considered invaluable to accident analysis, which is why ICAO mandate recovery. Only under the ‘Beyond all reason’ methodology can a commissioner declare the information of no practical or intrinsic value and decide which information is relevant:-
Quote:"[and] relevant information will be included in the ATSB’s final report, which is expected to be released in the first quarter of 2016."
Bollocks - In the interest of probity – all data and transcript should be released to the Senate Committee – in camera – as evidence; to provide a ‘clean’ unadulterated version of fact. The TSBC should be invited to examine and provide an independent report. ATSB cannot be trusted to provide an unvarnished, unbiased version. Not any longer.
The likes of Hattley and Chopin must be having a quiet smile – honour and investigative probity satisfied.
The damage Beaker and his mates have done to ATSB credibility is palpable and toxic; the time to restore industry and public faith is now. Dolan must go, for he cannot possibly stay, not if ATSB is to be rehabilitated and restored to credibility.
Selah.
Quote:Pel-Air 2nd final report now has data, and a stab at a date
Ben Sandilands | Nov 25, 2015 10:35AM |
The aft section of the ditched jet as seen early this year
:Quote:1
Dan Dair
Posted November 26, 2015 at 5:12 pm | Permalink
Will 2 hours & 4 minutes of CVR data be sufficient to prove or disprove the Captains claim of inaccurate information being supplied to him by Australian ATC.?
I suspect not.?
2
Fred
Posted November 27, 2015 at 1:23 pm | Permalink
Dan,
Perhaps I’m mistaken, but my understanding is that the information provided by Nadi and Auckland ATC (not Australian!) during the two-hour window recorded by the CVR is not in dispute. The original ATSB report clearly states that an amended forecast for the aircraft’s ETA at Norfolk Island was not provided, and neither was the 0830Z SPECI report that indicated the weather was below landing minima. The ATSB brushed that off by saying that ATC were not required to provide the information by any international agreement, and the report failed to make any safety recommendations on that issue.
The aircraft ditched at 1026Z, so the CVR should have recorded any communications from 0822Z onwards. According to the ATSB’s timeline, the aircraft’s last point of safe diversion for Noumea didn’t occur until after 0900Z. If the 0830Z SPECI had been provided on first contact with Auckland ATC, the crew may well have made the decision to divert to Noumea. Unfortunately we’ll never know, because, as already acknowledged by the ATSB, the crew was not advised of that report.
That said, the 0800Z SPECI that WAS provided to the aircraft indicated that the observed weather had deteriorated and was below the alternate minima. That should have been a trigger for the crew to start looking at diversion options and to start being far more pro-active in seeking out the latest weather information. That didn’t happen for some reason, perhaps due to fatigue or communication difficulties with ATC. I’m not sure that the CVR will shed much light on that aspect, given that the recording only commences at 0822Z.
I think the bigger issues with the re-opened investigation are the organisational, regulatory and human factors issues that were ignored in the original investigation. Hopefully the ATSB will get that part right the second time around and will also point the finger at CASA’s deplorable oversight of Pel-Air’s operations. I’m not holding my breath.
3
comet
Posted November 27, 2015 at 4:17 pm | Permalink
And after that somebody needs to investigate the ATSB to find out why it did not release a competent investigation report.
4
Posted November 28, 2015 at 1:22 am | Permalink
Fred,
Thanks for clarifying my errors.
I didn’t realise that the (Auckland) ATC communication failings were accepted, but considered irrelevant by the report.??
It will be very interesting to find what was actually said in the cockpit prior to the pilots realising the true extent of the weather problems at Norfolk Island.?
I will be extremely surprised if the outcome of the investigation is the strong censuring of the ATSB & CASA, as would appear to be appropriate based on what is already in the public domain, especially as a result of the Canadian ‘peer-review’.?
5
PAIN_P2
Posted November 28, 2015 at 11:19 am | Permalink
Fred that was a fairly accurate account of what was (or wasn’t) transmitted by ATC (NADI/Auckland)& received by VH-NGA.
For the record (courtesy Senate RRAT committee) here is a link for a Bryan Aherne supplied copy of the official transcript: http://www.aph.gov.au/DocumentStore.ashx...2ffa885397
From that it can be seen that at 0801 UTC NADI first gave the 0630 METAR followed closely by the 0800 SPECI. It should be remembered that the 0630 METAR contained an error that was later discovered by the ABC 4 Corners program. NADI stated FEW at 6000 ft when in actual fact it was FEW at 600ft. The ATSB later had to correct their report to reflect this.
How the METAR/SPECIs from NADI were actually interpreted by the flight crew prior to the 0841 UTC transfer to Auckland will unfortunately not be covered in most part by the CVR. From part of the 4C program transcript Dominic James was shocked when told about the NADI cloud-base error transmitted. This was what he said in reply:
Quote:DOMINIC JAMES: If I’d been told that there was cloud at 600 feet, even given the fact that I suspected the automatic system was overstating the weather at Norfolk, I would’ve gone to Fiji.
GEOFF THOMSON: But moments later another weather report comes from Fiji which is acknowledged by the flight crew as the latest weather available.
It contradicts what they’ve just heard and says weather conditions on Norfolk Island are in fact deteriorating.
DOMINIC JAMES: I maintain that that weather report, exactly as it appears in that transcript, is not what we had on the flight deck. That’s not what I copied down, it’s not what I comprehended.
GEOFF THOMPSON: And how do you explain that?
DOMINIC JAMES: To be honest with you, I can’t
So it is reasonable to assume that this was a significant (previously not identified)hole in the Swiss cheese. Combined with (as Fred stated) the absence of the amended TAF being relayed you have two holes already aligned.
Therefore the CVR transcript will still be significant (from approx. 0830 UTC) because it should at least have the crew interaction/interpretation of the relayed deteriorating wx conditions in the lead up to the ditching.
Cheers
P2
Ps Another fact about the 0801 UTC NADI transmission (0630 METAR), is that the CASA version (summary) of the ATC transcripts in their CAIR 09/3 investigation report (see pg 51 here: http://auntypru.com/wp-content/uploads/2..._CASA1.pdf ) conveniently omits all the details from the 0630 METAR.
(11-29-2015, 05:37 AM)kharon Wrote: Why Beaker elected to leave the OBR in the water has always intrigued the curiosity bump. Perhaps there is some common or garden reason, maybe even the pragmatic ‘of no value to the investigation’ could be the simple, truthful answer. But, the accursed bump keeps itching away; motive and who benefits, nag, nag, nag. Put that aside for the moment.
Since the Senate inquiry there has been a massive, sulky, passive resistance to recovery of the OBR, dragging of feet and general reluctance to get on with it. Hell, it took a directive from the blasted minister to get the ball rolling and even then, every back door was checked for an escape route. Time goes by, but eventually the day arrives and up from the shallows off Norfolk – the black box emerges: and, bugger it all; the rotten thing works, just fine.
Dom J is not too concerned about this, the Senate and punters are happy, so why the long faces at Beaker bunker? IMO the OBR will not shed much more light on the general picture; it will tidy up some loose ends and provide ‘hard’ data, but it will not explain why it was consigned to a watery grave.
Toot 123, 123, 123 –( ¾ time, eminently suitable for Sunday).
Quote:...The FAR 91.169 states that an alternate airport is always required except when the worse forecast at the destination airport from 1 hour before to 1 hour after the estimated time of arrival (ETA) is expecting a ceiling of at least 2000 feet and 3 statute miles of visibility..Also relevant - from the blog piece - to the Ferryman question IMO is this statement:
Quote:..Approved sources of weather forecasts for the purposes of alternate requirements are: Terminal Aerodrome Forecasts (TAF) and Area Forecasts (FA). The pilot must also remember that a TAF is only valid within 5 statute miles from the terminal of an airport, and, consequently, referencing to a TAF as a “forecast source” when the first point of intended landing is 5 or more statute miles from the nearest reporting TAF station would be invalid...
![[Image: taf.jpg]](http://auntypru.com/wp-content/uploads/2015/11/taf.jpg)
![[Image: nadi.jpg]](http://auntypru.com/wp-content/uploads/2015/11/nadi.jpg)
}Quote:Senator XENOPHON: Can you explain that? I am just trying to get the context here. What are our international obligations in regard to the sharing of hazardous weather information with other air traffic service organisations?
Mr Harfield : We have a monitoring system where the Bureau of Meteorology obviously monitors a number of locations around Australia and within the jurisdiction of the airspace that we manage. When we get information provided that is of a differing nature from the forecast, such as a hazardous weather event or the SPECI information that you mentioned previously, that information is then sent to the control positions. It is then relayed to the particular aircraft based on certain parameters where the weather has changed. We call that a hazard alerting service. What we would do, for example, if an aircraft which had a terminal area forecast for Sydney was flying between Melbourne and Sydney and the weather conditions rapidly changed is issue a hazard alert and notify all aircraft going to that destination of the change in circumstances.
Quote:CHAIR: We are not blaming you for the—
Mr Harfield : No, I understand. I just want to make sure that I am clear in what I am saying. The fact is that it was Fijian air traffic control that did not pass on the amended weather information, not New Zealand air traffic control. On the basis of what happened in the accident, that weather information was critical in the sense that if that bit of information was seen, the outcome may have been different. I am reluctant to say that the procedure is unsafe because I do not have the broader information on what is going on. Here was a piece of information that should have been passed to the aircraft which could have prevented this outcome.
Quote:CHAIR: You are the bunnies. None of this affects you because there was nothing in the report upon which you have got to act, even though it is critical to the crash, perhaps. ATSB, for whatever reason, whether it is just to protect the bureaucracy or whether it was adjusted by CASA, which is a possibility, did not mention this critical factor of the nonreporting of the weather change, which leads to a very big question. Senator Fawcett?
Senator FAWCETT: The thing that the committee is struggling to come to is that there have been many witnesses who are pointing fingers of blame at particular incidents. Australia has been a leader in aviation safety for a number of years through its fairly robust adoption of a systems approach, and James Reason is the classic person who has driven that. So, clearly, the actions of the pilot in command and his decisions around flight planning and fuel have a role to play—so do the actions of the company in terms of their checks, training et cetera. But each slice of the Swiss cheese, as the James Reason bowl is often laid out, has the potential to prevent the accident. So the importance that the committee is placing on an incident such as a proactive alert to the pilot that there is now a hazardous situation is not the reason the accident occurred, but it is one of the defences that may well have prevented the accident. If Australia are to remain at the forefront of open, transparent and effective aviation safety then one of the roles of this committee is to make sure that our organisations collectively keep working towards having a very open discussion around that systems safety approach and making sure that each of those barriers is as effective as it can possibly be. That, I guess, is the intent behind a lot of the questioning this morning.
We see that, whatever else occurred, if the pilot had been made aware proactively about the hazardous situation that now existed then perhaps he would have made a different decision. Should he have been there in the first place? Should he have had more fuel? They are all other slices of cheese. We are concerned with this one. The thing we are really trying to establish is, if the ATSB report had had a recommendation that said, 'This was something that could have prevented the accident. Is it possible to have it put in place for the future?' then you would have taken action on that as a matter of course. Is that a correct assumption?
Mr Harfield : That is a correct assumption.
Senator FAWCETT: And without that recommendation being there it is a matter of some conjecture at the moment as to whether or not that would or would not have been raised at a future forum. Is that a fair assumption?
Mr Harfield : That is a fair assumption.
Senator FAWCETT: Under the current model, if ATSB come across in one of those slices of Swiss cheese in the recent model a question of whether or not existing legislation directed a pilot to make a decision that he had to divert if the weather minima went below alternate or landing minima, and they contacted the regulator and said, 'Hey, regulator, here is a critical safety issue' and they thrashed that through, do they have a similar mechanism where if they see another slice of Swiss cheese—that the pilot was not advised of this new hazard—do they come to you as the relevant body? Although it is not your rule set, you are the Australian point of contact to speak to regional players; do they come to you and say, 'We think there is an issue here, can we discuss this?' Did they come to you in this case?
Mr Harfield : In this case I do not recall and I do not think that they did. However, in other instances where things have occurred they have come to us to ask for assistance—for example, with some incidents that have happened in Indonesia.
CHAIR: But no-one cared about the prang off Norfolk Island?
Mr Harfield : That is not correct, Senator; I just do not recall the ATSB coming to us to ask us for assistance in this particular jurisdiction.
CHAIR: How long have you been at Airservices?
Mr Harfield : Nearly 25 years.
CHAIR: I think you need a change of career.
Senator FAWCETT: Can I clarify that if ATSB did come to you in the same way they came to CASA and said, 'Here is something that potentially could be a barrier to a future accident,' that would be a sufficient trigger for you to then take that on corporately and see what action you could take with your regional partners?
Ms Staib : Absolutely.
Senator FAWCETT: That is what we are trying to look at here—we are trying to ascertain what are the things that we can drive into the relationships between departments to make sure that we wrap up the system safety to the best extent possible
Quote:P2 – “The significance of these omissions was brought fully to the attention of the RRAT Senate Committee PelAir Inquiry on the 19 Nov 2015.
Quote:CHAIR: You are the bunnies. None of this affects you because there was nothing in the report upon which you have got to act, even though it is critical to the crash, perhaps. ATSB, for whatever reason, whether it is just to protect the bureaucracy or whether it was adjusted by CASA, which is a possibility, did not mention this critical factor of the nonreporting of the weather change, which leads to a very big question
Quote:Sen. Fawcett: “So the importance that the committee is placing on an incident such as a proactive alert to the pilot that there is now a hazardous situation is not the reason the accident occurred, but it is one of the defences that may well have prevented the accident.
Quote:CHAIR: How long have you been at Airservices?
Mr Harfield : Nearly 25 years.
CHAIR: I think you need a change of career.
Quote:It’s almost three Australian winters since a Virgin Australia 737 with 91 people on board made an emergency landing at Mildura on a fog bound runway the pilots had difficulty seeing and came to a stop with its fuel tanks near empty.
That emergency also affected, although less severely, a Qantas 737, a Qantaslink Q400 turbo-prop and a small SAAB 340, but it was on the Virgin flight that passengers had to adopt the crash position while a pilot called BRACE BRACE BRACE .
Such a drama is extremely rare in an Australian airliner, and no record of anything similar happening in routine domestic operations has been found.
The ATSB inquiry into what has become known in the game as the 2013 Mildura fog and fuel f*ckup is of exceptional importance, because it raised what the safety investigator regards as crucial matters in terms of fuel regulations, airline operational policies and the competency and relevance of services that were or were not being provided by the Bureau of Meteorology.
Or to be blunt, it is about an event where the national slogan ‘she’ll be right’, was wrong, and many, many lives were put at risk.
The Virgin and Qantas 737s, both bound for Adelaide, were forced to land at Mildura because they weren’t obliged to carry enough fuel to go anywhere else when fog suddenly closed the runways as they approached their destination, only to find that the forecast for the MIA town was wrong, and it too was fog bound.
A very lengthy investigation by the ATSB has now reached the stage where the draft final report is in the hands of the airlines affected, as well as the BoM, and CASA, whose rule making wisdom and fortitude is again under scrutiny, and on last word, due for public release in March.
There is a potential problem with this, in that the review period gives directly interested parties like airlines and the weather bureau, an opportunity not just to correct anything claimed to be factual, but to airbrush if they see fit, the language the safety investigator might choose to use.
In short, to provide an opportunity to ensure that as far as possible, the public will be told that ‘passenger safety was never compromised/threatened/affected’ and that there is ‘nothing to see here, just move along’.
ATSB press releases are like the sedatives used in palliative care for the aged, and seldom contain or convey the critical matters it does, sometimes, and to its credit, thrash out in its full reports. They generally put what is left of the media to sleep before it occurs to anyone to actually read the real document and its appendices, and get some help from professional pilots in understanding it.
Make no mistake, the Mildura fog emergency (etc) concerns incidents where the lives of Australian airline travellers were right on the line. But tightening the fuel rules to those followed in the developed world, and even much of the undeveloped world, might cost the airlines money by requiring more fuel to be carried for that rainy, foggy or stormy day when the current practices could result in the filling of truckloads of body bags.
There are times when less obsequious or more direct language needs to be used, and this is one of them.
The interim report of the ATSB was obscured on its web site in a November update saying the draft report was ready for the review process. However it can be read in full here if you click on the ‘interim’ tab, which doesn’t have its own sub link and might not catch the eye of the casual visitor.
That interim report was reviewed by PT at this link.
Quote:What say you P2? If you take the PT links the 'ATSB report' is linked from the article - the ATSB link is HERE - click Interim for the report.Yes Old'Tom in the case of the Mildura fog cock-up (& numerous other newsworthy but ignored serious incidents) very convoluted..
I say bring back the old crash comics at least then you had a hardcopy that you could easily refer. Beats the hell out trying to find the progress of, or recently updated ATSB investigations on their website. Someone could surmise that CC Dolan has something to hide... Quote:1
George Glass
Posted January 25, 2016 at 12:11 am | Permalink
There is no requirement to carry alternate fuel for single runways in Australia, contrary to pretty well every other serious country.
ILS facilities at most Australian airports are Cat 1. Pretty much useless in fog.
Diverting to a remote airport with non-precision approaches and no ATC only makes sense if you understand that the Pilot in Command felt that his obligation to conform to regulations over-road common sense.
Contrary to what most of the traveling public assume Australia does NOT have world class facilities. Truth is we just get away with it.
There needs to be a comprehensive review of ATC and ground facilities in this country to work out where we want to be in 30 years time because right now its a joke.
2
Posted January 25, 2016 at 7:53 am | Permalink
George Glass,
After ten years of ‘boom-times’, Australia’s infrastructure is not noticeably better for it.?
Sure the weather’s not generally so good in Northern Europe, but CAT III is considered ‘base-line’ for any significant airport which expects to safely serve it’s commercial passengers.
How many Australian commercial airports actually have full ILS capability.?
The problem with the remoteness of some of Australia’s cities could be mitigated by improvements in ILS systems & of course, much more accurate weather forecasting.
Perhaps Ben is right when he suggests ‘that rainy, foggy or stormy day when the current practices could result in the filling of truckloads of body bags’ & the depressing thing is that it looks like this will have to happen before a programme of upgrades is begun.
CASA should be mandating improvements at all commercial airports above certain passenger or aircraft-movement numbers, where there is any clear history of weather-related incidents.
It should create a defined programme of targets, to be implemented over a equally defined time period.
There is no reason why the cost-burden should not be shared around.
The Government can put some tax-dollars in & the rest can be shared between the airlines & the airports.
The only other safe option is to enforce the same fuel-reserve rules commonplace throughout most of the rest of the world.?
Ultimately, passengers will end up being those who really pay for it, but they’ll be buying considerably a improved
safety regime for it.
(01-22-2016, 10:38 AM)Peetwo Wrote: Four incidents, a ditching & two cover-ups? - Safety risk mitigation Oz style.
On the 22 February 2000 the ATSB issued safety recommendation 2000004 addressed to the BOM, under 'Safety Action' it states:
Quote:..As a result of these occurrences, the Civil Aviation Safety Authority has commenced a project to review the fuel requirements for flights to remote islands...
& under the BOM response text:
Quote:..The Bureau is actively participating in the review of fuel requirements for flights to remote islands being undertaken by the Civil Aviation Safety Authority...
Yet here we are nearly 18 years from the first reported incident; nearly 16 years since the SR was issued; more than 6 years since the Pel-Air ditching; & 949 days since the Mildura fog incident occurred. For a reminder of the seriousness of that incident, here is a Planetalking article from 18 months ago - ATSB Mildura fog crisis report delayed for good reasons:
Quote:..Today’s announcement indicates that important changes are being pursued in the interests of safety, presumably with the enthusiastic support of the Australian carriers, as Mildura proved to be both a harrowing yet lucky night for each, in which the professionalism of their pilots played an essential role in getting them out of a situation in which a commercial jet flight in this country should never have been put at such risk...Well finally there is a sign that some sort proactive action to address these identified safety issues maybe on the horizon - HOORAH!
Firstly from the CASA 'Standards Development and Quality Assurance Branch' issued 2 days ago:
Quote:CD 1508OS - Fuel and oil quantity requirements
Background
Regulation 234 of the Civil Aviation Regulations 1988 (CAR) requires the pilot-in-command of an aircraft to take reasonable steps to ensure that the aircraft carries sufficient quantities of fuel and oil for the proposed flight to be undertaken safely. The regulation also requires the operator of an aircraft to take reasonable steps to ensure that an aircraft does not begin a flight unless it is carrying sufficient fuel and oil to allow the flight to be conducted safely.
Australian Transport Safety Bureau (ATSB) reports have revealed incidents and accidents directly related to carriage of insufficient quantities of fuel. CASA proposes to address this safety issue by amending regulation 234 of CAR to provide updated fuel and oil requirements.
The current regulation 234 of CAR allows courts to consider any guidelines provided by CASA when determining whether sufficient fuel and oil were carried on a flight, which includes the guidelines provided in CAAP 234-1(1). While some of the information provided in the CAAP should be read as a requirement empowered by the current regulation 234, other information is advisory in nature. CASA intends to the make clearer the distinction between the regulatory requirements and the guidance material by transferring the requirements for determination of fuel and oil quantity from the CAAP to a proposed legislative instrument.
- SPC to CD 1508OS
- Annex A - Draft Civil Aviation Amendment (Fuel and Oil Requirements) Regulation 2016
- Annex B – Draft Civil Aviation (Fuel Requirements) Instrument 2016
- Annex C - Summary of key changes introduced by Civil Aviation (Fuel Requirements) Instrument 2016
- Annex D – Draft Civil Aviation Order 82.0 Amendment Order 2016 (No.X)
- Annex E – Draft CAAP 234-1(2) – Guidelines for aircraft fuel requirements
And then even better yesterday - some 30 odd years after the rest of the developed world - CASA made an announcement about a change to the regs, which they predict will pass on $10 million p.a. to industry, courtesy the OZ:
Quote:New aviation rules to slash weather delays
(01-25-2016, 04:18 AM)kharon Wrote: Whats wrong with KISS, easy to remember rules work every time; Throw the AIP out along with 61 and the 'new fool fuel rules'.Exactly "K" & guess what they're not prepared to sit on their laurels in regards to continuingly improving the system either, courtesy of Recode:
Quote:IFR Alternate Airports (1-2-3 Rule).
When filing an IFR flight plan, you must include an alternate destination airport when the weather forecast at your original destination predicts conditions below those specified in CFR 91.169. To help remember those conditions, you can use the 1-2-3 rule.
1 - During the time 1 hour before to 1 hour after the estimated arrival time
2 - Ceiling less than 2,000 feet
3 - Visibility less than 3 miles
If the above conditions exist, an alternate airport must be filed.
But then, WTF would the USA know about aviation or bad weather operations.
Quote:The Future of Aviation and Weather ForecastingHmm...so do you think such innovative thinking & suggestions were put forward at the ATSB talk-a-thon that occurred in the wake of the '2013 Mildura fog and fuel f*ckup'?? Not bloody likely when we're already 40 odd years behind other first world aviation nations - UFB!
By George Spencer, Manager, Air Traffic Systems, Raytheon
January 22, 2016, 5:00 AM PST
As air traffic controllers safely direct the arrival and departure of airplanes at a major airport, a convective thunderstorm engulfs the once-sunny skies, unleashing a flood of downpours, raging winds and dangerous lightning.
The treacherous weather across the airfield scrubs the flight plans of pilots and creates havoc for the flying public. Modern technology assists the controllers and airline operations centers, which do their best to optimize air traffic flow during a weather event, but delays eventually wreak disorder on the air transportation system, resulting in frustrated travelers and airlines and unplanned costs.
Quote:Bad weather is the cause of 70 percent of all traffic delays within the U.S. National Airspace System, adding about $6.7 billion a year in passenger costs.
Bad weather is the cause of 70 percent of all traffic delays within the U.S. National Airspace System, according to the Federal Aviation Administration (FAA), adding about $6.7 billion a year in passenger costs. An estimate from the Congressional Joint Economic Committee puts the annual cost of delayed flights at about $40 billion. That spending also adds up to lost time. In fact, in 2013 alone, the airline industry experienced more than 12 million minutes worth of weather-related delays.
While these air-traffic controllers and planners are well trained to decipher air traffic and the impact of weather on operations, they’re not professionally trained meteorologists. Predicting future weather patterns is not what they trained for or signed up for when taking on such a critical role within the transportation industry. They need technology to deliver accurate representations of the aviation environment including the impact of weather to enable confidence in decision making regarding the impact to both near and longer term operations.
What needs to change
Some 66 percent of delays are preventable with the right data and enhanced air traffic management decision-support tools, so it’s critical that air-traffic personnel work with the most accurate and timely weather information possible. The current landscape of weather data for aviation is scattered across various complex systems that ingest and display a myriad of data to air-traffic controllers and planners.
Quote:The current landscape of weather data for aviation is scattered across various complex systems that ingest and display a myriad of data to air-traffic controllers and planners.
After all, the weather needs for aviation are much different from those for general meteorology. The FAA needs specific types of weather data and modeling capabilities that show whether or not any given airspace is safe for travel. This is a much more complex challenge than merely issuing a forecast that dictates whether a sensible traveler will need to bring an umbrella on the way to the airport, or after landing, for that matter.
Critical improvements in the management and monitoring of aviation weather data will be absolutely necessary to keep up with the anticipated growth of air traffic over the coming decade — and the technology is already evolving rapidly to accommodate increasingly sophisticated and complex meteorological algorithms.
Imagine a situation where thousands of simultaneous algorithms process gigabytes of data streaming over interconnected networks and flowing into astute algorithms tuned for real-world weather applications, high-performance computing humming in remote server rooms 24/7/365, with redundancy and real-time display of the output across hundreds of systems. This orchestrated concert of events produces the most accurate aviation weather products on the planet, the FAA’s NextGen Weather Processor. In the years ahead, aviation weather forecasting will increase time frames of weather predictability, create more confident and accurate forecasts and provide safer and more efficient travel for passengers.
Of course, innovation in the field is by no means limited to the aerospace and defense sector, and aviation weather technology certainly does not grow in a vacuum. In fact, forward-thinking concepts and technologies seem to be coming out of every corner of industry, which will undoubtedly continue to accelerate a collective shift toward accuracy and immediacy. For example, Vaavud is building a crowd-sourced weather platform that has been likened to a “Waze for weather.” The company sells personal wind meters that will turn a smartphone into a high-tech meteorological tool to provide a community of users with highly personalized weather.
Quote:It’s imperative to have modernized weather sensors, processing and integrated decision support systems in place that will benefit the airspace, all segments of flight, air-traffic controllers, planners, airlines and, of course, passengers.
Panasonic Weather Solutions’ patented Tropospheric Airborne Meteorological Data Reporting (TAMDAR) sensor has helped change the way atmospheric data is collected and forecasts are assembled. TAMDAR sensors are currently installed on over 225 commercial aircraft operating in the National Airspace System (NAS), where they continuously transmit atmospheric observations via the global Iridium satellite network in real time as the aircraft climbs, cruises and descends. This results in approximately 50,000 more daily weather observations when compared to today’s weather balloon (radiosonde) program.
Boston-based startup Understory is fielding small and easily deployable weather stations that measure three-dimensional wind, rain and hail, as well as other atmospheric variables, to bring a hyperlocal — and therefore more accurate — picture of the weather to communities. The city of Somerville, Mass., is using Understory technology to constantly measure weather intensity. This helps city officials figure out what kinds of crews might need to be dispatched during a blizzard, for example. The company also has pilot tests under way in Kansas City, Mo., and Dallas, Texas.
Meanwhile, data and analytics players such as Hwind Scientific have grown out of the NOAA Technology Partners Office, aimed at commercializing NOAA innovations. HWind’s founder, Dr. Mark Powell, is leveraging his work at NOAA’s Hurricane Research division. His company is harnessing the power of real-time hurricane data to help insurance and risk-mitigation companies and government agencies prepare, respond and recover when faced with disastrous weather.
Just as weather intersects with most every aspect of our everyday life, it also impacts every phase of flight — not just takeoff and landing. So it’s imperative to have modernized weather sensors, processing and integrated decision support systems in place that will benefit the airspace, all segments of flight, air-traffic controllers, planners, airlines and, of course, passengers.
The future of aviation weather technology looks brighter than ever — regardless of any rain in the forecast.
George Spencer is a manager of Raytheon’s Air Traffic Solutions.
(01-25-2016, 02:34 PM)Peetwo Wrote: Spot the disconnect -
Quote:What say you P2? If you take the PT links the 'ATSB report' is linked from the article - the ATSB link is HERE - click Interim for the report.Yes Old'Tom in the case of the Mildura fog cock-up (& numerous other newsworthy but ignored serious incidents) very convoluted..
Couple of recent comments worthy of regurgitating off Ben's blog:
Quote:1
Posted January 25, 2016 at 12:11 am | Permalink
There is no requirement to carry alternate fuel for single runways in Australia, contrary to pretty well every other serious country.
ILS facilities at most Australian airports are Cat 1. Pretty much useless in fog.
Diverting to a remote airport with non-precision approaches and no ATC only makes sense if you understand that the Pilot in Command felt that his obligation to conform to regulations over-road common sense.
Contrary to what most of the traveling public assume Australia does NOT have world class facilities. Truth is we just get away with it.
There needs to be a comprehensive review of ATC and ground facilities in this country to work out where we want to be in 30 years time because right now its a joke.
2
Posted January 25, 2016 at 7:53 am | Permalink
George Glass,
After ten years of ‘boom-times’, Australia’s infrastructure is not noticeably better for it.?
Sure the weather’s not generally so good in Northern Europe, but CAT III is considered ‘base-line’ for any significant airport which expects to safely serve it’s commercial passengers.
How many Australian commercial airports actually have full ILS capability.?
The problem with the remoteness of some of Australia’s cities could be mitigated by improvements in ILS systems & of course, much more accurate weather forecasting.
Perhaps Ben is right when he suggests ‘that rainy, foggy or stormy day when the current practices could result in the filling of truckloads of body bags’ & the depressing thing is that it looks like this will have to happen before a programme of upgrades is begun.
CASA should be mandating improvements at all commercial airports above certain passenger or aircraft-movement numbers, where there is any clear history of weather-related incidents.
It should create a defined programme of targets, to be implemented over a equally defined time period.
There is no reason why the cost-burden should not be shared around.
The Government can put some tax-dollars in & the rest can be shared between the airlines & the airports.
The only other safe option is to enforce the same fuel-reserve rules commonplace throughout most of the rest of the world.?
Ultimately, passengers will end up being those who really pay for it, but they’ll be buying considerably a improved safety regime for it.
Particularly relevant to the Planetalking blog was my post off Skimore Corner, here is an extract:
(01-22-2016, 10:38 AM)Peetwo Wrote: Four incidents, a ditching & two cover-ups? - Safety risk mitigation Oz style.
On the 22 February 2000 the ATSB issued safety recommendation 2000004 addressed to the BOM, under 'Safety Action' it states:
Quote:..As a result of these occurrences, the Civil Aviation Safety Authority has commenced a project to review the fuel requirements for flights to remote islands...
& under the BOM response text:
Quote:..The Bureau is actively participating in the review of fuel requirements for flights to remote islands being undertaken by the Civil Aviation Safety Authority...
Yet here we are nearly 18 years from the first reported incident; nearly 16 years since the SR was issued; more than 6 years since the Pel-Air ditching; & 949 days since the Mildura fog incident occurred. For a reminder of the seriousness of that incident, here is a Planetalking article from 18 months ago - ATSB Mildura fog crisis report delayed for good reasons:
Quote:..Today’s announcement indicates that important changes are being pursued in the interests of safety, presumably with the enthusiastic support of the Australian carriers, as Mildura proved to be both a harrowing yet lucky night for each, in which the professionalism of their pilots played an essential role in getting them out of a situation in which a commercial jet flight in this country should never have been put at such risk...Well finly there is a sign that some sort proactive action to address these identified safety issues maybe on the horizon - HOORAH!
Firstly from the CASA 'Standards Development and Quality Assurance Branch' issued 2 days ago:
Quote:CD 1508OS - Fuel and oil quantity requirements
Background
Regulation 234 of the Civil Aviation Regulations 1988 (CAR) requires the pilot-in-command of an aircraft to take reasonable steps to ensure that the aircraft carries sufficient quantities of fuel and oil for the proposed flight to be undertaken safely. The regulation also requires the operator of an aircraft to take reasonable steps to ensure that an aircraft does not begin a flight unless it is carrying sufficient fuel and oil to allow the flight to be conducted safely.
Australian Transport Safety Bureau (ATSB) reports have revealed incidents and accidents directly related to carriage of insufficient quantities of fuel. CASA proposes to address this safety issue by amending regulation 234 of CAR to provide updated fuel and oil requirements.
The current regulation 234 of CAR allows courts to consider any guidelines provided by CASA when determining whether sufficient fuel and oil were carried on a flight, which includes the guidelines provided in CAAP 234-1(1). While some of the information provided in the CAAP should be read as a requirement empowered by the current regulation 234, other information is advisory in nature. CASA intends to the make clearer the distinction between the regulatory requirements and the guidance material by transferring the requirements for determination of fuel and oil quantity from the CAAP to a proposed legislative instrument.
- SPC to CD 1508OS
- Annex A - Draft Civil Aviation Amendment (Fuel and Oil Requirements) Regulation 2016
- Annex B – Draft Civil Aviation (Fuel Requirements) Instrument 2016
- Annex C - Summary of key changes introduced by Civil Aviation (Fuel Requirements) Instrument 2016
- Annex D – Draft Civil Aviation Order 82.0 Amendment Order 2016 (No.X)
- Annex E – Draft CAAP 234-1(2) – Guidelines for aircraft fuel requirements
And then even better yesterday - some 30 odd years after the rest of the developed world - CASA made an announcement about a change to the regs, which they predict will pass on $10 million p.a. to industry, courtesy the OZ:
Quote:New aviation rules to slash weather delays
Quote:This incident highlights the importance of lateral thinking during flight planning, particularly where operations to remote areas are planned, and when an alternate aerodrome is close to the planned destination. In this case, the captain assessed the broader weather picture, and added fuel above the minimum requirements on the basis of that assessment. That additional fuel ultimately provided the crew with a safe option, despite encountering unexpected conditions that prevented a landing at the planned alternate aerodrome.
Quote:ATSB comment
Following a small number of safety occurrences where unforecast weather events have led to unforeseen diversions or holding, the ATSB commenced a research investigation (Reliability of aviation weather forecasts) to examine how often weather events are not forecast in enough time allow pilots to make appropriate decisions (carry additional fuel, make a timely diversion or delay departure). Although the research investigation will focus on weather data for major Australian airports, the results should help operators better understand how much reliance can be given to forecast weather at destination airports at the time of pre-flight planning. This research investigation is linked in part to ATSB investigation AO-2015-100 (Weather related operational event involving B737s VH-YIR and VH-VYK at Mildura Airport, Victoria on 18 June 2013). On that occasion, the two aircraft involved diverted from Adelaide, South Australia, to Mildura, Victoria, due to poor weather in Adelaide. Unforecast weather was encountered when the aircraft subsequently arrived at Mildura.
In another weather-related incident, the ATSB found that the onset of fog at Perth Airport at the estimated time of arrival of a flight, was not forecast until after the aircraft had passed the point when it had insufficient fuel remaining to divert to a suitable alternate aerodrome. Before that point, there had been no requirement for the aircraft to carry fuel to continue to a suitable alternate (see ATSB investigation AO2012073 Weatherrelated operational event involving Boeing 717, VHNXO, Perth Airport, Western Australia on 01 June 2012). The safety message attached to that investigation report included ‘…pilots should be alert to the fact that the actual weather conditions can differ significantly from forecasts.’
- to examine the bigger picture of mandatory alternate fuel requirements:Quote:Reliability of aviation weather forecastsUFB
Following a small number of safety occurrences involving aircraft inbound to Sydney or Adelaide where unforecast weather events have led to unforeseen diversions or holding, this research investigation will examine how often weather events are not forecast in enough time for airlines to make appropriate decisions (carry additional fuel, timely diversion or delayed takeoffs). It will analyse Bureau of Meteorology weather data for major Australian airports. The results of this report should help airlines and pilots better understand how much reliance can be given to forecasted weather at destination airports at the time of pre-flight planning.
- again Mr Mimi & his cronies supply the perfect top-cover through delay, spin & bulldust for what - "better understand how much reliance can be given to forecasted weather" - FFS pilots in Australia have understood that fact since the BOM was first formed.
:Quote:7
mrdeux
Posted January 27, 2016 at 9:45 am | Permalink
And in the interim CASA introduces “advisory holding”.
If it isn’t mandatory, airlines will not load it. Which means that any aircraft that is held, especially after a long flight, may well leave the holding pattern with virtually no margin at all.
Another buck passed.
Quote:IFR Alternate Airports (1-2-3 Rule).
When filing an IFR flight plan, you must include an alternate destination airport when the weather forecast at your original destination predicts conditions below those specified in CFR 91.169. To help remember those conditions, you can use the 1-2-3 rule.
1 - During the time 1 hour before to 1 hour after the estimated arrival time
2 - Ceiling less than 2,000 feet
3 - Visibility less than 3 miles
If the above conditions exist, an alternate airport must be filed.
Quote:The most recent update on the re-opened investigation can be read at this link. It is import to then click on the tab marked re-opened, to get a much fuller picture of this saga
(02-07-2016, 01:35 PM)kharon Wrote: Courtesy of Crikey, from Plane Talking, by Ben Sandilands – HERE - is a reminder (not that we need it) that the second version of the ATSB report into the Pel-Air ditching is, as expected, overdue. So much we knew.
Quote:The most recent update on the re-opened investigation can be read at this link. It is import to then click on the tab marked re-opened, to get a much fuller picture of this saga
But the old question still stands, will the report be not only overdue, but obfuscated?
Before you race off to place your bets, we have some ‘interesting’ little wisp’s of rumour floating around, which may temper your ardour for the favourite. The first tantalising wisp is that the ‘Invisible Manning’ and only the IM is allowed to tinker with the final draft. That could just be simply to add credibility and/or deniability to the report. Some prefer to take a slightly darker view, drawing inferences which make sense.
Another wisp of purely unsubstantiated gossip is that original IIC the and Manning have spent days and days together, discussing the whole sorry episode. Again, it makes sense that the original IIIC and IM would spend a little time together; but, a short session would indicate lip service to a report, the more time spent, the more detail and understanding is gained. This is a positive sign. The IIC was treated most shabbily, sent off to the pencil sharpening cupboard and only allowed to play with small, insignificant make work pieces. If the Manning report is to have any credibility then a full apology and re-instatement of the original, first class IIIC would lend much respect to a report which will need to withstand some intense, domestic and international scrutiny.
Aye well, we shall see and we shall compare. Manning is deemed to be a good egg and should the rumours be true, then the movie and the book will be worth a look see. We shall wait until Negroni publishes and Warner Brothers call ‘Action’.
No, you bearded buffoon, it’s only over in your mind. MH 370 was not a good place to hide, you’ve got that wrong too. No matter, July is not too far away now then you can slither off to the pencil sharpening cupboard to learn how to do something of value. The Merde’k approved method for where to shove a pencil and how to rotate it. Maybe he’ll give you the pink ones to start with.
What angel shall
Bless this unworthy husband? he cannot thrive,
Unless her prayers, whom heaven delights to hear
And loves to grant, reprieve him from the wrath
Of greatest justice. (AWTEW)
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(01-22-2016, 10:38 AM)Peetwo Wrote: Four incidents, a ditching & two cover-ups? - Safety risk mitigation Oz style.
Quote:Handling unexpected developments
A recent ATSB investigation shows how unexpected developments or confusion about procedures can contribute to decisions and actions that increase the safety risk to the aircraft.
In the incident, the crew of a Cobham Airline Services Boeing 717 aircraft, was conducting an instrument approach to land on runway 03 at Perth Airport.
The aircraft was conducting an approach in instrument meteorological conditions after a flight from Paraburdoo, Western Australia. When they reached the decision altitude, the crew initiated a missed approach procedure as they had not obtained visual reference with the runway.
Almost immediately, however, they obtained visual reference with the runway, discontinued the missed approach procedure and landed, despite the aircraft being in an unstable condition.
The ATSB found that the onset of fog at Perth Airport at the estimated time of arrival was not forecast until after the aircraft had passed the point in the flight when it had insufficient fuel remaining to divert to a suitable alternate aerodrome. Before that point, there had been no requirement for the aircraft to carry fuel to continue to a suitable alternate.
Under the circumstances, the flight crew considered that the better option was to discontinue the missed approach procedure and land, in spite of the aircraft being in an unstable condition due to the initiation of the missed approach.
This incident highlights the risk of an unstable approach from not following a missed approach through to its conclusion.
Unstable approaches are a frequent factor in approach and landing accidents, including controlled flight into terrain. The Flight Safety Foundation has developed an Approach and Landing Accident Reduction Tool Kit to reduce the risk of approach and landing accidents.
‘Handling approach to land’ is also a top safety concern in the ATSB’s SafetyWatch initiative. The ATSB has identified an increasing trend where pilots mishandle or mismanage their aircraft and flight profile when unexpected events arise during the approach to land.
The occurrence also highlights that during a flight, the forecast weather at the destination may change and it is advisable to obtain the most up-to-date weather forecasts.
However, pilots should be alert to the fact that the actual weather can differ significantly from forecasts.
Read the investigation report AO-2012-073
Last update 25 February 2016
Quote:From the evidence available, the following findings are made with respect to the weather-related operational event involving a Boeing 717, registered VH-NXO, which occurred at Perth Airport on 1 June 2012. These findings should not be read as apportioning blame or liability to any particular organisation or individual.Now according to the investigation page the Final Report for AO-2012-073 was published on the 12 October 2015, i.e. 3 years 4 months & 12 days after the incident occurred; no surprises there I guess??
Contributing factors
Other factors that increased risk
- The weather forecast for Perth Airport was amended to include the requirement to carry sufficient fuel to divert to a suitable alternate aerodrome when the aircraft no longer had that amount of fuel remaining.
- The captain, as the flying pilot, continued an approach to land after the approach had been destabilised by initiating a go-around procedure.
Other findings
- The flight crew did not update the weather forecast for Perth Airport en route which, although in this instance did not indicate an operational requirement, was a missed opportunity to update pertinent operational information prior to the aircraft being committed to its destination.
- Given the circumstances, when confronted by a choice between completing the missed approach with an indeterminate outcome and landing from a discontinued missed approach, the captain chose the option that was considered to represent lower risk.
- The operator’s procedures in the case of an unstabilised approach were unambiguous and reflected those promoted by the Flight Safety Foundation.
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