[Peetwo]

ATSB O&O Investigation number: AO-2014-043

So after 1352 days we end up with a ATSB investigation that is summarised like this:

What happened
On 3 March 2014, the flight crew of a Tiger Airways Australia Pty Ltd (Tigerair) Airbus A320 were preparing for a scheduled passenger service from Sydney, New South Wales to Perth, Western Australia. The flight crew had earlier completed uneventful sectors from Sydney to the Gold Coast, Queensland, and return. As part of that preparation, the flight crew reviewed the operational flight plan (OFP) for the sector. The OFP was produced by the operator’s Operations Control Centre. That OFP contained significant errors in the aircraft weights, and as a consequence the required fuel upload for the sector was also significantly in error. The aircraft captain chose to re-calculate the required fuel load using resources available on the flight deck. The resultant required fuel load calculated and uplifted by the captain did not include the operator's requirement to carry a '60 minute top-up' additional fuel, resulting in the fuel upload being below that required under the operator's operations manual. The aircraft’s flight computers, however, identified that the aircraft would arrive at its destination with more than the minimum inflight fuel requirements. During the subsequent flight, the flight crew regularly checked the fuel usage and expected arrival fuel at Perth. All company and regulatory inflight fuel requirements for the flight from Sydney to Perth were met, and the aircraft landed with fuel in excess of the required fuel reserves.

What the ATSB found
There were deficiencies within the processes and procedures used by the operator's Operations Control Centre that permitted incorrect plans to be produced and subsequently provided to flight crew. This increased the risk that, in the time pressured environment of pre-flight planning, flight crews could either overlook incorrect data and accept an incorrect flight plan, or err in the calculation of the required fuel upload. Further, the operator provided limited guidance and assistance for flight crews on the processes and procedures for correcting identified fuel planning errors. For the occurrence flight crew, this lack of guidance, as well as the remoteness of resources that could assist, resulted in the decision to determine a correct required fuel load calculation using only those resources available on the flight deck. Due to the short layover between sectors, which was further aggravated by curfew restrictions, this increased the risk of critical fuel planning considerations being overlooked.

Safety message
A correctly calculated flight plan not only provides assurance to both the captain and the operator that all operational factors likely to influence the flight have been considered and accounted for, it also forms an important inflight validation tool to allow crews to monitor and continually assess those decisions made at the pre-flight stage. Where variances are noted, timely alternative plans can be implemented to ensure that aircraft arrive at either the destination or an alternate aerodrome with required fuel reserves preserved.

However if you continue to read down the page you will eventually get to the 'nuts & bolts' section of the final report i.e. the safety analysis/conclusions/safety issues.

 'Safety analysis' (note part in bold):

Tiger Airways Australia Pty Ltd used an Operations Control Centre (OCC) to provided flight planning support for the flight crew of their regular public transport flights. Operations controllers (OC) were responsible for the production of flight planning and supporting documentation, which included generating the operational flight plan (OFP) and associated air traffic services flight plan.

There are various reasons for using an OCC for flight planning, including cost and duty time considerations. The use of an OCC system to produce flight planning products enables operators to reduce the flight crew’s flight planning task from gathering information and developing the flight plan, to one of reviewing prepared documentation and a finalised OFP. This has enabled operators to significantly reduce the time spent by flight crew in the flight preparation phase. Under regulation and the operator’s own policy and procedures, however, the aircraft captain was responsible for the proper planning and conduct of a flight.

The production of a correct OFP is essential for the safe completion of a flight. It ensures, amongst other things, that:

• the calculated fuel upload contains all required components
  
• the fuel upload is sufficient for the required flight given the conditions expected for that flight
  
• there is an accurate method of tracking inflight fuel usage
  
• the aircraft will arrive at the destination with sufficient fuel to ensure a safe landing.
  

   
Does this indicate that despite 'just culture' and the fact that the aircraft under 'Other Findings' met...

"...All company and regulatory in-flight fuel requirements for the flight from Sydney to Perth were met, and the aircraft landed with fuel in excess of the required fuel reserves..."

...that the Captain may have been scapegoated in order to allow time for the ATSB to again O&O an investigation (to the benefit of the operator) but at the detriment of the real glossed over safety issues i.e. safety risks associated with quick turn-around & LCC operations. 
 

MTF...P2