ATSB Report: QF B737 838 VH VXF

[Raider1]

See the ATSB report into last Julys Canberra incident has finally been released. Nothing really unexpected. But seems there is a few lessons there for everyone from ATC...QF maintenance procedures and the crew.

http://www.atsb.gov.au/aviation/occurs/occurs_detail.cfm?ID=659

[Capn Bloggs]

Bloody Hell! 10°! I would've melted long before they had got to CBR.

Why don't FMSs have 3 fields (time, length and distance) for holding patterns, all of which would have to be verified prior to inserting?

I was impressed with the gallant promise from the operator that they would ensure "ensure earliest rectification".

[ferris]

It is not immediately apparent to me how the activation of the contingency procedure for TCU staff shortage would have had any effect on the incident. Do they infer that the aircraft wouldn't have held in the first place? Is the tower able to determine the a/c has descended below the lowest safe? Would the tower have instigated an arrival other than an ILS? ie; how does the tower at CB transition the a/c from en-route to an arrival?
Anyone care to enlighten me on this aspect?

[Ralph the Bong]

Mate, anything that goes into the FMS needs to verified before inserting. Failure to do so kills people. (AA B757 Cali, for instance..) :hmm:

[OhForSure]

Interesting to note that the F/O (obviously a cadet) only had 1900 hours and a CPL.

I would have thought that by this point in time a cadet would have had his/her ATPL. Am I missing something here?!?!?!?

[The_Cutest_of_Borg]

ATPL is not required for short haul FO's in QF because they, unlike their LH counterparts, are never required to act in command of the aircraft i.e. when the captain is on a break.

[ratpoison]

Yes well, from the hours that the Capt had on the aircraft, obviously BOTH of them were ex L/H. Need we say more. !!!

[The_Cutest_of_Borg]

Well that didn't take long.:rolleyes:

[Capn Bloggs]

Ferris,
Would the tower have instigated an arrival other than an ILS? ie; how does the tower at CB transition the a/c from en-route to an arrival?
My understanding (from my "location") is that when the TCU is manned you get a radar control service down to wherever you want: I would say down to the LLZ with a radar descent. Mind you, the only time I go to CBR is in the SIM, and the slack-o "ATC" that looks after us just tells us to "join the holding pattern"! Unionistic @#$%^ (sorry cinders!:{ )

[MrApproach]

I heard that Tower controllers are not allowed to be trained in approach control techniques because ASA does not want to lose TCU airspace when/if the government allows airports to operate their own towers.

The radar towers have at least one radar display, some have two, others three, only the training is missing. Coolangatta Twr controllers who at the time even had the training, offered to do approach control in the evenings to save ASA money but were knocked back for the reason above. Now if BNE Approach can't be manned around Cg the airspace becomes restricted even though there is a tower operating.

Apparently it was all part of an ASA pitch to convince the DoTRS that Approach/Departures control was part of en-route control and therefore belonged in the two Centres (ie ASA). I guess DoTRS were too stupid to examine the RAAF model and see that APP/DEP and TWR go together.

Short answer is that any TWR controller with appropriate training could have provided the Class C service in the absence of the radar controller.

[PureRisk]

Fatigue? maybe.
but this could have been one of the worst aviation disasters in modern australia times. !!!! thank god it wasnt

-------------------------------------------------------------------
from the report :

Role : Co-Pilot/1st Officer

Class of Licence Hours: Commercial

Hours on Type: 530.0

Hours Total : 1992

-------
Also It may be legal but what the hell? no atpl? ...but then again such high hours of experience .... :confused:
-------------------------------------
another........

With a lot of cadets now becoming FO's after moving from their highly experienced SO roles ( :yuk: ), after moving straight out of there $100 000 + paid cadetships where NO real practical command/decision making, raw flying experience has been gained, lets hope to god these ace pilots dont ever lose their captain and "MAP" mode.
I would hate to think of them flying on a dark and stormy night attempting an approach with no FMC.
There is still a lot to be said for experience.

[Col. Walter E. Kurtz]

Pure Risk - there are ALOT of people that will tell you that TRAINING in an AIRLINE ENVIRONMENT makes up for (lack of) EXPERIENCE.

Usually it is those that don't have the experience you speak of that don't believe that the experience they haven't got matters.

Go figure.

[blueloo]

PureRisk, what a load of BS.

I think you will find throughout the years that both experienced and inexperienced pilots make mistakes. Its only human.

What are your thoughts on Captain Captain Jacob Veldhuyzen van Zanten of KLM (Teneriffe) - he had heaps of flying experience, yet he was a significant part of one of the worlds worst aviation disasters. Or, because he didnt do the 'hard yards' in Australia's GA industry (in Australia's benign weather & terrain) he also wasnt suitably experienced? - And i say Australia's GA industry because the animosity towards other pilots be they Cadets or other is rife primarily only in Australia.


Did experience have anything to do with it - probably - but i would suggest your hard yard GA experience isnt the key factor -rather local route knowledge - and ultimately I would suggest it was more simply an error in entering data.

Did you not see Air Crash Investigations - the 757 in south america ? The captain enetered the incorrect selection for a navigation aid - (Purerisk, was this a mistake because the Captain didnt have GA experience from Australia?)

Anyway, I could list lots of big crashes with experienced pilots - but whats the point? It wont change your petty views, nor will it add to the topic.

[Col. Walter E. Kurtz]

Blueloo: The argument that says that plenty of experienced pilots have crashed planes is true - plenty of high time pilots have made errors.

BUT

What you can't document though, is the COUNTLESS accidents that experienced captains have AVOIDED. That stuff is not documented, and happens each and everyday in one way or another; in countless decisions made based on EXPERIENCE.

Those who know - understand.

Those that don't - don't believe it or don't care.

But what would I know - after all, I'm just an old fart and no match for a psych/skills/ hotshot - hotdog - jet jockey - SO/FO who has seen it all ' on the line ' . :hmm:

[blueloo]

Kurtz - The argument can easily go full circle....


What about the countless young, low experience pilots who have saved the older experienced guys............


Those who know - understand.
Those that don't - don't believe it or don't care

....and there are those that live with the blinkers on and live with tunnel vision.



...................................

All of these incidents keep reminding me of Fate is the Hunter.

[Iron Bar]

Awww Gee come on you blokes, give the poor cadet a break.

She's only a girl................:E :E :E

[schlong hauler]

To all the smart arses, have a look at the Jeppesen ILS page for CBR. The holding pattern limit is shown as D 14 with no mention of it being a dme limit unlike the MEL holding pattern limits for example. In the heat of the moment this could have happened to anybody at 5 in the morning when this is the last thing you expected! And for the anti cadet bashing, most of you would never have flown with one. Nearly all can outfly and out think some of the more seasoned ex GA pilots of which I am one. Do not believe for moment that experience in one facet of aviation is transferable to another.

[En-Rooter]

Mr Approach, (and if anyone else is interested)

There is probably more to it than that, ASA don't want to keep terminal areas if and when the greatest f!ckup of a transport minister decides on privatisation.

Like towers, app/dep simply don't make money, the cash cow is en-root. (this is the new correct spelling for the word previously spelt 'en-route')

I would suggest that the real reason ASA don't want tower controllers to do approach is that it sets a precedent for on site approach control and therefore stuffs ASA's plan to consolidate all approach control units to BN-ML.

Cheers.

:hmm:

[GT-R]

schlond hauler you are an idiot and no doubt this could/will happen to you.

some of us however use this button called 'TERR' and amazingly it will show the colour red in front of you if you are going to hit a hill, red usually means bad so most of us would not sit there for several minutes watching it come towards us.

and what an absolute stuffup to climb to 1,000-odd feet below MSA and sit there for ten miles before intercepting the ILS

WTF were they thinking?
WTF were they doing during the downwind leg? obviously just sitting there fat dumb and happy discussing why the F/O hadnt applied for an ATPL yet. didnt they monitor ANYTHING???

of course, situational awareness is not in the fam.



Four days holiday for flaming another user!!!

:mad: :mad:

Woomera

[MrApproach]

En-root, I believe your assumption to be correct but your logic does not follow. Why consolidate the radar TCUs if they are not profitable? They probably are and will be moreso as staff are cut and positions eliminated.

Back to the thread - the report seems to indicate that the Tower controller(s) were on duty. If they had been properly trained for contingency duties then they have all the equipment they need to safely conduct limited operations in the Class C airpspace. The ATSB seems to believe that it is perfectly reasonable to expect a tired crew to struggle with an unfamiliar environment while perfectly capable air traffic controllers watch helplessly from their Tower.

[7gcbc]

experience is really just making lots of little mistakes that don't kill you or end in tears. There is a saying that goes like 100 hours but ten times the experience of 1000, or something like that.

Everybody makes them, its just those that learn are the ones who benefit and your Character is measured by how you face up to them, either privately or in public.

Rare enough these days in corporate land, and airlines are no different from any other business in this respect

No comment on the Specific Incident, I was not there, and I'm not privy to the cockpit events. - But I'll bet none of that crew will ever be involved in a CFIT ever.

[GT-R]

But I'll bet none of that crew will ever be involved in a CFIT ever.

What a lovely compliment for any pilot to hear, I would however add "provided EGPWS is there to save them again."

[alidad]

GT-R,
look oin the bright side ; if they did not have EGPWS they would never have known that they had stuffed up- the relatives of the pax might have......

[bushy]

7gbc
Your last sentevce is so important. There is no point in crucifying the pilots. They have had a very powerful and valuable lesson , which is far more effective than any training anyone is prepared to give them.
They are now much wiser and better pilots because of it.

[schnauzer]

GTR. I will laugh my ar$e off the day you smack into a hill, you sm@rt @arse holier than thou sanctimonious pr1ck....!

[En-Rooter]

Mr Approach,

It's not my logic it's the bean counters logic, out of interest have you ever known app/dep positions to be cut and numbers reduced in a TCU? I haven't seen it since I've been here.

Why consolidate? These were promises made to industry in an effort to sell them TAAATS and eventual cost savings. There will be serious loss of face from those who promised it if they don't. Safety is no bearing on these decisions.

Yes, back to the thread, the tower controllers if they were in attendance before the approach dood, would have been in most cases able and willing to fill in. Why not? Who knows? Don't ask the manager responsible, it's not their decision, it's the bean counters.

I sat in on a presentation from the sky-guide fellow (urberlingen) who stated that it's not just controllers at the workface that face charges when something un-fortunate happens, it goes right back up to the top. The top brass were solemny nodding their heads in agreement convinced only as the brainwashed and performance bonus paid are, that we are totally safety focussed and it couldn't happen to us.

Me thinks that it will only be when some of the decision makers are doing time in the big house that this current philosophy will change.

o = before prison.

o = after prison.

Sorry for hi-jacking the thread fellas

:ok:

[OhForSure]

Nothing against cadets... good on 'um...

But what I still don't get (and what I was alluding to before, sorry Borg) is that I was under the assumption that QF cadets did their ATPL theory (lets hope:)) and then entered the industry... (either QF or now a regional/3K). Then when one has amassed the hours required, one would recieve a 'full' or 'un-frozen' ATPL. What's the go?

ForSure

[7gcbc]

GT-R,


I'm not sure about your comment, however I'm sure you will agree that we all make mistakes, and we hopefully learn from them.

My point was succinctly articulated by Bushy, that is what I was getting at.

such is life, we all can't be perfect all the time, but trying to get there distinguishes us from the mediocre.

reasonably important in aviation you would think?

g'luck to the crew, I wish them the best.

7g

[stillalbatross]

Can someone explain why Lufthansa and BA have used cadets for the past 5 decades and managed to have a safety record a damn sight better than that which is floating round GA?

The arguments against cadets in the real world (with hard facts based on the last 50 years of flying) outside smallminded Aust or NZ doesn't really stack up I'm afraid.

Some people on this forum need to get out a bit more. The anti-cadet thingy that only occurs down-under has to be a product of inbreeding and isolation.

[Captain Can't]

Can someone explain why Lufthansa and BA have used cadets for the past 5 decades and managed to have a safety record a damn sight better than that which is floating round GA?
ummm equipment, maintainence and operating conditions??? i'm sure the list goes on... but a dud is a dud is a dud... be it cadet, military, GA etc...

[blueloo]

To be labeled a dud for a 1 off mistake be they cadet, GA or military is somewhat harsh. Everyone makes mistakes - its only human to.


Lets just hope they learn, and indeed, we all learn/benefit from something (a tragic outcome) which luckily didnt happen .

[Captain Can't]

blueloo,
point noted. It was not my intention to label this crew as a dud... just trying to make a point about the round-about circle that cadet-bashing takes.
:ouch:

[wing_nut]

Regardless of the Cadet issue which seems to be causing some people problems. I question the validity of an FO not holding an ATPL in an aircraft of 5700KG or greater.

The_Cutest_of_Borg says that:

ATPL is not required for short haul FO's in QF because they, unlike their LH counterparts, are never required to act in command of the aircraft i.e. when the captain is on a break

This is a very interesting statement because just three years ago or thereabouts the Adelaide Advertiser reported that a Captain in a Qantas B737 became incapacitated on an approach into Adelaide (chest pain?) and the approach and landing was executed entirely by the FO while the Captain was attended to. I would say that in this case, the FO suddenly was “in Command” of the aircraft!

So, does that mean that if an FO has only a CPL, the CASA God’s would say “Bless you my son (or daughter) you now have a temporary ATPL to operate this aircraft above 5700KG until you land it”!

No doubt, the Insurance companies and lawyers for the SLF would think differently, if an accident occurred. As it is, Insurance companies now dictate qualifications and experience required to many operators. I bet they don’t know about Qantas using non-ATPL pilots as FO's in their aircraft?

[b55]

I believe that Qantas is self insured. Is this correct?
Flight time does not equal experience and experience does not equal safe. But in the end, give me up front, two experienced pilots following their S.O.P.'s, and giving their full attention to what they are doing over two 4+ cadets following their S.O.P.'s and giving their full attention to what they are doing.

[Keg]

I had the requirements for my ATPL for two or three years before I actually got around to getting the magic letters put onto my license! I mean seriously, it's not like you do a seperate test or anything. It's not like you're assessed differently whether you have a CPL or ATPL. The expectations of performance are the same, the checks are the same, the sack if you don't perform is the same. Lots of ATPL holders haven't got through the checks whilst cadets have and viccy verka.

What I find funny about b55's comments is that 'experience' and 'cadet' is obviously mutually exclusive. At what stage does a pilot 'cease' to be a cadet and then become 'experienced'. Never? :suspect:

All i want is well trained and appropriately experienced pilots. I couldn't give a stuff where they learnt there trade 5-10 years ago! All I care about is how they perform NOW! :*

[b55]

Keg,
I didn't say "cadet" and "experience" are mutually exclusive. Please read my 3rd sentence again slower.

[Captain Can't]

wing-nut
read your CAOs... you need an ATPL to be in command of RPT... etc... etc... not to be a F/O in the outside case that the skipper is going to keel over. If there were liability issues following an incident, they would rest on the CAOs, not QF. All it means i guess is, that if the skipper does cark it, if you don't have an ATPL you can't log the CMD time! :}

[wing_nut]

Capt. Can't

You've mis-read my submission completely. I'm quite aware of what the CAO's state and fully aware that you don't need an ATPL to act as an FO.

However, I am suggesting that problems could arise where an FO does not have an ATPL and is required to assume command for whatever reason leaving the door open for possible legal action in the event of an accident.

[Captain Can't]

and wingnut,
you've missed mine.... how could a carrier be liable if they are covered (completely) by the regs/CAOs??
they'd be up against the government... good luck with that!

[haughtney1]

Captain Cant....

I have to disagree with your comments re: Equipment, maintenance..operating conditions...

Are you seriously suggesting Oz is a more difficult environment to operate in than Europe? (IMHO thats rubbish...Ive operated in both)
As far as equipment is concerned OF..VB..and the rest operate A/C that are every bit as capable as their BA..and Luftwaffe equilvalents. In terms of maintenance..well it depends who you talk to...so I dont know about that!
Perhaps your comments were tounge in cheek, it is my experience however that your first two points are inaccurate.

The big thing that came out of this report for me seems to be the lack of CRM..just at the time when the crew should have been extra vigilant..given the time of day (we are all taught about times of peek arousal...and the times to be aware of our frailties) sadly in this case it was not evident...and they were VERY lucky to get away with it.
We all make mistakes........thats why the Guy/Gal next to you crosschecks during critical phases of flight.

Just my thoughts.

:ok: H

[Captain Can't]

haughtny,
my statement was a direct comment on stillalbatross' post which was along the lines of
Can someone explain why Lufthansa and BA have used cadets for the past 5 decades and managed to have a safety record a damn sight better than that which is floating round GA?
where stillalb compared Luft/BA cadet safety record against GA... I was not in anyway comparing operating a jet in aus to europe... or did I miss something???
:confused:

[blueloo]

b55

But in the end, give me up front, two experienced pilots following their S.O.P.'s, and giving their full attention to what they are doing over two 4+ cadets following their S.O.P.'s and giving their full attention to what they are doing

I agree with Keg here, when do the Cadets become experienced and not considered cadets?


Surely if your sentence wasnt mutually exclusive it would have ended at the first 'doing'.

[haughtney1]

OOOOOppps sorry Captain...my mistake..apologies

(Hanging my head in shame......just dont tell the Missus I was wrong or I'll never hear the end of it!):rolleyes:

[b55]

blueloo,
New (cadet) pilot and experienced are not mutually exclusive. A cadet pilot who has had a real in-flight fire is now more experienced at that type of event than a 20,000 hour pilot who has not had a real in-flight fire.

My understanding of "experienced" pilot is one who has been constantly exposed to the James Reason "Swiss cheese" model for a time that has given that pilot a broad range of small and/or large abnormal events and even just recognition of various uneventful "swiss cheese" holes and then learning from those events.

Experience itself has its limitations. The next time that cadet pilot has an in-flight fire, all the circumstances will be different. We never stop learning until we stop flying.

[Brian Abraham]

The trick is to fill the bag of experience with out emptying the bag of luck.

EGPWS – Even Good People Will make an error Someday

And I admit to being involved in a near CFIT at the 20,000 hour point in my carreer.

[Raider1]

Good for you Brian in admitting it. After all we are all only human.
My point with the original post was simply so everyone could learn from the experience. I dont blame the crew.
If anything I would make mild critisism of the ATC set up. After all if early AM flights are approved into Canberra.......appropriate back up should be available to ensure a fail safe system.
:D