[Peetwo]

Yet another MH370 v PelAir parallel -
{LONG post Warning}  

The disappearance of MH370 in one of the busiest airway bottle necks in the world, highlighted many safety deficiencies of several SE Asian ICAO signatory States but none more than the Malaysians. The MH370 1st anniversary interim report (see link HERE) highlighted many of these deficiencies & significant safety issues of the Malaysian ATC airspace & system. The following is a quote from Nural Izzah Anwar, in Malaysiakini publication April 2015, that called for action on the Malaysian MH370 Annex 13 interim report findings:

MH370 exposed massive failure




As the MH370 incident has shown us, there are still many weaknesses in Malaysia’s aviation safety. While commenting on the interim report on the case, CNN news anchor Richard Quest, has said that the biggest scandal in the MH370 case is the failure of the air traffic controllers in South East Asia including Malaysia to take action even though the radars has managed to pick up strange movements by the plane in the hours prior to the search and rescue is launched.

It is imperative that Malaysia begins to disclose these audit reports to the stakeholders including to the members of the public, as this would open up opportunities for the stakeholders to suggest ways and new technologies that is available to improve aviation safety.

As such, I demand the government to reveal audit findings by local and international bodies in a transparent and timely manner. Improvements would inch along if government keeps the “government-knows-best” stance. 

For this, I urge the government to set up a parliamentary select committee on Civil Aviation Safety and Security. In dealing with safety issues, the public deserves to know that the government is working at its best to ensure the public’s lives are of the utmost importance

In another strange comparison, although with different identified safety issues, the PelAir VH-NGA ditching involved a very similar cross-jurisdictional FIR/ATC situation that contributed to the causal chain that led to the accident. Reference O&O thread post #51:  

Why Beaker elected to leave the OBR in the water has always intrigued the curiosity bump. Perhaps there is some common or garden reason, maybe even the pragmatic ‘of no value to the investigation’ could be the simple, truthful answer.  But, the accursed bump keeps itching away; motive and who benefits, nag, nag, nag.  Put that aside for the moment.

Since the Senate inquiry there has been a massive, sulky, passive resistance to recovery of the OBR, dragging of feet and general reluctance to get on with it.  Hell, it took a directive from the blasted minister to get the ball rolling and even then, every back door was checked for an escape route.  Time goes by, but eventually the day arrives and up from the shallows off Norfolk – the black box emerges: and, bugger it all; the rotten thing works, just fine.

Dom J is not too concerned about this, the Senate and punters are happy, so why the long faces at Beaker bunker?  IMO the OBR will not shed much more light on the general picture; it will tidy up some loose ends and provide ‘hard’ data, but it will not explain why it was consigned to a watery grave.

Toot 123, 123, 123 –( ¾ time, eminently suitable for Sunday).

Very clever Ferryman  
I have a very vague memory of the old 123 ALT requirements..

For the record from an excellent blog piece titled - IFR Alternate Requirements

...The FAR 91.169 states that an alternate airport is always required except when the worse forecast at the destination airport from 1 hour before to 1 hour after the estimated time of arrival (ETA) is expecting a ceiling of at least 2000 feet and 3 statute miles of visibility.. 

Also relevant - from the blog piece - to the Ferryman question IMO is this statement:

..Approved sources of weather forecasts for the purposes of alternate requirements are: Terminal Aerodrome Forecasts (TAF) and Area Forecasts (FA). The pilot must also remember that a TAF is only valid within 5 statute miles from the terminal of an airport, and, consequently, referencing to a TAF as a “forecast source” when the first point of intended landing is 5 or more statute miles from the nearest reporting TAF station would be invalid...

The part in bold is continuously overlooked when considering the weather information that was apparently relayed under request to the pilots of VH-NGA. Although there was two BOM amended TAFs issued (both of which required the provision of an alternate) in the course of VH-NGA's final fateful flight, neither of these TAFs were relayed by either Auckland or Nadi:
  

And see transcript link:  http://www.aph.gov.au/DocumentStore.ashx...2ffa885397

The significance of these omissions was brought fully to the attention of the RRAT Senate Committee PelAir Inquiry on the 19 Nov 2015: Transcript - Monday, 19 November 2012 - Aviation accident investigations
{Somewhat ironically both of these quotes come from Harfwit }

Senator XENOPHON: Can you explain that? I am just trying to get the context here. What are our international obligations in regard to the sharing of hazardous weather information with other air traffic service organisations?

Mr Harfield : We have a monitoring system where the Bureau of Meteorology obviously monitors a number of locations around Australia and within the jurisdiction of the airspace that we manage. When we get information provided that is of a differing nature from the forecast, such as a hazardous weather event or the SPECI information that you mentioned previously, that information is then sent to the control positions. It is then relayed to the particular aircraft based on certain parameters where the weather has changed. We call that a hazard alerting service. What we would do, for example, if an aircraft which had a terminal area forecast for Sydney was flying between Melbourne and Sydney and the weather conditions rapidly changed is issue a hazard alert and notify all aircraft going to that destination of the change in circumstances.

&..

CHAIR: We are not blaming you for the—

Mr Harfield : No, I understand. I just want to make sure that I am clear in what I am saying. The fact is that it was Fijian air traffic control that did not pass on the amended weather information, not New Zealand air traffic control. On the basis of what happened in the accident, that weather information was critical in the sense that if that bit of information was seen, the outcome may have been different. I am reluctant to say that the procedure is unsafe because I do not have the broader information on what is going on. Here was a piece of information that should have been passed to the aircraft which could have prevented this outcome.

&..

CHAIR: You are the bunnies. None of this affects you because there was nothing in the report upon which you have got to act, even though it is critical to the crash, perhaps. ATSB, for whatever reason, whether it is just to protect the bureaucracy or whether it was adjusted by CASA, which is a possibility, did not mention this critical factor of the nonreporting of the weather change, which leads to a very big question. Senator Fawcett?

Senator FAWCETT: The thing that the committee is struggling to come to is that there have been many witnesses who are pointing fingers of blame at particular incidents. Australia has been a leader in aviation safety for a number of years through its fairly robust adoption of a systems approach, and James Reason is the classic person who has driven that. So, clearly, the actions of the pilot in command and his decisions around flight planning and fuel have a role to play—so do the actions of the company in terms of their checks, training et cetera. But each slice of the Swiss cheese, as the James Reason bowl is often laid out, has the potential to prevent the accident. So the importance that the committee is placing on an incident such as a proactive alert to the pilot that there is now a hazardous situation is not the reason the accident occurred, but it is one of the defences that may well have prevented the accident. If Australia are to remain at the forefront of open, transparent and effective aviation safety then one of the roles of this committee is to make sure that our organisations collectively keep working towards having a very open discussion around that systems safety approach and making sure that each of those barriers is as effective as it can possibly be. That, I guess, is the intent behind a lot of the questioning this morning.

We see that, whatever else occurred, if the pilot had been made aware proactively about the hazardous situation that now existed then perhaps he would have made a different decision. Should he have been there in the first place? Should he have had more fuel? They are all other slices of cheese. We are concerned with this one. The thing we are really trying to establish is, if the ATSB report had had a recommendation that said, 'This was something that could have prevented the accident. Is it possible to have it put in place for the future?' then you would have taken action on that as a matter of course. Is that a correct assumption?

Mr Harfield : That is a correct assumption.

Senator FAWCETT: And without that recommendation being there it is a matter of some conjecture at the moment as to whether or not that would or would not have been raised at a future forum. Is that a fair assumption?

Mr Harfield : That is a fair assumption.

Senator FAWCETT: Under the current model, if ATSB come across in one of those slices of Swiss cheese in the recent model a question of whether or not existing legislation directed a pilot to make a decision that he had to divert if the weather minima went below alternate or landing minima, and they contacted the regulator and said, 'Hey, regulator, here is a critical safety issue' and they thrashed that through, do they have a similar mechanism where if they see another slice of Swiss cheese—that the pilot was not advised of this new hazard—do they come to you as the relevant body? Although it is not your rule set, you are the Australian point of contact to speak to regional players; do they come to you and say, 'We think there is an issue here, can we discuss this?' Did they come to you in this case?

Mr Harfield : In this case I do not recall and I do not think that they did. However, in other instances where things have occurred they have come to us to ask for assistance—for example, with some incidents that have happened in Indonesia.

CHAIR: But no-one cared about the prang off Norfolk Island?

Mr Harfield : That is not correct, Senator; I just do not recall the ATSB coming to us to ask us for assistance in this particular jurisdiction.

CHAIR: How long have you been at Airservices?

Mr Harfield : Nearly 25 years.

CHAIR: I think you need a change of career.

Senator FAWCETT: Can I clarify that if ATSB did come to you in the same way they came to CASA and said, 'Here is something that potentially could be a barrier to a future accident,' that would be a sufficient trigger for you to then take that on corporately and see what action you could take with your regional partners?

Ms Staib : Absolutely.

Senator FAWCETT: That is what we are trying to look at here—we are trying to ascertain what are the things that we can drive into the relationships between departments to make sure that we wrap up the system safety to the best extent possible

Ok so yet again there are for all intent & purposes still outstanding safety issues that are still to be proven to have been risk mitigated. No surprises there I guess, when it comes to Harfwit's mob & the Dolan led ATSB top-cover experts...

However given that the PelAir re-investigation & MH370 Annex 13 investigation is still ongoing, wouldn't now be a perfect opportunity to invite for input from the 'other' cross-jurisdictional FIR/ATC States involved in both accidents.

Annex 13 Chapter 5.23 allows for this scenario:

Rights

5.23 Any State which on request provides information, facilities or experts to the State conducting the investigation shall be entitled to appoint an accredited representative to participate in the investigation.

Note.— Any State that provides an operational base for field investigations or is involved in search and rescue or wreckage recovery operations may also be entitled to appoint an accredited representative to participate in the investigation.

      
With the VH-NGA investigation, both Fiji & NZ ATC service providers supplied ATC transcripts of all communications with the accident aircraft.

In the Fijian transcript, this was how the errant 0630 METAR relayed by NADI at 0801 UTC, was picked up by the 4 Corners program and ultimately led to the ATSB correcting their report:

GEOFF THOMSON: With good weather forecast, Dominic James headed to Norfolk Island with his fuel tanks 83 per cent full.

The first weather update for Norfolk comes from Air Traffic Control in Fiji.
It says there's some cloud over Norfolk island at 6,000 feet.
This is wrong.

MICK QUINN: In review when you look at the actual weather report that was issued, the actual cloud base was not at 6,000 feet. It was at 600 feet.

That indicates to Dominic, it reinforces his mental picture, that the forecast still is as it was, it's even better than what it was when he got the original forecast when he departed.

MARTIN DOLAN: That's not one that I am familiar with at the level of detail in the report so ...

GEOFF THOMPSON: So it might be a mistake.

MARTIN DOLAN: It, it may well be a mistake. I'll have to take a look at that.

GEOFF THOMSON: And he did.

Last Friday the ATSB acknowledged Dominic James received incorrect weather report from Fiji and changed its report.

   
IMO that is a good enough reason to include both Fiji & NZed in the re-investigation. And in the MH370 case the factual evidence in the interim report is evidence enough to include all regional ATC/FIR partners in the investigative/safety issue mitigation process..


MTF...P2