[Peetwo]

ATSB post Beaker: From the sublime to the ridiculous -  

Today the ATSB released a final report that took 1105 days to investigate into a pushback incident, which saw a Virgin B737 collide with the tail cone of a Jetstar A320  - UDB!

Collision during pushback between Boeing B737-8FE, VH-YID and Airbus A320-232, VH-VGR Melbourne Airport, Victoria, on 10 August 2013
 
Investigation number: AO-2013-125
Investigation status: Completed
 

• Final Report
  
• Photo
  

Final Report
Download Final Report
[ Download PDF: 1.35MB]
 
 
Listen to this PDF
Alternate: [ Download DOCX: 10.15MB]
 
What happened

On 10 August 2013, an Airbus A320-232, registered VH-VGR (VGR) and operated by Jetstar Airways Pty Ltd was holding short of gate D2 at Melbourne Airport, Victoria. At the same time, a Boeing B737-800, registered VH-YID (YID) and operated by Virgin Australia Airlines Pty Ltd. (Virgin) was approved by air traffic control for a pushback from bay E1 once VGR was on the gate at bay D2. The dispatcher for YID assessed VGR was on the gate and commenced the pushback. During the pushback, the left wingtip of YID collided with the tail cone of VGR, damaging both aircraft. There were no injuries.

What the ATSB found

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.

What's been done as a result

Virgin advised that following this occurrence, they issued a local instruction to ground staff, mandating the use of wing walkers from certain bays at Melbourne Airport, including bay E1.

Safety message

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.
 
Photo

Download Wing tip damage to the Virgin Australia aircraft VH-YID - Source: ATSB

Download Gates D2 and E1 - Apron diagram of Melbourne Airport. Source: Apron diagram Melbourne Airport, occurrence details by ATSB

Download Figure 3: Damage to the tail cone of VGR aft of the APU, looking from left to right of the aircraft. Source: ATSB

Download Figure 4: Screenshot of YID during pushback, 5 seconds before the collision with VGR and showing the position of the tug and the dispatcher. Source: Melbourne Airport, modified by the ATSB

Download Figure 5: Pushback of the same Virgin flight from bay E1 on the next day. Source: ATSB 

General details

Date: 10 Aug 2013
 
Investigation status: Completed
 
Time: 9:33 EST
 
Investigation type: Occurrence Investigation
 
Location   (show map): Melbourne Airport
 
Occurrence type: Taxiing collision/near collision
 
State: Victoria
 
Occurrence class: Operational
 
Release date: 18 Aug 2016
 
Occurrence category: Accident
 
Report status: Final
 
Highest injury level: None
 
 
Aircraft 1 details

Aircraft manufacturer: Airbus
 
Aircraft model: A320
 
Aircraft registration: VH-VGR
 
Serial number: 4257
 
Operator: Jetstar Airways
 
Type of operation: Air Transport High Capacity
 
Damage to aircraft: Substantial
 
Departure point: Melbourne, Vic.

Aircraft 2 details

Aircraft manufacturer: The Boeing Company
 
Aircraft model: 737
 
Aircraft registration: VH-YID
 
Serial number: 38709
 
Operator: Virgin Australia
 
Type of operation: Air Transport High Capacity
 
Damage to aircraft: Substantial
 
Departure point: Melbourne, Vic.
 
 
 


Last update 18 August 2016

Planetalking has picked up on this report and more than adequately highlights the totally farcical laughing stock that the ATSB has become in the world of ICAO Annex 13 aviation accident/incident investigative authorities:

ATSB takes three years to investigate pushback bingle

Australia's safety investigator exhaustively concludes that airlines need to keep a sharp lookout while reversing their jets. Really? Yes.

Ben Sandilands

This is the Virgin violated tail cone of the Jetstar A320

In what might be an attempt to embarrass Government over lack of resources the ATSB has today published its final report into a low speed terminal area bump and grind between a Virgin 737-800 and a Jetstar A320 at Melbourne Airport three years ago on August 10.

It was a minor incident although it carried the risk of a becoming major had fuel in the wing of the Virgin flight caught fire when it ripped off the tail cone of the Jetstar plane.
After 36 months the ATSB concluded that:

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.

No shit Sherlock. This is really laying it on the line about the under funding of the transport safety investigator. No-one takes three years to investigate the aviation equivalent of a car in a shopping carpark reversing into a stationary vehicle.

The clear message, and it is a genuine safety message, is that the ATSB has been so gutted of resources that this bingle which should have taken less than a month to exhaustively investigate was left to only fitful moments of attention for three years while the safety investigator struggled to sort out more serious matters.

Not that it always succeeds in such efforts. It not only screwed up a compromised investigation into the Pel-Air medivac charter crash of 2009, but seems hopelessly lost in dealing with its past serious errors and coming up with a credible and comprehensive new final report.

It took three years to fail to address the principle safety issue which saw a Virgin and a Qantas 737 both forced to land short on fuel at a fog shrouded airport in Mildura the same year because neither needed to be fuelled under Australia rules to find an alternative to Adelaide airport when it was closed by a deterioration in the weather when neither had anywhere else they could go.

But while there are many valid grounds for criticising or despairing about the ATSB, it hasn’t been given the government support necessary to actually do its job in a timely manner.  It treatment is a reflection on successive governments who have adopted policies of cutting back on spending on public services until they break.

If the ATSB can’t deal with a pushback incident at Melbourne airport in less than three months let alone three years, it is broken.

It may be severely broken but the questions are can it be fixed; is Greg Hood the man to fix it; and/or has he been given a mandate to fix it? If the answer is no to any of those questions, then I am afraid the ATSB is doomed to irrelevance and the eventual scrap heap...

MTF...P2

ATsBollocks hits an all time low

How utterly atrocious! Surely this report is someone taking the piss and pulling a late April fools prank, surely?
If not, this investigation and subsequent report will go down in the annals of history as one of the most embarrassing investigations and reports of all time! 3 effing years!!!! Are they serious?

Oh Beaker, you should hand back your last 5 years salary you worm. I weep for the good ATsB people still working there, and the good ones who have been forced out. What an embarrassing load of shit.

Heads should still roll. Jules Verne? Folly? Hoody? Chester? Barnaby? MrDak? This is a sham. Surely ICAO can no longer sit on it's fat useless hands and accept for one minute that its 'state', Australia, is compliant with annexe 13? And these same muppets are searching for MH370? Christ almighty.
THIS FARCICAL SITUATION CAN NOT BE ALLOWED TO CONTINUE ANYMORE!

I'm shell shocked. Do I cry some more tears or just start laughing?? 3 years for this absolute shit! Unbelievable.
Pull the pin on them now. Shut down the ATsB and contract it out to Zimbabwe or some other chickenshit third world outfit who can produce the same pre-school crap at a tenth of the price.

#bringbackalan

Ps - CF for Gobbles for best summary of the current diabolical state of affairs at the ATSB. 

Pps Perhaps another solid reason why the 'powers to be' (if they were remotely interested in saving the bureau) should seriously consider bringing back Alan:

Tragedy inspires Indonesian investigator to improve safety
Indonesian safety investigator Apib Prayogi can trace his journey to working at the Australian Transport Safety Bureau in Canberra to two tragic aviation accidents.

The first was the loss of Air France Flight 4590 from Paris to New York on 25 July 2000. All 100 passengers and nine crew members aboard the Concorde died when it crashed into a hotel on take-off. On the ground, four people were killed and one was critically injured. It was the only fatal Concorde accident during its 27-year operational history.
A few years later in junior high school, Apib was fascinated by a Discovery Channel documentary on the accident and, more importantly, the investigation that followed.
“I was very curious as to how the investigators did their detective work to uncover the cause of the crash,” Apib said.
It struck a chord in the mind of the young Apib such that when career consultants paid a visit in senior high school, aeronautical engineering was presented as an option that could lead to interesting work.
With (very) solid maths results at school, Apib completed a Bachelor of Aeronautical Engineering (2010) in Adisutjipto College of Technology, Jogjakarta, and then a Master of Aeronautical Engineering (2014) from the prestigious Institute of Technology, Bandung.
This led to Apib becoming a junior investigator with Indonesia’s National Transportation Safety Committee (NTSC).
The second accident was in March 2007 when a Garuda Indonesia Boeing 737 over-ran the runway while attempting to land at Yogyakarta airport in central Java. The accident claimed 21 lives, five of whom were Australian. The accident lead to the development of the Australian government Indonesia Transport Safety Assistance Package (ITSAP).
ATSB Manager International Richard Batt says the main elements of the ATSB's contribution to ITSAP is to deliver training and support for investigators from the NTSC.
“This includes the ATSB providing staff dedicated to various capacity building projects, funding ATSB training courses in Indonesia and Australia, and opportunities for aviation, marine, and rail investigators to work with their ATSB counterparts for extended periods,” Richard said.
“Our Indonesian colleagues learn much from us. But it’s not all one way. The programs that we develop are mutually beneficial. Cooperation between the ATSB and the NTSC is a key element in ensuring lasting transportation safety for the people of Indonesia and Australian travelers to Indonesia.”
Apib, 28, was selected as the first of two junior investigators who will spend time at the ATSB in Australia this year, thanks largely to his English language skills.
“I started learning English in junior high, where it is compulsory,” Apib said. “I continued into senior high and when I did my tertiary studies, most of the aeronautical engineering texts were in English.”
Apib is delighted with his time at ATSB, working with professional and highly committed staff and expanding his knowledge and experience.
“It’s like on-the-job training, especially with the short level (Level 5) investigations. We don’t have the kind of system and databases that you have here,” he said.
“I am learning how ATSB does its investigations, especially with its more advanced tools and laboratory. I already have a better understanding of how an investigation goes. And from that I can see how we can improve in Indonesia.
“We would like to have a system, such as you have at ATSB, which meets international standards. We will get there, but in my view it may take up to 10 years.”
Perhaps not surprisingly, Apib sees himself as a senior aviation investigator ‘in about 10 years’.
Married with a young daughter, Apib will continue to gain more qualifications, expand his knowledge and undertake more training.
In the meantime, he is grateful for the opportunity to work in Canberra at the ATSB, even if it is the middle of winter.
“I would like to thank Australia, the ATSB and the ITSAP program for this opportunity, and for assisting to improve our investigator qualifications and set up our flight recorder laboratory,” Apib said.
“I especially would like to thank Dr Soerjanto (NTSC Chairman) and Dr Richard Batt and the team in Level 5 investigations at ATSB. Everyone has been helpful and supportive and given me the opportunity to learn.”
Apib said he was also grateful to those who took him “out bush” for a first-hand encounter with kangaroos, koalas and a platypus!
 

 Yes indeed time to #bringbackalan

Update: With tongue in cheek comments from Comet, Dan Dair & Jacob courtesy PT...

comet
August 18, 2016 at 8:35 pm
“This occurrence highlights the importance of ensuring that adequate clearance exists prior to commencing pushback.”

Wow. It took the ATSB three years to reach that earth shattering conclusion.
The once proud ATSB can now join the once proud Australian Bureau Of Statistics (ABS) as being modern day basket cases, and the laughing stocks of the entire world.

1. 1. 
      Dan Dair
      August 18, 2016 at 9:02 pm
      Meanwhile the membership of the AABCO* is increasing by the day.!!
      (* Australian association of basket-case organisations)
      

1. 1. 
      Jacob HSR
      August 18, 2016 at 11:50 pm
      I wonder if the pushback driver was on a 457 visa.
      

Dan Dair
August 19, 2016 at 9:00 am
Not that I’m the kind of bloke to kick a man when he’s down………
(or a state-funded organisation)
But,

if they’d asked me, I’d have been quite happy to consult on this matter.
Obviously I’d have wanted first class travel to investigate (where available) but to be honest, I could have been happy to have followed a directive/nod-&-a-wink to deliver that result in under three months.

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.

 I’d have expected n actual procedure to be in-place, even if it was a formal walk-around or a formal-visual from the cab of the tractor, before an aircraft was moved.????

Next time the ATSB is struggling, you can reach me through these pages & I’ll be happy to offer my services as a consultant.!!!!

  
Choccy frog for Dan Dair's last, pure GOLD! - And Hoody you can count me in for the next hangar rash incursion, except I reckon I can get it done and dusted in < a month...


MTF...P2