[Peetwo]

Them holes are aligning

Very disturbing report that perfectly highlights all the major problems with an aviation safety system that is totally rooted beyond redemption and will remain so while the current crop of inept, self-serving, ass-covering,  aviation safety bureaucrats is allowed to continue unabated covering up potentially embarrassing serious safety issues & occurrences...



Courtesy the Oz:

Near miss for planes carrying 18 people  

• by: Matthew Denholm
  
• From: The Australian
  
• September 17, 2015 12:00AM
  

Tasmania Correspondent
Hobart




Too close for comfort. Source: TheAustralian



An “unsafe” close encounter ­between two planes near Mount Hotham Airport in Victoria allegedly placed up to 18 lives at risk, fuelling demands for better use of radar at Australia’s regional airports.  

According to an incident ­report obtained by The Australian, two Beechcraft B200 King Air planes on private charters from different companies — one from Essendon in Melbourne and one from Bankstown in Sydney — were vertically within 300ft (90m) of each other on September 3.

It appeared the Essendon-based pilot, struggling with a faulty GPS in heavy morning cloud and poor weather, did not know where he was and reported being in vastly different locations, varying by up to 20 nautical miles, within a short period of time.
Radar traces of this plane, chartered from small Essendon-based operator Seidler Properties, show an apparently erratic path at times, and that the scheduled 38- minute flight took an hour and 27 minutes.

The Essendon plane came within one nautical mile (1.8km) of the other aircraft and eventually landed at Mount Hotham, in the Victorian Alps northeast of Melbourne, but only after what the report by the other pilot ­described as an “unsafe” approach from the “wrong direction”. There were three other aircraft also en route to the airport at the time.

The report, titled “breakdown of separation”, says passengers on the Essendon-based plane were so shaken they refused to return with the same pilot later that day, ­requiring another to be flown to Mount Hotham to pick them up.

In a report being investigated by the Australian Transport ­Safety Bureau, the pilot of the Bankstown-originating aircraft — a senior pilot at a major charter firm — describes the situation as “not safe”.

He suggests he is making the report not to attack the Essendon-based pilot, but rather to highlight an ongoing risk of tragedy in the absence of a safety back-up in cases of pilot error at uncontrolled regional airports.

“If this event did result in a midair collision, two aircraft would have been destroyed and 18 people would have been killed,” says the Bankstown-originating pilot in the report, sent to the ATSB two days ago.

“As a chief pilot, I am significantly concerned with the breakdown of (aircraft) separation caused by this incident. This is not a standard of operation that I would tolerate from my pilots and I do not accept that his event goes without investigation.

“Two high-performance aircraft with 300ft separation (vertic­ally), within one nautical mile of each other (horizontally), in IMC (instrument meteorological conditions), is not safe.”
The incident has further highlighted the lack of radar control of aircraft to low altitudes at ­regional airports in Australia, which The Australian has documented in the series of articles over the past two months.

In uncontrolled airspace, ­pilots must communicate with each other by radio to ensure they remain safely separated, with no support from an air traffic controller monitoring them on radar or providing co-ordination.

At Mount Hotham, radar-based separation of aircraft ends at 18,000ft, below which pilots must self-separate, despite radar being available to a far lower altit­ude.

Veteran aviator Dick Smith told The Australian the latest Mount Hotham incident highlighted the need to make full use of radar coverage at regional airports to improve safety.

“If they were using the existing radar for control at Mount Hotham, neither of these things (the ­alleged mid-air near collision and subsequent alleged dangerous ­approach) would have happened, because the controller would have told the pilot what was happening,” Mr Smith said.

He said it was particularly frustrating the existing radar was not being used to control aircraft to low altitude at Mount Hotham, given the deaths of three people in a crash there in 2005 and of six people in an accident at Benalla, about 150km from Mount Hotham, in 2004. He believed both crashes could have been averted had radar control close to ground level been provided.

“How many more frightening incidents like this before there are more unnecessary deaths?” Mr Smith said.

He said all that was needed to make use of existing radar for separation control to low altitudes at regional airports was for Airservic­es Australia to provide more training to controllers at its Melbourne and Brisbane radar centres.

Airservices insist the air traffic system is safe and that levels of control around the country are appropriate for local traffic volumes and types.

An ATSB spokesman said the latest Mount Hotham incidents were being investigated.
However, an official statement on the bureau’s website refers only to the “unstable approach” to the runway; not the earlier alleged close encounter. Seidler Properties suggested it was unaware of any investigation and declined to comment.

To think this 'serious incident' may have gone unreported 
How many other similarly serious occurrences have gone unreported (I personally know of a couple) because of fear of retribution or incriminating oneself.
MTF..P2
Tick..tick..tick..tick..
  

Update to ATSB investigation AO-2015-108.

Near-collision and Operational Event involving Beech Aircraft Corp. B200, VH-OWN and Beech Aircraft Corp. B200, VH LQR, Mount Hotham Victoria on 3 September 2015

 
Investigation number: AO-2015-108
Investigation status: Active
 

• Summary
  

Updated: 11 November 2015
At approximately 0830 Eastern Standard Time[1] on 3 September 2015, four low capacity twin engine turboprop aircraft flew towards Mount Hotham Airport, Victoria, as part of a passenger charter involving a number of different operators. On arrival at Mount Hotham the weather conditions were below that required for a visual approach. As a result, it was necessary for each aircraft to carry out a published Global Navigation Satellite System (GNSS) instrument approach, in order to navigate clear of cloud before landing (Figure 1).

Figure 1: GNSS instrument approach chart for Mount Hotham Airport 

Source: Airservices Australia

The first aircraft to arrive in the Mount Hotham area was Beech Aircraft Corp. B200 King Air, registered VH-OWN. The pilot of that aircraft commenced the GNSS approach from the south-east and, having descended below the specified altitude of 7,700 ft overhead initial approach fix HOTEC, experienced tracking difficulties approaching the intermediate fix HOTEI. In response, the pilot discontinued the approach and climbed the aircraft in a north-easterly direction (Figure 2). Having climbed back to the lowest safe altitude for that area, the pilot of VH-OWN commenced manoeuvring in the airspace above the Mount Hotham Airport as the other charter aircraft progressively arrived in the area and commenced the instrument approach.

Figure 2: VH-OWN partial radar tracking during the first approach
(Note: the climb back to the lowest safe altitude is not displayed)

Source: Airservices Australia, modified by the ATSB

The second aircraft arrived at Mount Hotham on the same track as VH-OWN. The pilot of that aircraft conducted the GNSS approach and landed on runway 29.

The third aircraft to commence the approach was another B200 King Air, registered VH-LQR, which tracked inbound from the north-east at 8,000 ft. During this time the pilot of VH-OWN continued manoeuvring in this area at 7,700 ft and the two aircraft passed in close proximity of each other with a vertical separation of approximately 300 ft.

The pilot of VH-OWN then conducted a second approach and experienced similar tracking difficulties. The pilot reported becoming visual and clear of cloud during the approach and continued to descend. VH-OWN was then observed to carry out significant manoeuvring while on short final to the runway before landing.

The airspace around Mount Hotham was designated as uncontrolled Class G airspace. Civilian radar coverage was unable to track all parts of the flight, and there was no control tower or certified air/ground radio service at the airport. Neither VH-OWN nor VH-LQR were fitted with airborne traffic avoidance equipment such as the Traffic Collision Avoidance System. The primary means of separation was the use of radio communication between the pilots and flight in accordance with the published instrument approach chart.

The investigation is continuing and will include examination of the:

• navigation and autopilot system fitted to VH-OWN
  
• recorded radio and radar data
  
• planning and conduct of the multiple aircraft charter operation
  
• air traffic services provided in the Mount Hotham area.
  

 

MTF..P2