[Peetwo]

For the record: UP thread heating up - 

Ref:

Hooded Canary releases Mangalore mid-air prelim report - 

Via HC central yesterday:

Warning: Bucket may be required for the Hooded Canary segments -   

Read the preliminary report AO-2020-012: Mid-air collision involving Piper PA-44-180 Seminole, VH-JQF, and Beech D95A Travel Air, VH-AEM, near Mangalore, Victoria, on 19 February 2020

For a more damning assessment of the ATSB's findings so far IMO you can't go past the 'Advance' post off the UP -   

  US vs Australian airspace

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In the USA ALL IFR aircraft are separated by ATC.

Dick Smith has been trying to bring Australian safety standards up for at least 30 years by insisting on the same ATC separation here.
The ATSB report confirms what this forum has known for some time => both aircraft were visible to ATC via ADS-B tracking.
Airservices have a flow chart that demonstrates the workload of providing separation is LESS than the workload of only providing traffic.
WHY?
Each task requires ATC considering the trajectory of every aircraft in the sector.

To separate aircraft, the ATC makes a decision and issues an instruction.

If the ATC passes traffic then the pilot may respond with his decision to change altitude or track or otherwise avoid the conflict.

BUT then the ATC has to assess this change to determine if a different conflict will occur and perhaps pass further traffic.

So let us stop accepting the nonsense argument that it costs more to provide separation compared to traffic information - it does not.

What is the total cost of this accident going to be?

Almost two decades ago Dick organised a trip by both Airservices and CASA staff to the United States with flights arranged to demonstrate the ease of use and safety of Class E airspace.

A very experienced US ATC from the Southern California Terminal Radar Control Unit addressed the team and pointed out how easy it was to provide separation and how safe the result.

John and Martha King of King schools tried very hard to educate the team on why US airspace is as safe as Australian airspace in terms of collisions per flight hour but has so much greater traffic density and thus greater actual safety.

A lot of very experienced pilots and controllers in this country know Dick was right back then and he is proven right again by this accident.

CAN WE LEARN FROM IT THIS TIME???

Given the obvious subject matter expertise on display over on the UP, I thought it was about time I dragged the Mangalore Mid-air Elephant in the sky across to where it belongs. as the passion and sentiment heats up on the UP - 

Mr Approach: From the interim Report (my underlining):


The investigation is continuing and will include further examination and analysis of:

• weather conditions at the time of the accident
  
  
• recovered radios from the aircraft
  
  
• recorded radar data, as well as recorded area frequency calls and recollections of CTAF radio broadcasts.
  
  
• pilot qualifications, experience and medical histories
  
  
• aircraft maintenance and operational records
  
  
• air traffic services actions, procedures and practices
  
  
• traffic density in and around Mangalore Airport
  
  
• classification of the airspace around Mangalore Airport
  
  
• Class G and CTAF operational and communication processes and procedures around Mangalore Airport
  
  
• visibility from both aircraft.
  

Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken.

Come on ATSB, should a critical safety issue be identified - FOUR PEOPLE DIED!

Why is this not a safety problem when it could have been prevented with an airspace model and ATC services that were accepted by CASA back in the '90s?

Why was the Federal Government provider of ATS allowed to then argue with the regulator and have the plan overturned? (At a time when it was managing the FAA Pacific Towers that used exactly the separation services they were rejecting for Australia!)

Even the State Safety Programme starts off with complacency:

"Australia has an enviable record in aviation safety, among the best in the world, which has been built on a strong safety governance system, forged over many years."

That's OK then we don't really have to try any harder, do we?

I believe I could guarantee that if the two aircraft at Mangalore had been airliners, with or without passengers, then action would have been taken.

There is a better way, Minister! For the sake of a few dollars and a few more controllers, those four men need not have died.

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Advance: Responsibility in ATC

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Let me prefix these remarks by saying I lay no blame at the foot of the unfortunate ATC who had to sit and watch two blips merge and vanish.

That person was doing precisely what they were paid to do and acting in accordance with both training and written instructions.

On 5th October 1999, a train went through a red light at Ladbroke Grove near Paddington London.
31 dead, 417 injured. This signal was known to be problematic - it had been passed eight times in six years though the driver had not been told of this.
This particular signal was almost impossible to see with the sun behind it, and on curved lines, it was not immediately obvious which of a myriad of signals related to the particular line this train was on.
All of this was known to management but nothing was done to rectify the safety deficiencies.
Other known but not corrected safety issues came out at the inquiry.
This is one of the major contributing factors to the UK enacting the offence of Corporate Manslaughter.“Section1. The offence

1. An organisation to which this section applies is guilty of an offence if the way in which its activities are managed or organised—
   

1. causes a person's death, and
   
   
2. amounts to a gross breach of a relevant duty of care owed by the organisation to the deceased............................
   

So far as I know we do not have an equivalent offence in Australia - yet - but let me tiptoe very gently here.

Airservices is an organisation that provides a service known as Air Traffic Control whose function is to prevent collisions between aircraft...............
CASA has an Office of Airspace Regulation which is required to operate in accordance with a policy statement issued by Michael McCormack and Para 47 reads:

The Government expects CASA to adopt international best practice in airspace administration. This includes adopting proven international systems that meet our airspace requirements. The Government’s airspace strategy recognises that international airspace systems include a range of characteristics to be considered, and implemented as appropriate.

Aviation has two sets of rules; VISUAL for those who can see other aircraft and visually separate themselves from others, and INSTRUMENT for those who may not be able to see other aircraft as they are permitted to operate in cloud and conditions where visual separation is not possible.

VERY PLAINLY any system of airspace administration that is able to separate IFR aircaft but does not do so, in the full knowledge that those aircraft may be operating in conditions where they can not visually separate themselves is NOT applying any form of international best practice nor proven international systems.

The CEO of Airservices and the Manager of the OAR are both controllers and should both be thinking very carefully about their responsibility as individuals, let alone as the persons responsible for their respective organisational functions.

May I also most respectfully commend the Chief Commissioner of ATSB, himself an ex-controller and ex Safety Manager of Melbourne Center to consider whether this ongoing unsafe mode of airways operation be permitted to continue or is deserving of an immediate safety recommendation to both CASA and AA.

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ACMS: You guys can argue about the rules for when ATC are supposed to advise traffic all you want...


BUT, why did ATC wait soooo long to tell AEM about JQF and also to tell JQF about AEM when they should have realized it could be a separation issue quite a while earlier?

JQF taxied at 1111 but AEM wasn’t advised at all until 1119......8 minutes later
JQF taxied at 1111 while AEM was inbound but they weren’t advised of AEM until they became airborne at 1122 .....2 minutes before impact.....why did ATC wait 11 minutes to advice them of AEM descending inbound across their departure track...

So experts can quote required times all you want but to me THEY WERE BOTH ADVISED WAY TOO LATE.....

AEM had a whopping 5 minutes notice of JQF before the impact
JQF had a whopping 2 minutes notice before the impact.

That’s supposed to be the whole idea of calling on the ground, you get given traffic so you can plan BEFORE getting airborne.....otherwise why bother...

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Lead Balloon: Yep, they were advised way too late.


But we’ll now have to sit through a few years of the unedifying and expensive pantomime of the conflicted ATSB coming up with a report as to why the tragedy was not a consequence of anything other than pilot error. So very ... Australian.

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Hoosten:

BUT, why did ATC wait soooo long to tell AEM about JQF and also to tell JQF about AEM when they should have realized it could be a separation issue quite a while earlier?

I really don't know how many times it needs to be explained to you? And the others posting similar.


The sector boundaries do not allow traffic to be passed any earlier to AEM than it was. This accident is a combination of airspace classification and airspace (sectorisation) boundary issues.

- The Departures North Controller would have handed the aircraft off to Dookie Sector as soon as Dep North had no separation issues, AEM would have been in controlled airspace when this hand off had taken place. The rules of a handover of aircraft are many. You can't just hand an aircraft off to another controller on a whim. Nine times out of ten the Dookie Controller will launch straight into the traffic statement. 9 times out of 10 the aircraft will acknowledge the traffic and advise the airwork details then switch straight to the CTAF.

- When it is busy at MNG it is virtually impossible to monitor both fequencies when you are conducting an IFR training flight.

- It doesn't matter how many times you say 'they should have had traffic earlier' it CANNOT change unless there is a sector boundary change (virtually impossible given that the terminal needs the boundary where it is to process traffic into ML, AV & EN). Stomping your feet and demanding that traffic be given earlier is analogous to a 6 year old child asking her mother why she can't go to the pub.

OR

- There is an airspace classification change that would have seen these two aircraft positively separated.

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Advance: Hoosten we have a problem exactly as your last line identifies.

Thanks

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Nomde plume:

Originally Posted by Hoosten 


Stomping your feet and demanding that traffic be given earlier is analogous to a 6 year old child asking her mother why she can't go to the pub.

4 people aren’t dead because a 6 year old couldn’t go to the pub.

JQF needed that traffic info at taxi because that’s when they had an opportunity to do something about it.

The moment you take off and enter IMC you can do nothing other than climb to LSALT/MSA at an absolute minimum. That’s exactly all they did.

The only thing(sans TCAS) that stops an IFR-IFR collision in IMC in class G airspace is accurate, clear and timely traffic information. The report offers nothing to the first two parameters but is damning of the third.

People are rightfully upset about this. Many pilots on here have lost friends and mentors in this accident.

Go and jump in the driver’s seat of your car on a rainy night with a blindfold on and think about who you’re going to ask to sit in the passengers seat giving you directions.

Don’t try and play down the seriousness of this accident and say all pilots here are 6 year olds. We place an incredible amount of trust in ATC. I have no problem placing my trust in the guys and girls on the other end of the radio. I will continue to place my trust in them.

But something happened here that let them down. It’s not going to be put down to the fact that a CTA boundary 20nm away meant it was all too hard.

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Hoosten: Nomde plume, I think you need to go back to the start of this thread, read it all the way through. I was accused of being too emotional as I lost a friend and acquaintances as well.

The only thing (sans TCAS) that stops an IFR-IFR collision in IMC in class G airspace is accurate, clear and timely traffic information. The report offers nothing to the first two parameters but is damning of the third.

You know what would have prevented this accident? The appropriate class of airspace for the level of traffic in a supposedly first world country.

You are blaming the controllers when you should be blaming a third world airspace system. You are blaming the controllers when you should be blaming the inability of aviators and public servants in this country to see past their egos and jingoistic belief that we have 'one of the best safety records in the world' so let's just leave things the way they are, the way things were done 20 years ago. Cos nothing has changed right? Oh, except the traffic levels right?

You don't know how a traffic assessment is done by an ATC, you don't know how and when that information is displayed and just when it becomes available. And you most certainly won't get all of that information in the accident report in 2023 sometime.


Yes, we do trust the ATC's. I do too, any time I head up that way. But I also know what goes on on the other side of the mike. So I can give you a heads-up, you are focusing on one part, a small part in the great scheme of things here.

MTF...P2