3 years later The Mildura report
Oakape, velocity was over the top for more than 39 mins, and had 2 cracks. their decision based on the 0902 taf for Mildura and the metars seems reasonable.
The system failed.......miserably.
As most know on here, the fuel policies for any airline are simply a box ticking excerise. The companY accountants and CEO's have zero appreciation of the true ramifications of an incident like this. So the lickers and climbers will continue to be on the phone to question crews integrities when it comes to fuel uplift.
I'm yet to see an absurd amount of fuel in tanks preflight!
I feel for the crews involved but the crazy thing is, the exact same thing could occur tomorrow morning.
The system failed.......miserably.
As most know on here, the fuel policies for any airline are simply a box ticking excerise. The companY accountants and CEO's have zero appreciation of the true ramifications of an incident like this. So the lickers and climbers will continue to be on the phone to question crews integrities when it comes to fuel uplift.
I'm yet to see an absurd amount of fuel in tanks preflight!
I feel for the crews involved but the crazy thing is, the exact same thing could occur tomorrow morning.
Have not yet read the report, but may I ask as SLF why the two crews may not have done an outoland in Adelaide as was done by a untrained crew previously when caught out by unforcast fog (320 I think).
Because at the time Mildura was a adequate alternate. You would get into a heap of trouble doing a Cat I autoland in fog with a alternate open to you.
[T]he crazy thing is, the exact same thing could occur tomorrow morning.
Let's hope we can keep relying on the training and professionalism of crews to see through the facade (fog?) of all the regulatory and company policy waffle, and focus on safety.
At least crews faced with the same circumstances know what awaits them if the coin falls differently at the next toss: The "Dominic James Treatment". And probably not 3 years later.
Edit: In all honesty, captains on here, from a company and legal viewpoint, are you expected to just carry on if this above scenario occurs mid-flight
- enough to a suitable airport
-10% of the above
-special fuel
- reserve fuel etc etc
A suitable airport is one that has ok weather. So when presented with fog, the crew have to look for a 'suitable airport' that they can make. In practice this means you are always aware of which airports you can make and what the weather is doing there, if options start getting slim you start paying more attention.
Most of the time any issues can be sorted out at the pre flight stage by adding more fuel, many states mandate carrying an alternate on every flight ( not Australia) this reduces risk and removes potential for poor judgement or interpretation of the forecasts.
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What framer said!!!.Great points made.There is only one scenario when you have too much fuel that I know of.Yesterday,I was given two alternates,and ended up going to the second after starting the approach for the first.The fueling amount needs to be discussed by both crew members and the dispatcher.There is ABSOLUTLY no reason to short yourself
In saying that,Ive been in this very situation,some things don't go as planned,nothing is a guarantee,and that's why we plan,fuel is serious planning.I ve read the report,bottom line,decisions were made,Aircraft landed,everyone safe......and,lessons were learned.
In saying that,Ive been in this very situation,some things don't go as planned,nothing is a guarantee,and that's why we plan,fuel is serious planning.I ve read the report,bottom line,decisions were made,Aircraft landed,everyone safe......and,lessons were learned.
Snakecharma,
Airlines not Australian based have ALTN planned and fuel loaded from departure. So the EK A380 flying DXB-BNE carries fuel for SYD as well as contingency.
Airlines not Australian based have ALTN planned and fuel loaded from departure. So the EK A380 flying DXB-BNE carries fuel for SYD as well as contingency.
fpvdude:
It's been a while since I've flown under Australian regs, but isn't it covered by ENR58.2.4?
Snakecharma:
As don said, international airlines based outside Australia always plan for an alternate. There are exceptions such as Perth, where some airlines use isolated airports rules which allow them to plan additional holding fuel in lieu of an alternate, provided the weather is above the alternate minima. If the weather is below the alternate minima, then an alternate must be planned, which can mean carrying enough fuel to divert to Adelaide or even further.
Once airborne, some airlines have rules that allow the crew to drop the alternate if it becomes obvious the aircraft will arrive at its destination with less than minimum diversion fuel. That's only allowed if certain conditions are met, such as two independent runways at the destination, weather above the alternate minima, no ATC delays, etc.
Can anyone point me to any mention, in the AIP, with regards to the requirement (or lack there of) of diverting/allowing sufficent fuel for a destination airport, which deteriorates to a INTER/TEMPO below minima while in flight?
"58.2.4
The AIP makes no distinction between "pre-flight" and "in-flight", so you still need to comply if the weather forecast deteriorates after you get airborne.When weather conditions at the destination are forecast to be above the values specified at para 58.2.1, but, additionally, intermittent or temporary deteriorations in the weather below the values are forecast, provision of an alternate need not be made if sufficient additional fuel is carried to allow the aircraft to hold for:
a. 30 minutes for intermittent deterioration (INTER); and
b. 60 minutes for temporary deterioration (TEMPO)."
a. 30 minutes for intermittent deterioration (INTER); and
b. 60 minutes for temporary deterioration (TEMPO)."
Snakecharma:
out of interest, when a 380 arrives in Sydney, Perth, Brisbane do they carry an alternate all the way to the destination or do they plan to a decision point and then give the alternate away if the conditions suit?
Once airborne, some airlines have rules that allow the crew to drop the alternate if it becomes obvious the aircraft will arrive at its destination with less than minimum diversion fuel. That's only allowed if certain conditions are met, such as two independent runways at the destination, weather above the alternate minima, no ATC delays, etc.
Aircraft details – VH-YIR
Manufacturer and model: Boeing 737-8FE
Year of manufacture: 2012
Operator: Virgin Australia Airlines Pty. Ltd.
Serial number: 39925
Type of operation: Air Transport High Capacity
Persons on board: Crew – 6 Passengers – 85
Injuries: Crew – Nil Passengers – Nil
Damage: None
Manufacturer and model: Boeing 737-8FE
Year of manufacture: 2012
Operator: Virgin Australia Airlines Pty. Ltd.
Serial number: 39925
Type of operation: Air Transport High Capacity
Persons on board: Crew – 6 Passengers – 85
Injuries: Crew – Nil Passengers – Nil
Damage: None
Reading between the lines, it seems to me that the report finds that both crews made reasonable decisions and acted within the CASA regulations (including the below minima landing).
They were caught out by a 5% probability weather event at Adelaide that occurred simultaneously with a 1% probability weather event at Mildura.
It appears that all parties acted within their procedural requirements, but ATC and the BOM did not meet best practice benchmarks primarily in communicating a METAR and some changed forecast data. It would appear that this would not be acceptable under regulations in other jurisdictions.
The whole deal was exacerbated by failure of the Mildura AWIS. The report notes that it was unavailable on THE DAY, but fails to mention if it was U/S for a single day or a longer period. I think that the report could have included an evaluation of AsA's performance in maintaining critical facilities such as this or an analysis of the "uptime" of these facilities.
Frankly, I found it a bit alarming to read that the BOM's primary fog observation mechanism for Mildura is satellite images. Mildura is an RPT airport with significant ground based personnel. The report skips over this, but I'm prepared to bet that territorial bureaucratic rules prevent the BOM using one of the existing ground staff for weather observations.
Autoland and the decision not use use it features in the report and these discussions on this board, but it should be remembered that Adelaide airport is not certified for autoland. If the pilots had landed and something went wrong, they may well have been crucified. On the information they had available at the time, they took a sound, conservative decision. The real question is why Australia has an International airport that is not Cat III certified. Surely, in this day and age that is the infrastucture you expect from a first world country.
So, my reading is. Pilots: OK. ATC: OK rules & procedures: big question mark. Infrastructure: big question mark. BOM: question mark.
In the words of Cool Hand Luke "what we have here is a failure to communicate". And all roads lead to government instrumentalities.
They were caught out by a 5% probability weather event at Adelaide that occurred simultaneously with a 1% probability weather event at Mildura.
It appears that all parties acted within their procedural requirements, but ATC and the BOM did not meet best practice benchmarks primarily in communicating a METAR and some changed forecast data. It would appear that this would not be acceptable under regulations in other jurisdictions.
The whole deal was exacerbated by failure of the Mildura AWIS. The report notes that it was unavailable on THE DAY, but fails to mention if it was U/S for a single day or a longer period. I think that the report could have included an evaluation of AsA's performance in maintaining critical facilities such as this or an analysis of the "uptime" of these facilities.
Frankly, I found it a bit alarming to read that the BOM's primary fog observation mechanism for Mildura is satellite images. Mildura is an RPT airport with significant ground based personnel. The report skips over this, but I'm prepared to bet that territorial bureaucratic rules prevent the BOM using one of the existing ground staff for weather observations.
Autoland and the decision not use use it features in the report and these discussions on this board, but it should be remembered that Adelaide airport is not certified for autoland. If the pilots had landed and something went wrong, they may well have been crucified. On the information they had available at the time, they took a sound, conservative decision. The real question is why Australia has an International airport that is not Cat III certified. Surely, in this day and age that is the infrastucture you expect from a first world country.
So, my reading is. Pilots: OK. ATC: OK rules & procedures: big question mark. Infrastructure: big question mark. BOM: question mark.
In the words of Cool Hand Luke "what we have here is a failure to communicate". And all roads lead to government instrumentalities.
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Originally Posted by Old Akro
but it should be remembered that Adelaide airport is not certified for autoland
So, my reading is. Pilots: OK. ATC: OK rules & procedures: big question mark. Infrastructure: big question mark. BOM: question mark.
What interests me is the seeming reluctance to let an incident report go by without at least having a little stab at the pilots. These guys were handed at least three weather reports/ forecasts that were wrong. They made decisions based on information that they are actively encouraged to base their decisions on and when it became apparent to them that the Adelaide forecast was wrong, they had two choices;
A) Auto-land below minima at YPAD even though they had fuel for a 'suitable airport' as per the latest observation at Mildura,or
B) Divert to the 'suitable airport' as per the regs and their own Airlines exposition.
They chose option B. Who wouldn't?
Then in the final report the ATSB suggests that a 'factor that increased risk' was that the crews based their divert decision on the observation rather than the TAF......well if the TAFs for the area are not doing the trick and fuel is getting to be a concern then an observation telling me a field is open seems like good current gen that shouldn't be ignored.
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Surely the main take home message from this is it all would have been a non event if they carried more fuel.
ATSB should have made that it's main recommendation.
Regulator should step in - fat chance with current CASA mob.
ATSB should have made that it's main recommendation.
Regulator should step in - fat chance with current CASA mob.
That is an incorrect statement for one of the operators involved in this incident. Whist the ILS approach is only certified to Cat I minima, autoland and on RWY23 was (and still is) permitted by the operator.
B) Divert to the 'suitable airport' as per the regs and their own Airlines exposition.
If hypothetically Mildura remained CAVOK and you autolanded in CAT II conditions on a CAT I ILS you would have a alot of explaining to do. The ATSB is kidding themselves if they are subtly suggesting that this is what should have happened.
Surely the main take home message from this is it all would have been a non event if they carried more fuel.
Last edited by neville_nobody; 1st Jun 2016 at 05:10.
Surely the main take home message from this is it all would have been a non event if they carried more fuel.
In order to get them out of trouble, they would have needed enough to get to Adelaide & hold, then go to Mildura and hold, then go to Melbourne or Avalon. All because accurate known information on the weather was not passed to the pilots and because the Mildura AWIS was u/s (again). Really??
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Misquote
It was The Captain, NOT Cool Hand Luke, who uttered the phrase "What we've got here is failure to communicate". (Although I'll concede Luke did later paraphrase him). Get it right on the small stuff guys or how are we supposed to be taken for professionals on the big stuff
Geeze
Geeze
If hypothetically Mildura remained CAVOK and you autolanded in CAT II conditions on a CAT I ILS you would have a alot of explaining to do. The ATSB is kidding themselves if they are subtly suggesting that this is what should have happened.
It was The Captain, NOT Cool Hand Luke, who uttered the phrase "What we've got here is failure to communicate". (Although I'll concede Luke did later paraphrase him). Get it right on the small stuff guys or how are we supposed to be taken for professionals on the big stuff
Hindsight's a wonderful thing I guess, but what's less 'legal' - diverting to an airfield that has a 60 minute holding requirement on the TAF when you don't have the required fuel, or doing an autoland in low visibility conditions at an airfield that's only certified to Cat I?