[Peetwo]

More ATSB (Popinjay) WOFTAM reporting vs NTSB benchmark as World No.1 in TSI??

I note the following Popinjay HQ media blurb for a  interim report that took 4 months to produce...

Interim report outlines Cairns approaches below minimum altitude



Key points

• Two Boeing 737-800 aircraft descended below minimum altitude during approach into Cairns on separate flights in October 2022;
  
• ATSB’s interim report details information gathered in early evidence-collection phase of investigation;
  
• Investigation is on-going, with analysis and findings to be presented in final report at later date.
  

An Australian Transport Safety Bureau interim report details a pair of occurrences involving Boeing 737-800 passenger aircraft which descended below minimum altitude constraints on approach into Cairns Airport, in North Queensland, in October 2022.

The interim report aims to provide timely information, gathered in the early evidence collection phase of the investigation, which is on-going. It contains no analysis or findings, which will be detailed in the final report.

In each occurrence, flight crews (one Virgin Australia, the other Qantas) entered the same standard arrival (HENDO 8Y) and approach (RNP Y runway 33) into their flight management computers, ahead of a planned landing on runway 33 at Cairns. However, neither flight crew selected the required approach transition.

In both cases, when presented with the discrepancy by the flight management computer, flight crews resolved it by manually connecting the arrival waypoint HENDO to the intermediate approach fix waypoint noted on the approach chart.

“As an unintended consequence, this removed the 6,800 ft descent altitude constraint associated with the initial approach fix waypoint in each aircraft’s programmed flight path,” ATSB Director Transport Safety Stuart Macleod explained.

“In both occurrences, the aircraft therefore descended below that constraint, as well as the 6,500 ft minimum sector altitude in that segment of airspace.”

In both cases, air traffic control alerted flight crews of their low altitude. No terrain warnings were triggered in either occurrence.

“The first flight, on October 24, took place on a dark night, so the Virgin Australia flight crew conducted a go-around, and then landed without further incident,” Mr Macleod said.

“The second flight, on October 26, occurred in daylight under visual conditions, so the Qantas flight crew was approved for a visual approach by air traffic control, and landed without further incident.”

To date, the ATSB has interviewed the flight crews, examined recorded flight data, reviewed air traffic control audio and surveillance data, and reviewed operator and air traffic control procedures.

The interim report notes both operators have already taken steps to provide flight crews with further guidance, relating in particular to approaches where the selection of an approach transition is required.

“Going forward, the ATSB’s investigation will include further review and examination of the evidence gathered, as well as instrument procedure and waypoint naming processes and standards, and arrival and approach chart information and presentation,” Mr Macleod said.

A final report will be released at the conclusion of the investigation.

“However, should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so that appropriate and timely safety action can be taken,” Mr Macleod concluded.

Read the report AO-2022-051: 

Flight below minimum altitude occurrences, 40 km south of Cairns Airport, Queensland on 24 and 26 October 2022

Publication Date
28/02/2023

I also note that along side that bollocks media blurb it states this:

Final report

AO-2022-051 Flight below minimum altitude occurrences, 40 km south of Cairns Airport, Queensland on 24 and 26 October 2022

-   

Perhaps the IIC and the investigation team did intend for this to be Final Report and that further investigation would be discontinued? Especially when you consider the following from the (3 month overdue) interim report...

Safety action

The ATSB has been advised of the following proactive safety action in response to these occurrences.

Virgin Australia

Virgin Australia updated flight crew operation notice information for Cairns with detailed guidance for the conduct of the HENDO 8Y arrival and RNP Y runway 33 approach. Virgin Australia also provided guidance to all Boeing 737 flight crew for the conduct of arrivals and approaches where the selection of an approach transition was required.

Qantas

Qantas issued an internal notice to flight crew providing guidance for the conduct of arrivals and approaches where the selection of an approach transition was required.

In other words the FMC flight path 'discontinuity' error that led to the two incidents briefly flying below min altitude, has been fully addressed/mitigated by both airlines inside their SMS, probably about a week after the incidents occurred. Yet the ATSB is continuing with the investigation - FFS!

Meanwhile, at the recent Estimates hearing, Popinjay begged limited resources and the Ministerial SoE as reasons why the ATSB did not investigate the Kybong mid-air collision:

Senator McKENZIE: Recreational Aviation Australia recently declined to investigate a fatal accident in Kybong, Queensland due to the burden these investigations were putting on the organisation. Has the bureau had any discussions with Recreational Aviation Australia about their resourcing concerns?

Mr Mitchell : I've certainly had discussions with RAAus over that particular incident and others. There have been a number of incidents. I think, in that particular sector: there are anywhere between six to 10 fatal accidents, generally, per year. The recent decision by RAAus not to investigate there is certainly one for them. In terms of our priority list, our priorities lie with general greatest benefit for the travelling public, and sport, recreational and experimental aircraft are lower down on our list.

Senator McKENZIE: That significant service is now no longer to support police and coroners into the future. Recognising the resourcing concerns, have you asked the minister for more resources in the upcoming budget round?

Mr Mitchell : We are certainly in discussions with the department around our resourcing and expectations. Our expectations need to be matched with resourcing, so it has been a long established position that we do not investigate in that recreational space, and that has been since 2014, since the Forsyth review was conducted.

Senator McKENZIE: So the minister would actually have to change the expectations for you to actually do that—is that your argument here?

Mr Mitchell : I think it would be a combination of changing expectations or funding and potentially—

Senator McKENZIE: Let's hope the minister funds you appropriately so you can assist Recreational Aviation Australia with their coronial assistance. And my apologies we couldn't spend more time, but I'll have questions on notice. Thank you, Mr Mitchell.

 

Talk about 'discontinuity' - 

Meanwhile I note the following blurb from the NTSB's 'Office of Aviation Safety':

The mission of the Office of Aviation Safety (AS) is to:

1. Investigate all civil domestic air carrier, commuter, and air taxi accidents; in-flight collisions; fatal and nonfatal general aviation accidents; and certain public-use aircraft accidents; uncrewed aircraft systems accidents; and commercial space mishap accidents.
   
2. Participate in the investigation of major airline crashes in foreign countries that involve U.S. carriers or U.S.-manufactured or -designed equipment to fulfill U.S. obligations under International Civil Aviation Organization agreements, and
   
3. Conduct investigations of safety issues that extend beyond a single accident to examine specific aviation safety problems from a broader perspective.
   

AS has the responsibility for investigating domestic aviation accidents and incidents (about 1,750 annually) and for proposing probable cause for the Board's approval. In conjunction with other offices within the NTSB, the office also works to formulate recommendations to prevent the recurrence of similar accidents and incidents, and to otherwise improve aviation safety.

   
Finally, on the accidents overseas thread AP is covering the fatal PC12 medevac inflight break up accident investigation: PC12 fatal inflight breakup

Here is a MSM Youtube link (has to be viewed on Youtube) that covers some snippets from the NTSB media briefing on that tragic accident: https://youtu.be/PqBPgit8yK8

And this is the NTSB B-roll documenting the accident site:

Note the resources at the disposal of the NTSB include the FBI and working in conjunction with local authorities.

Considering the PC12 is the predominant a/c type used by our own RFDS, there will be many industry stakeholders interested in monitoring the progress of this investigation. I wonder how long it will take the NTSB to release an interim report??

MTF...P2