[Peetwo]

AO-2022-035 (Short) & AO-2022-052 (Short): Two more from the list completed -   

Courtesy of this week's (attributed to) DTS Stewie (stating the Ducking obvious) Macleod...  :

737 issued incorrect runway arrival clearance after undetected verbal slip

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• During scheduled passenger flight from Brisbane to Sydney, airliner was cleared for standard arrival for runway 34L at Sydney, which was operating runway 16L at the time.
  
• Error was not detected initially by flight crew, despite ATIS indicating 34L was not operating. It was also not detected by crew or controller during read-back or hear-back.
  
• Sydney Approach controller identified discrepancy and corrected clearance; aircraft landed 16L without incident.
  
• Incident is a reminder that verbal slips can happen at any time, and that pilots and controllers should seek verification when there is confusion or misunderstanding.
  

A mistakenly-issued standard instrument approach arrival clearance for the incorrect runway at Sydney Airport highlights the importance of pilots and air traffic controllers being alert to verbal slips and seeking verification when there is confusion.

On 19 October 2022, after a Virgin Australia Boeing 737-800 reached top of descent on a scheduled passenger flight from Brisbane to Sydney, the flight crew contacted air traffic control, advising they were maintaining flight level 340.

The enroute controller provided the flight crew a clearance to conduct a standard instrument arrival for a landing on runway 34L in Sydney. The flight crew then read back this clearance to the controller, including runway 34L.

This was despite runway 16L being operational at Sydney at the time, and information available to the crew via the automatic terminal information service (ATIS) indicating runways 16L and 16R were in operation for arrivals and departures.

The ATSB’s investigation of the incident found the incorrect clearance was verbally communicated, and not identified, likely due to momentary interference of related, coinciding information about the assigned flight level (FL 340) and the runway (34L).

“This error was not identified by the enroute air traffic controller or the flight crew during the read-back or hear-back,” ATSB Director Transport Safety Stuart Macleod said.

“However, the information entered into the air traffic management system was correct, and when the crew transferred to Sydney Approach, the approach controller identified the error and rectified it well before an undesirable state for landing had the opportunity to develop.”

Once the approach controller had established the correct runway clearance, the crew performed an uneventful landing on runway 16L.

Mr Macleod said the incident is a reminder to pilots and air traffic controllers that verbal slips can happen at any time, and are less likely to be detected when there is a high degree of similarity between the presentation of simultaneous, related information, while performing a familiar and repetitive action.

“Slips in verbal communication can pose a threat to safe operations if the content of the message is inaccurate, and then not identified during the read-back or hear back process.

“In this case, the read-back and hear-back procedure was the opportunity for both parties to detect the error before it propagated further.”

Read the report: Air traffic control error involving Boeing 737, VH-YFT, near Armidale, New South Wales on 19 October 2022

Publication Date
06/06/2023

 
BRB member's OBS on this:  

Of course, ATCs issue a completely conflicting STAR, yet the lessons are for pilots to hear better! ?. Nicely worded to protect our beloved AsA!

Next:

Flight crew declares fuel MAYDAY to receive priority landing at Perth to maintain required reserve fuel

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Higher than planned fuel burn and longer than anticipated arrival delays meant the crew of a Boeing 737 operating a passenger service from Brisbane to Perth were required to declare a fuel MAYDAY to avoid landing below fuel reserves.

On 18 July 2022, the Qantas Airways Boeing 737-838 was operating flight QF933 from Brisbane to Perth with 174 people on board, including two flight crew.

During the cruise, the flight crew descended from 34,000 ft to 28,000 ft due to turbulence and to take advantage of lesser headwinds, but identified they were using more fuel than planned.

“As the aircraft reached the decision point, the flight crew were aware the aircraft had used 600—700 kg more fuel than planned, but there was still sufficient fuel to continue to Perth,” ATSB Director Transport Safety Stuart Macleod said.

“However, advice then came from air traffic control (ATC) that delays at Perth were longer than the promulgated estimate of 10 minutes.”

Given this new information, the flight crew determined they would be unable to accept the ATC delay without landing in Perth below fuel reserves (sufficient fuel, as required by the Civil Aviation Safety Regulations, to allow up to 30 minutes flying at holding speed, at 1,500 ft above the aerodrome elevation).

ATC advised the flight crew that the order of aircraft in the arrival sequence could not be changed unless they declared a fuel MAYDAY.

“This left the flight crew with no other option than to declare a fuel MAYDAY to receive priority landing,” Mr Macleod said.

After declaring the fuel MAYDAY, the aircraft was given priority for the approach, and landed in Perth without incident, and with the required reserve fuel intact.

The ATSB investigation report from the incident notes that sophisticated flight planning and monitoring systems allow fuel usage and aircraft movement to be accurately determined, and that the ATSB independently verified that the aircraft had departed Brisbane with the required fuel on board.
“Decisions by flight crew and air traffic controllers can result in higher-than-planned fuel usage, reducing available airborne options,” Mr Macleod said.

“Where flight crew find that they may not have required fuel reserve, it is vital – as in this case – that flight crew alert air traffic control and, if necessary, declare a fuel MAYDAY, to ensure the aircraft receives priority during the approach, preventing an unsafe situation from developing.”
Read the report: Fuel Mayday declaration involving Boeing 737-838, VH-VZO, abeam Wave Rock, Western Australia on 18 July 2022

Publication Date
08/06/2023

Hmmm...elements of the Mildura Fog Duck-Up and QF28 revisited?? But my question is...where is the ATSB analysis of the QF fuel policy?? Is this yet another case of CASA and ATSB capture by the Red Rat?? - 

MTF...P2