3 years later The Mildura report

[ozbiggles]

3 years later the ATSB final report finally appears.
Cover page - First safety message. Pilots are reminded of their responsibility for collecting all relevant information to support inflight decision making...
Qantas did that and ended up in the situation they did.
The report says the forecast was inaccurate in terms of significance and length of the fog at Adelaide and the Mildura met wasn't accurate either.
I have a feeling this report will make the Norfolk report look like a Shakespearian classic.

[UnderneathTheRadar]

Link:

Investigation: AO-2013-100 - Landing below minima due to fog involving Boeing 737s, VH-YIR and VH-VYK Mildura Airport, Victoria on 18 June 2013 (http://www.atsb.gov.au/publications/investigation_reports/2013/aair/ao-2013-100/)

[rexxxxxy]

Nothing to see here.

This occurrence has highlighted the effect of various factors coming together to create and influence a rare event.

The VA 737 landed with less than 15 mins of fuel and essentially no one stuffed up (not BOM, not ATC, not Crew, not Ops Control/Dispatch). :cool: - and if it wasn't for the QF skipper taking extra fuel they would have been in the same boat...

What is wrong with the ATSB?!!

http://i.imgur.com/hRJpFy4.jpg

When will we be like the rest of real world and carry technical alternates.:ok:

[TBM-Legend]

and if it wasn't for the QF skipper taking extra fuel they would have been in the same boat...


Well the fact is that the QF captain DID take extra fuel so he was not in the same boat!

[rexxxxxy]

http://i.imgur.com/r8vtK5k.jpg

[framer]

From the report:
The availability of a code grey forecast is unique to Australia, and is used to highlight the possibility of weather conditions that airline operators may wish to consider in terms of flight planning.
How are code grey forecasts promulgated?
Can a crew look at them on the internet or is it only available to Airlines?

[ozbiggles]

3 years to tell us what the aircraft did, nothing new from the interim report.

This was an opportunity for a top down dissection of how business Is done in this country. Two aircraft from different companies ended up on a country airstrip conducting emergency landings and the conclusion is they should have been getting more regular updates on inaccurate forecasts?

What about the infrastructure? All modern jet aircraft can auto land, in fact the report mentions when emergency autolands have saved us in the past. No recommendation to mandate it at capital airports at least? The bean counters will tell you it's not statiscally significant to warrant the expense but how many times has it saved the day already?

The NOC, National Operations Centre. What the hell does it do, it seems to have got involved right about the time both aircraft were in the circuit area at Mildura. Shouldn't the NOC be the centre of knowledge and information for these types of unfolding events or is it just somewhere in Canberra to sit and drink coffee? Surely we should have a central point for ASA,BOM, major airlines to co-ordinate unfolding scenarios so all the missed opportunities that occured here don't happen?if not why not?

ASA who the hell decided that not passing on SPECIs wasn't going to cause any real problems? That if they can only get that information within visual range it wouldn't be an issue. What the hell is going on there with risk mangement and what other chocolate eggs are hidden?

How did it happen the AIP didn't reflect the intent of the change at ASA? Where else is this a problem. How come the majority of the pilot group didn't know this was the intent?

This just on the first read, I'm sure there is more

How did it happen they had to ask CASA for an interpretation of inflight fuel requirements? Haven't we sorted that out in 100 years of flying.

Nothing on if current fuel policy is appropriate or what other countries might use.

We did cover the big issue that the air ambulance pilot didn't start his radio call with Airep, glad that made it in.

[ratpoison]

When will we be like the rest of real world and carry technical alternates.
Probably when parasitic corporate bean counters stop running flt ops. :rolleyes: I would advise not to hold your breath.

[ozbiggles]

This report should have been a good chance to begin a move to mandate it. But it didn't touch that elephant in the room. That would have been a bit bold. Unless it's mandated the inmates will continue to run the asylum charging $1 tickets....checked baggage not included. Surely fuel policy and facilities should have been the main thrust of this report. Forecasting is a black art, getting lost in the aviation world. It will never be 100% therefore the risk controls would be fuel, facilities and timely supply of bad news...but we did find out the air ambulance pilot didn't say Airep....

[hotnhigh]

When will we be like the rest of real world and carry technical alternates

They did.....Mildura

[Capn Bloggs]

How are code grey forecasts promulgated?
Can a crew look at them on the internet or is it only available to Airlines?
Forget it, Framer, AIP SUPP 65/16 finishes off Code Grey, that forecast that shall not be mentioned... Come to think of it, a coincidence? As is the push to turf the TTF?

Given what's gone on here (inadequate forecasting), a technical alternate should be an airport with an ILS. Then at least you've got a chance of getting in doing an autoland somewhere.

[Oakape]

TBM-Legend, do you have level 6 English?

Hotnhigh - a technical alternate doesn't get you there with 15 mins of fuel. They didn't have an alternate of any sort & used contingency, FR, and any extra above the plan that they loaded.

[Capt Fathom]

They didn't have an alternate of any sort
What alternate do you suggest they should have carried?

[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?

[JamieMaree]

Code Grey covers the situation where all the met criteria does not generate the forecast of fog neither real or the possibility thereof. If there is a remote chance of fog occurring based on aches in grannies bones or the ants are stirring or any other meteorological condition, then a cOde Grey is issued by BOM. (In the old days BOM used to issue forecasts with prob 5% or 10% fog to cover grannies bones but these days the criteria is that if the chance is less than I think 30% then fog is not mentioned).
The concept was introduced by QF and fuel policy dictates that fuel for an alternate must be carried from a pre- flight point of view when there is a code grey.
Not sure how many other airlines use it , if any.
QF uses it because lots of flights don't carry alternate fuel if the weather forecast doesn't demand it.

[hoss]

For that airport, at that time of day, at that time of year = MEL + fixed reserve at a minimum. (and that's before I check the WX and NOTAMS)

Totally inexcusable!

[Keg]

QF doesn't use code grey anymore. We use OPRISK instead. Different criteria but in this sort of event the intent is the same.

[framer]

By the looks of the report these crews carried the fuel that the regulator and their own companies required them to carry or in the case of the QF crew even more, but then we're faced with the situation where the forecasts and the observations were not accurate for not one but two airports. Even being set up like that they both got their aircraft safely on the ground. You can bet your bottom dollar that the next time they see a one degree split with less than five knots of wind they will take full alternate fuel regardless of what the met guys and flight planning guys say. Hopefully many others will too.
In spite of the ATSB folk preaching to pilots about getting weather updates most would have to agree that the system failed and the pilots successfully dealt with the unusual situation.

[neville_nobody]

If Australian Capital city airports had CAT II or III facilities like every other capital city airport in the world it would have been a non starter. Given the amount of money generated by airports in fees and charges this woeful lack of infrastructure is ridiculous.

[Capt Fathom]

For that airport, at that time of day, at that time of year = MEL + fixed reserve at a minimum

How do you know MEL will stay available as an alternate? You just cannot plan for every contingency.
If the flights involved had continued to Adelaide, it would not have been an issue.

[hotnhigh]

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.

[megan]

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).

[neville_nobody]

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.

[megan]

Thanks Neville, just read the report and it spells it out. Magnificent job by the crews.

[Lead Balloon]

[T]he crazy thing is, the exact same thing could occur tomorrow morning.Not "crazy". Just ops normal in a third world aviation nation.

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.

[framer]

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

No you aren't expected to carry on, you are expected to have loaded enough fuel to ensure that at all times in flight you have fuel onboard that is;
- 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.

[Pakehaboy]

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.

[donpizmeov]

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.

[BuzzBox]

fpvdude:
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?

It's been a while since I've flown under Australian regs, but isn't it covered by ENR58.2.4?

"58.2.4When 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)."

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.

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?

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.

[Squawk7700]

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

I was advised first hand that the aircraft suffered damage to the fuel system / pumps to the point that spare parts and a tech crew were flown out to repair it before it could go anywhere. Apparently fuel exhaustion in the pumps will cause this...

[Old Akro]

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.

[CurtainTwitcher]

but it should be remembered that Adelaide airport is not certified for autoland
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.

[framer]

So, my reading is. Pilots: OK. ATC: OK rules & procedures: big question mark. Infrastructure: big question mark. BOM: question mark.
I'm with OldAkro as per above.
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.

[rjtjrt]

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.

[neville_nobody]

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.

But only in CAT I conditions or better.

B) Divert to the 'suitable airport' as per the regs and their own Airlines exposition.

As far as I read it, at the time the decision was made and the information available to them diversion was the only option.

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.

But how much more? Full fuel?

[Old Akro]

Surely the main take home message from this is it all would have been a non event if they carried more fuel.

How long is a piece of string? How much fuel is enough? Both carried more than CASA regs or their companies policies required.

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??

[Jetstarpilot]

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:mad:

[BuzzBox]

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.


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?

[Old Akro]

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

You bastard! I was wondering if anyone would pick that as I was typing it!! It just sounded better from Paul Newman.

[neville_nobody]

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?

Not sure of the requirement you mean. When they diverted Midura's TAF was SCT cloud.

[BuzzBox]

Er, no it wasn't. If I'm not mistaken, the 1800/1812 TAF showed SCT cloud, but the aircraft's ETAs for Mildura were 2332Z and 2342Z. The 1718/1812 TAF that was valid for the ETAs read "TEMPO 1719/1724 BKN006".

[neville_nobody]

Check out page 65 of the report.

TAF YMIA 172302Z 1800/1812
20008KT 9999 SCT030 SCT050
RMK
T 08 12 13 10 Q 1020 1019 1019 1020

It went bad when they were enroute.

[framer]

Neville Nobody As far as I read it, at the time the decision was made and the information available to them diversion was the only option.

I probably didn't write it very clearly but I agree with you. I was trying to point out that the options they had were A) do something illegal or B) divert to a suitable airport.

[BuzzBox]

neville_nobody:

Yes, but that TAF was only valid from 18/0000Z. The aircraft arrived at Mildura at 17/2332Z and 17/2342Z respectively, so they had to use the earlier TAF. That earlier TAF had a TEMPO period for low cloud below the alternate minima between 1900Z and 2400Z. See page 62 of the report.

[Icarus2001]

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.

There is a legal grey area here. Has it been tested in court?

[BuzzBox]

I have no idea, but CASA doesn't seem to think it's a 'grey area'. From the ATSB report:

"CASA clarified that there was no ‘strategic difference between an in-flight scenario and a pre-flight plan’ in relation to the use of forecasts.

In relation to the use of observation reports for in-flight planning, CASA noted that ‘weather observations are not a legal instrument to determine if an alternate should be held or for fuel planning, unless the observation has a trend appended to it (eg TTF…)…’."

[CurtainTwitcher]

Icarus, there is an even more difficult scenario where you hold enroute first due to weather at the field, does this time count towards the INTER/TEMPO period? ie where is the actual INTER/TEMPO holding required? For example, I've held at TOJAM for 40 minutes, then CG for another 30min, then proceeded to BNE, which still had TEMPO requirements.
Have I satisfied my TEMPO holding requirement? Do I still need the additional holding fuel in the BNE terminal area? Its not clear to me.

[Capn Bloggs]

There is a legal grey area here.
I'm surprised you'd ask such a question. What's logical, safety-wise? Say even on a short sector, you depart for a place that has an Inter; you're not carrying a "proper" Alternate but have your 30 minutes, just. Half way there, the forecast goes to Fog (or Tempo 95TS). Logic surely says you now do not have the required fuel, and you must go somewhere else to top up (if you can). If you can't, then obviously press-on and become a Mildura statistic, hopefully with a satisfactory outcome, although you wouldn't have a leg to stand on in court if you could have diverted but didn't.

Curtain Twitcher, I would say if the forecast says Tempo, that's what is needed for the weather, nothing more. If you were the only aircraft in the sky, then the extra holding you required constitutes a f-up on BoM's part. If you were being held up by numerous other aircraft, then ATC has stuffed up because they didn't correctly predict the traffic holding.

It's about time the "system" started taking responsibility for the issues brought to light after this almighty stuffup. What would have been the consequences had the DJ 737 landed in the drain, or worse, on the tarmac??

[BPA]

Squwak7700, your first hand information is not that good. A replacement crew was flown up from MEL, with the engineer and replacement FDR due to the ATSB requiring FDR on the aircraft.

Once they FDR was replaced the aircraft flown back to BNE that afternoon.

[Capt Fathom]

I was advised first hand that the aircraft suffered damage to the fuel system / pumps to the point that spare parts and a tech crew were flown out to repair it before it could go anywhere. Apparently fuel exhaustion in the pumps will cause this...
Did it say somewhere in the ATSB report the aircraft experienced fuel exhaustion?
If fuel exhaustion damages the fuel system, how do aircraft with multiple fuel tanks get by when they run tanks down. In fact, doesn't the 737 have an auxiliary tank?

[Keg]

I've held at TOJAM for 40 minutes, then CG for another 30min, then proceeded to BNE, which still had TEMPO requirements.

It depends on why you were holding. I reckon the TOJAM hold isn't part of it but the CG hold may be depending on whether there is a TS at the field causing aircraft to hold or too many aircraft for the airspace. if it's the latter then you still need the 60 min for mine.

[BuzzBox]

It could also be argued that the INTER/TEMPO holding fuel requirements are only intended to cater for inaccuracies in the weather forecast. They provide some protection in case the weather is worse than forecast and ends up below landing minima, preventing the aircraft from landing. In that light, the enroute holding has no bearing on the destination holding requirement. The INTER/TEMPO holding fuel should therefore be available until the aircraft is close to the destination and likely to land within the 30/60 minute period.

Some interesting reading:
https://www.atsb.gov.au/media/32921/b20040246.pdf

[*Lancer*]

At what point specifically is TEMPO fuel no longer required?

If your fuel policy requires 60 min at 1500' over the airport, then after holding for 60 mins at any point prior to the FAF you will fail to meet that requirement.

So where is the cutoff? When can you commit?

[BuzzBox]

It's not specified, but I'd say you can commit once you're close to the destination and can confirm you're able to land within the 30/60 minute period. The ultimate requirement is that you land with fixed reserve intact.

Earlier post edited for clarity.

[wondrousbitofrough]

Ok, so I'll ask this as someone who is in the industry, but doesn't sit behind the control column. To those that do, do you have any confidence that this can't happen again?

[BuzzBox]

Nope, but hopefully we've all learnt to be a bit more sceptical about the absolute accuracy of weather forecasts, especially if we're on the bones of our ass for fuel! Seriously though, I think this incident was a big wake up call for the 'system'. The ATSB identified several areas where the pilots were let down, including the accuracy of the weather forecasts and the provision of SPECIs to aircraft in-flight, especially in situations where crews have to make rapid decisions under high workload. It's impossible to guarantee that an incident of this nature won't happen again. I think the best we can hope for is that we've learnt a few lessons and that the likelihood of a recurrence has been reduced.

[Keg]

So where is the cutoff? When can you commit?

This was an interesting couple of hours during command training. :ok: :}

[hoss]

Re: wondrousbitofrough

This will happen again.

It has been happening for years, plenty of reports out there!

As long as we have 'rule based thinkers' and decline in basic airmanship this will continue.

SOP vs Absolute Standards

[Icarus2001]

Originally Posted by Iccy
There is a legal grey area here.
I'm surprised you'd ask such a question.

It was not a question. Is there a question mark?

[Old Akro]

Nope, but hopefully we've all learnt to be a bit more sceptical about the absolute accuracy of weather forecasts, especially if we're on the bones of our ass for fuel!

I trust this is a general statement rather than an assertion that these 2 aircraft were "on the bones of their ass for fuel". They had reasonable fuel for both holding and alternates, but were basically suckered into going somewhere inappropriate by a bad forecast and a system that did not reasonably pass on pertinent information to the pilots in command.

I would suggest that if they had any awareness of the real weather at Mildura, that they would have made different diversion choices. The ATSB report notes discussion in the cockpit of Woomera as an option, although since the Airforce took control of Woomera from the Department of defense it may no longer meet the operational requirements for emergency response. Which raises another area where Australia is descending into the third world.

[BuzzBox]

Relax, it was a general statement, not intended to cast aspersions about the fuel state of the aircraft involved in this incident.

[Capn Bloggs]

Seriously though, I think this incident was a big wake up call for the 'system'.
You reckon? This morning, the joint had fog until 00. Then, at 2330 (us and others already enroute), BoM amends the TAF and puts on an Alternate until 0100! Not good enough! Reactive forcasting at it's best, just like Mildura.

Iccy, whatever. Maybe I should have just said "any person with half a brain would say it is not a grey area". Happy?

[BuzzBox]

Bloggs,

I said it was a "wake up call". I didn't say the problem had been solved.

Forecasts will never get to the point where they're 100% accurate, especially when it comes to fog. At the end of the day, it's the forecaster's "best guess" and they won't always get it right.

So what's the solution? Should we always carry an alternate like they do overseas? Frankly, I'm disappointed the ATSB didn't at least consider that aspect during its investigation.

[Di_Vosh]

hopefully we've all learnt to be a bit more sceptical about the absolute accuracy of weather forecasts

This is probably the most appropriate practical lesson for pilots.

In my relatively few years of RPT flying (8 at Qlink) I've noticed a significant degradation in the quality of the weather forecasts, especially at Melbourne.

It seems that almost every other month fog appears on the YMML TAF which wasn't forecast only eight hours prior. The last time it happened, I'd also checked the BOM website and the Melbourne forecast was for "Patchy fog in Northern and Eastern suburbs" but the YMML TAF had nothing at 10:00pm. 0500 the next morning: Fog.

On other occasions I've departed YMML (ML TAF with nil significant weather) for a Devonport return. Update NAIPS on the ground at DPO only to find INTER or TEMPO for Thunderstorms back at Melbourne.

Reactive forcasting at it's best

Agreed!

DIVOSH!

[Toruk Macto]

Think unions / associations should approach virgin cpt to see if he would be interested in giving some talks to pilot groups ( Sully style ) about company flight plan fuel and how he feels about it ?

[rexxxxxy]

the new non-pilot Dir of Flight Operations @ virgin will fix this ;)

[Squawk7700]

Did it say somewhere in the ATSB report the aircraft experienced fuel exhaustion?

If fuel exhaustion damages the fuel system, how do aircraft with multiple fuel tanks get by when they run tanks down. In fact, doesn't the 737 have an auxiliary tank?

No it didn't. The fuel in specific tank(s) went below the usual operating level.

Think back to https://en.wikipedia.org/wiki/TWA_Flight_800 (TWA Flight 800) - since this event, centre fuel tanks of the early 747 series are never run dry. Somewhat relevant.

[donpizmeov]

Not relevant at all squawky. Any pumps that were dry on this landing would have been dry on a normal landing. The pumps that were working were just a bit shallower than normal. Your mate told you porkies.

[framer]

On the NG we run the Center tank pumps until the low pressure lights flicker of the gauge reads zero. It causes no damage.

[CurtainTwitcher]

Buzzbox, thank you for the link, I am making my way through it, and this section caught my eye:
The use of en-route weather reports for updating operational decisions as a potential risk mitigant was examined to assess their capacity to provide a timely en-route warning that the destination weather would prevent a safe landing from being assured, thereby enabling an early diversion to an alternate airport.

The comparisons in this study suggests that the use of Australian rule sets alone to assess the risk of deteriorated weather at a destination airport by themselves does not ensure a level of safety as described in the International Civil Aviation Organization Continuing Airworthiness Manual. The fact that there have been very few serious incidents or accidents associated with landing at a destination with unforecast deteriorated weather, suggests that one or more other factors are also reducing risk. From this it may be suggested that although other risk mitigants appear to be effective, they may not be known or consistently managed.

ATSB document: Destination Weather Assurance, Risk associated with the Australian Operational Rules for Weather Alternate Minima (https://www.atsb.gov.au/media/32921/b20040246.pdf), page VIII

The assumption that "timely en-route warnings" will be passed on to crew(s) as a mitigator goes to the heart of this incident, I also note this document was published in 2006.

[morno]

I learnt that the reliability of forecasts in this country were somewhat dubious after departing for an aerodrome with only a TEMPO for rain on it, and after my second missed approach after waiting about 45mins between approaches, to then have the forecast on it and all my other alternates around it, be changed to require an alternate and neither of them any better than my destination aerodrome, even though they all had a very similar forecast to begin with.

Thankfully the final approach now on min fuel resulted in a landing.

The BOM I feel does the best job they can with the resources and funding they have. Having their funding cut more and more and therefore the inability to dedicate more money towards better technology doesn't help their cause.

morno

[Icarus2001]

Thanks for the laugh Capn Bloggs.

So using your late forecast change with fog as an example, requiring an alternate as you said (was holding fuel okay?). There you are inbound to Perth in your B717, passing through transition on descent, flying the star. The Bumet in their wisdom add some requirements that you were not aware of when you departed Paraburdoo.

Q1 How are you going to know about it? Do you hear approach read out new TAFs very often?

Q2 If you did know by some method, ACARs etc, and you DO NOT have the extra fuel but you can see bloody field, what would you do?

Q3 If you land are you "legal"?

Q4 Will you report yourself.

Happy Days

[le Pingouin]

A forecast is based on probabilities. Just like at Randwick the low probability event occurs a commensurate amount of the time.

[BuzzBox]

CurtainTwitcher:

You're welcome! That Research Report has some interesting findings that are as relevant today as they were 10 years ago. Of all the risk mitigators they analysed, it's probably no surprise that the requirement to always carry an alternate provided a significant reduction in risk. From page 29:

"The requirement to always carry fuel to fly to at least one alternate was tested, and demonstrated a marked increase in safety. However, the numbers of events that met the criteria were sufficiently low that it was not possible to make any statistically significant analysis beyond stating that this requirement does create a significant reduction in risk.

The Australian operating environment is different from many parts of the world where a similar operational requirement is used, both because of its more benign operating environment, and because of the larger distances than normally exist between suitable alternate airports. These factors could both reduce the perceived need to make a requirement for the mandatory carriage of fuel for an extra alternate, and to make such a requirement more onerous with a greater fuel uplift."

[UnderneathTheRadar]

Surprised nobody has commented on this:

In order to use Mildura Airport as an alternate, the forecast cloud and visibility were required to be above the alternate minima. The alternate minima for runway 27 at Mildura for large jet aircraft were 1,233 ft and 6 km if the forecast QNH was used. This could be reduced to 1,133 ft if the actual aerodrome QNH was used (see below), although the visibility requirement remained at 6 km.

WTF? - if I flight plan to an airport and look up the current actual QNH then I can reduce the alternate minima by 100 feet? I plan alternate minima based on runway I might be using? Who writes this crap?

UTR

[UnderneathTheRadar]

As a non-RPT pilot who regularly makes the decision to stay home on crappy days (not that this would have been one of those days), I was thinking about the decision process regarding a) do I go to Mildura or b) autoland below minima at Adelaide.

The logical wisdom on this thread has been that continuing to Adelaide for an autoland (presumably after holding) for as long as possible would have lead to tea and biscuits.

I wonder if anyone would do things differently now compared to before this event?

The other related point that I don't think has been discussed is the decision to divert to Mildura. As I read it, from the time of deciding to divert at 0904 and 0913, both crews had a TAF for Mildura which indicated TEMPO below the alternate minima and to within 100ft of the landing minima. The report doesn't indicate if, at that point, they had enough fuel to legally plan to Mildura - i.e. with 60 minutes holding fuel or to hold until 0030/1030 (30 minutes after the TEMPO finished)

It appears that QF735 did (but maybe not as they did call fuel and push in ahead of VA1384) but it's not clear for VA1384 - they didn't hold for an hour but they also did one full missed approach which would have used some of that holding fuel. I didn't notice anywhere the report indicates how far into the fixed reserve they were.

Based on the assumption that there wasn't sufficient fuel for one or both to legally go to Mildura, the report indicates that they did based at least partly on the METAR for Mildura. Technically, I would have though that diverting to an airport for which you didn't hold legal flight plan fuel would justify a PAN PAN. Had the PAN call gone out, I can't help but wondering if the focus of ASA and BOM might have been drawn towards the situation more than it was (the NOC certainly would have woken up). If MALEE controller knew a PAN aircraft was heading for Mildura, it would be reasonable to expect that the AIREP would have been passed on immediately. If the Alert phase was up and running earlier the BOM observer at Mildura might have been aware of it and their observations might have been made earlier or sought out specifically with VA1384 in mind.

So while I agree with the sentiment that both crews were let down by three main factors - poor forecasts, exacerbated by poor information management (from ASA) once it appeared things had gone to custard and inadequate infrastructure (ILS and a working AWIS at Mildura, CAT2 at YPAD) - I think the crew of VA1394 also let themselves down by not raising with ATC (or their company?) that they were being forced to divert somewhere that they probably shouldn't have been.

Finally, I put all that together with my original thoughts - would those crews (or others) do the same again? The report calculates that both could have changed plans again and gone back to Adelaide once they received the first SPECI. What would I have done/would do?

I suspect that this report and this thread would be very different had the outcome have turned out not so well.

Other key factors which I don't think have been considered are:

1. When should VA1384 ideally have become aware of the fog at Adelaide? As I read the report, the TAF they had was the same one they planned at Brisbane with. They ended up at Mildura almost by default (although again, they could have/should have(?) made it to either Broken Hill or even Melbourne - we don't know the forecasts for these locations except that Melbourne also wasn't good but did at least have CAT2/3 infrastructure)

2. The Adelaide ATIS (via ACARS or VHF) I would have thought would have been received/receivable at or before the time they were transferred to Tailem Bend sector - potentially giving an earlier heads up to the problems ahead.

3. I've always been suspicious on the ASA policy of providing directed weather information only within an hour of ETA. Surely if a TAF amendment or observation goes to SPECI type conditions then why does my distance matter? I'm airborne and have no guaranteed access to the change. I've had this happen to me - flight plan out of Essendon on a clear TAF at Adelaide, mange to get some 3G coverage over western vic to discover a prob 30 FOG at Adelaide. Without that I too would potentially have been a VA1384 had the fog actually appeared.

UTR

[framer]

WTF? - if I flight plan to an airport and look up the current actual QNH then I can reduce the alternate minima by 1000 feet? I plan alternate minima based on runway I might be using? Who writes this crap?

No. Only 100 feet.
I think what a lot of people who write these reports, and many who comment on the reports don't have is an understanding of the mental processes going on real time for the crews when a situation like this is unfolding. It is fine and dandy to sit at a desk and flick through the regs to confirm that the crew should have technically made diversion decisions based on the TAF not on the observation.
It is a completely different thing to be doing 450kts across the ground using two tonne an hour and realising that the forecasts you based your fuel load on have been wrong and that your Plan A is not going to happen. When developing plan B information is gathered and options considered. Both crews were presented with information ( the Mildura met observation) that suggested a safe landing could be made at Mildura. At this point in time, when 'the system' is not working as advertised, real likely outcomes are more important to the crew than regulations. So they should be too, the crew have to make whatever decisions are necessary to keep their aircraft safe.
If this situation was presented to a new Captain in a simulator as a LOFT and the new Captain decided that holding in the hope that the unforecast fog cleared was a more appropriate decision than diverting to a field nearby that was reported as being open, many check Captains would debrief that as a new Captain, don't forget your primary role is to keep the aircraft safe and if you have to break the regs to do that,my then so be it.

[Squawk7700]

donpizmeov et al, replacement fuel system components were flown out the next day with a tech crew. Ask anyone at VA, it was hardly an internal secret at the time and was also mentioned in threads on this topic elsewhere.

"Damage" in the eyes of the ATSB report presumably would not include internal system components versus collision type damage.

I also heard a "rumour" that ditching was seriously contemplated...

[megan]

I also heard a "rumour" that ditching was seriously contemplated...What!!!!! In the River Murray? About the most ridiculous suggestion made, ditching that is.

When the flight service units were removed it is said that there was a marked reduction in the accuracy of weather reports, with attendant necessity to carry additional fuel to cover exigencies. And Mildura used to have a FSU.

[Snakecharma]

If I remember correctly at least one of the jets flew past Mildura on the way to Adelaide and at the time of passing was clear.

This would have, I imagine, gone some way to influencing any decisions made at the time.

Good decision making is making the best use of all available resources to inform the decision. In this instance the above would have been part of that decision making process.

I know the captain of one of the aeroplanes and he is a truly professional pilot who took his role seriously, is an outstanding individual and role model and from everything I can see got stuck in an awkward position through the confluence of events.

I would put myself, wife and kids in a jet under his command any and every day of the week.

[UnderneathTheRadar]

No. Only 100 feet.

My mistake - yes 100 feet - the point being, that the alternate minima can't be reduced with actual QNH - only the approach minima.

[Captain Nomad]

UTR, you sure about that?

"Where instrument approach charts are identified by a shaded background to either the minima titles for IAL plates or the published minima for DME or GPS arrival procedures, landing, circling and alternate minima have been calculated assuming the use of Aerodrome Forecast (TAF) QNH. These minima may be reduced by 100 ft whenever an actual airport QNH is set."
Jepp Terminal page AU-29 7.3.2

If the AWIS is NOTAMed out then obviously alternate minima can't be reduced. If it can be reasonably expected to be available, why not?

[Capn Bloggs]

When the flight service units were removed it is said that there was a marked reduction in the accuracy of weather reports, with attendant necessity to carry additional fuel to cover exigencies. And Mildura used to have a FSU.
MIldura had better than that during this event, a person actually trained in the weather:

...In response the forecaster contacted the BoM observer located at Mildura Airport.

[Squawk7700]

My interpretation of ditching = land or body of water

I guess some may refer to landing on land as crashing, controlled crashing, attempted landing, prec landing, out landing or otherwise.

Perhaps I should have said out-landing.

Either way the aircraft would be pretty much screwed.

[BuzzBox]

MIldura had better than that during this event, a person actually trained in the weather...

True, but in this case the 'system' got in the way and made the observer's input all but useless by the time the information was relayed to the aircraft. I'm willing to bet that information about the deteriorating weather conditions would have been passed along a darn sight quicker back in the good old days of FSUs.

[megan]

A met observer can be anybody delegated by BOM. It may be your local baker or candle stick maker, not someone trained in meteorology, but able to read the gauges and dials. Just down the road it's a station owner.

[LeadSled]

It may be your local baker or candle stick maker, not someone trained in meteorology, but able to read the gauges and dials. Just down the road it's a station owner.

Megan,
Don't downplay the knowledge and ability of the BoM observers, they have all completed BoM courses successfully. There is significant meteorological knowledge required, probably not much different to a PPL standard, plus the specific training to be an accredited BoM observer.
Tootle pip!!

[*Lancer*]

No one wants to take on my question? :cool:

Destination requires TEMPO or Alternate. At what point - specifically - are you not required to have this fuel? When can you commit?

(Note: If you've been holding at any point prior to 1500' overhead, you will not have the fuel at the destination)

:8 :}

[IsDon]

No one wants to take on my question? :cool:

Destination requires TEMPO or Alternate. At what point - specifically - are you not required to have this fuel? When can you commit?

(Note: If you've been holding at any point prior to 1500' overhead, you will not have the fuel at the destination)

:8 :}
That because there isn't a hard answer Lancer.

Don't be suckered into thinking it's an exact science, and there is a prescribed rule for every contingency. There isn't.

My take on it, for what it's worth, is that holding is holding. Doesn't matter if it's above the field or some nebulous point in space used as a sequencing point on the way to the field. If you require a tempo, and you're required to hold at, by way of an example, BEVLY, on the way to Perth then that's when the clock starts. You're not then required to hold a further 60 minutes of fuel just because you've had en route holding. That what the original 60 minutes is for. I've never seen an aircraft actually hold over the airfield as the holding points are usually out at 20NM or so at most major airports. If you've planned for 60 minutes of holding and you actually need more then that's were you declare min fuel and land regardless. If you have experienced yet another display of incompetent forecasting by BoM and the field is below minima for longer than 60 minutes then, with nowhere else to go, you're committed to land regardless of the minima.

That said, expect the Monday morning quarterbacks (ATSB) to pillory whatever decision you make based upon airmanship and the best information you have available at the time. Especially if doing otherwise might actually find the route cause of the issue and that route cause may lay the blame squarely at the feet of Airservices Australia or BoM or some other government organisation that might be an embarrassment to some politician somewhere. How long has it taken for this report to come out, three years? How long did the pilots on these aircraft have to make their decisions? 15 mins? Maybe less.

The discussions here so far have missed the main point of this incident. I find a lot of similarities with the ATSBs handling of the disgraced Norfolk Is investigation and report on this incident. In both cases the ATSB has deliberately attempted to deflect any blame from BoM, CASA, Airsevices or any other government agency and has tried, and failed, to blame the crew.

It wasn't so long ago that the ATSB was formed. It was perceived, at the time, that CASA had a conflict of interest when it came to investigating accidents and incidents as it may seek to hide any blame possibly attributable to its own failings. Fair enough that an independent organisation should be tasked with that responsibility. This incident, and the Norfolk Is debacle, have demonstrated that the ATSB has a way too cosy relationship with other government entitities and will seek to deflect blame from them at all costs. Including destroying the reputations and careers of the crews involved.

Time for the ATSB to go.

[megan]

When can you commit?Men don't like to commit, so the girls say.

Weather forecasting has always been a somewhat intractable problem, being half science and half art.

Remember when we had operational control? Departed with a CAVOK report in hand, only to be told enroute the destination had been closed due weather, and what were the intentions re an alternate. No fuel for an alternate, nor holding, and FSU was told so. What are your intentions was the reply. Continue to destination was the only option open, and land in the crap weather was the answer, and duly executed.

[framer]

I must be too young to remember that Megan.
What was operational control? What is FSU?

[sunnySA]

This incident, and the Norfolk Is debacle, have demonstrated that the ATSB has a way too cosy relationship with other government entitities and will seek to deflect blame from them at all costs. Including destroying the reputations and careers of the crews involved.

Time for the ATSB to go.

No, its time that ATSB was resourced correctly. The workload to complete such a comprehensive reports is time consuming. Time = money, more staff to share the workload. Then investigations such as this (and many others) are completed within a realistic and meaningful time period (i.e. 6 months maximum). I'm not privy to the number of ATC/Pilot investigators are employed by ATSB but if this report took 3 years then this means a large increase in investigators (x6).

[oicur12.again]

Do the Australian airlines have dispatchers that are required to monitor these changes and keep crews updated for every flight?

It’s a while since I flew in oz and we didn’t really have such a system back then but I assumed things had evolved?

[IsDon]

No, its time that ATSB was resourced correctly. The workload to complete such a comprehensive reports is time consuming. Time = money, more staff to share the workload. Then investigations such as this (and many others) are completed within a realistic and meaningful time period (i.e. 6 months maximum). I'm not privy to the number of ATC/Pilot investigators are employed by ATSB but if this report took 3 years then this means a large increase in investigators (x6).

What? So more money will stop the collusion?

Give me a break! That's the biggest load of rot I've ever heard.

It took three years because it took that long to cover up. So those really responsible could get their ducks in a row. When the proposed report is sent to those that should have been held responsible for their comments and amendments such that any failings can be washed from the final report to save any embarrassment for the government agency or minister responsible. That's what takes three years.

[gettin' there]

Are both crews still with their respective employers?

[Goat Whisperer]

The VA Capt retired after a long and distinguished career.

[Slippery_Pete]

This report is a complete joke.

The discussions here so far have missed the main point of this incident. I find a lot of similarities with the ATSBs handling of the disgraced Norfolk Is investigation and report on this incident. In both cases the ATSB has deliberately attempted to deflect any blame from BoM, CASA, Airsevices or any other government agency and has tried, and failed, to blame the crew.

Completely agree. Government departments spending three years getting each others' backsides covered before finally releasing the report and hanging the crew out to dry. Same as Pelair.

1. The report doesn't place enough emphasis on the seriousness. Had one or both of these aircraft's automation not tracked the RNAV so accurately, we could have been looking at hundreds of dead bodies. This was a deadly serious occurrence where the last piece of cheese which saved the day was pot luck.

2. The elephant in the room was completely avoided - still CASA allows RPT to plan to a remote single runway destination.

3. The quality of the forecasts has dropped so much in twenty years. BoM understaffed - quite possibly, but get it fixed. I don't expect forecasts to be 100% all of the time, but last five years they've been a joke. "Fog forecasting is hard" in the report... No ****!!! But they used to get it right twenty years ago, why not now?

4. How long was the VOR AWIS not repaired? "Months" is the rumour I heard the other day. Why wasn't it fixed? Why did it happen to get fixed within a day of the incident occurring? Why didn't the ATSB mention this? What a huge cover up!! Had it been working, at TOPC out of Adelaide, the crew would have tuned in and realised Mildura was turning to crap. They could have turned around and done an autoland. FIX YOUR EQUIPMENT, ASA. This is why airports are forced to install their own AWIS VHF - ASA don't want the liability and cost of maintaining navaid AWIS, they're washing their hands of it.

5. Why do we only have one cat III ILS in the entire country? Mildura takes bunch of high capacity RPT every day. Why doesn't it have at least one or two ILS?

ATSB - complete joke, have lost all respect, in bed with regulator.
BOM - give them the money they need to get the forecasts right
ASA - stop wasting money on bull**** and spend it on infrastructure, like ILS and AWIS and maintenance
Pilots - do exactly what we were doing thirty years ago, with half the support, half the navaids, half the fuel - with the knowledge that if all the holes line up, you'll get hung out to dry by the ATSB.

[puff]

oicur - in regards to dispatch in Oz, both QF and VA(and TT) are the only operators with 'real dispatch' in the full sense of the word in that it's a department that does both flight planning, and flight watch. JQ used to have it, but they now have a mixed model where their flight plans are done by a contractor in the Phillipines, and they have a Co-Ordinator in Oz that does any late min changes, and flight watches the EDTO flights. All other operators as far as I am aware, their pilots do their own planning, and they have no form of flight watching.

As far as CASA go - they pretty much let it be a self regulation as such, the only legal requirement is that all EDTO(ETOPS) flights are dispatched under the requirements of the companies policy, and that they are flight watched. As far as I am aware, JQ tried to totally outsource dispatch, but ended up having to hire the 'co-ordinator' to flight watch their EDTO plans.

As per the report, at the time both QF and VA only had a policy that non EDTO plans and in the VA case flights below 3 hours were flight watched and info passed on on a workload permitting basis, however VA now flight watches all flights. I believe that VA flights are the only ones that are totally flight watched out of any RPT aircraft in OZ.

The US mandates that all operators of RPT ops have a flight dispatch department, with flight following, and all people working in these departments are licensed by the FAA, and have to pass exams which are ATPL in nature. Australia has no licenses, but VA and QF have some internal testing , but again nothing mandated by CASA.

As stated in the report also - both VA and QF have their own Met department as well.

[framer]

Did either of these crews receive any sort of recognition of a job well done?

I've had a quick read of the report but will go through it more slowly next week, from what I have read there were several statements that could be read as an admonishment of the crews actions but no statements recognising that they achieved a safe outcome despite being set up by years of cost cutting projects in various departments and a dose of bad luck.

[Goat Whisperer]

Yes, framer, they received much recognition. They won the CEO award for safety and the overall CEO award, and were flown to London (or was it Necker Island) for a function with Sir Richard and similar award recipients from other Virgin businesses.

[framer]

Great to hear. All is not completely wrong with the world then :)

[Chris2303]

Reactive forecasting was known as "pastcasting" in my day.

[IsDon]

Reactive forecasting was known as "pastcasting" in my day.
Also know as "ass covering" Chris.

Can also be applied to fixing an AWIS, which was U/S for a month, the day after a major incident.

[pistenbroke]

A number of posts as well as the report mention the crew could have done an Autoland in the low vis conditions. Whilst it might be an absolute last resort option it carries a large risk.

There is a very good reason why an airport is only classified Cat 1 and not Cat 2/3. It is not a "free get out of jail card" as many pilots seem to think. It has a large risk associated with it, namely it is not guaranteed to deliver the aircraft to the correct position on the runway.

Australia is about the only country that I am aware of that allows "practice autolands" to Cat 1 runways. It was not permitted when I was operating O/S. All autolands in whatever met conditions were only permitted on certified Cat 2/3 runways.

[Pakehaboy]

Quote...."Australia is about the only country that I am aware of that allows "practice autolands" to Cat 1 runways. It was not permitted when I was operating O/S. All autolands in whatever met conditions were only permitted on certified Cat 2/3 runways."

We do them Into KPHX Rwy 26..... Authorized in VFR conditions only.....there are about 5 others in the system.

[BuzzBox]

Australia is about the only country that I am aware of that allows "practice autolands" to Cat 1 runways. It was not permitted when I was operating O/S. All autolands in whatever met conditions were only permitted on certified Cat 2/3 runways.

I work overseas and we have approvals for autolands at a good many airports that only have Cat I runways, and most of them AREN'T in Australia. In fact, our SOPs recommend an autoland any time the vis is below 1,500m or cloud base below 300ft, assuming the runway is autoland approved.

[IsDon]

If the crew had of decided upon an auto land in ADL (of course that option was taken away from them once they were misled by BoM, a U/S AWIS and ATC into a diversion to MIA) they would have no doubt been criticised, once again, by the Monday morning quarterback (ATSB).

While not technically legal, given the circumstances, an auto land off a Cat 1 ILS is a far better option than landing below minima off an RNAV non precision approach. Could you imagine the outcome of this incident had it happened during the days before runway aligned RNAV approaches? I doubt a landing off a VOR approach would have ended as well as it did. Although, in the days before GPS we also has a far more robust system of competent ATC/BoM and functioning infrastructure such that this incident probably wouldn't have happened in the first place.

The crux is, whatever decision made by the crew, they will always be criticised by a regulator more concerned with deflecting blame from its cosy mates in other government agencies rather than finding and fixing the real causes.

I think we here are all in agreement though that the crews of both aircraft did a remarkable job, in extremely stressful conditions which were not of their own making, to safely deliver their aircraft, crew and passengers to terra firma. I'm sure those on board are grateful of your skills.

[framer]

Well said IsDon.
It is good that Virgin recognised the good work their crew did.
Did QF do anything for their crew? Anyone know?

[Capn Bloggs]

Odd that the report was quite detailed about what happened in the Virgin 737 fuel-wise (and FDR/CVR) but not a word on the QF operation, save the original departure fuel and expected burn, unless I missed a bit...

[Slippery_Pete]

Pistenbroke,

I don't think anyone on this site or otherwise is advocating autoland on a cat 1/non autoland ILS is an inherently safe or good thing to do.

But it's many, many magnitudes safer than coupling an RNAV and flying it into the ground and hoping you hit the runway. It is not ideal, but a much better alternative to what eventually had to be done due to BoM and ASA shortcomings.

I can't believe ASA weren't destroyed by ATSB in this report for allowing AWIS unserviceability for so long, and then fixing it the day after.

Hello ATSB, anyone home???

[CurtainTwitcher]

I can't believe ASA weren't destroyed by ATSB in this report
Between this report and Norfolk ditching fiasco, any sane professional will have absolute surety that there is no longer an independent investigator in the industry.

CASA, ASA & the ATSB will collude, cover-up & throw you under the bus in a heartbeat to protect themselves from their own grave failings.

Fuel order & manage fatigue accordingly!

[sunnySA]

IsDont
What? So more money will stop the collusion?

Give me a break! That's the biggest load of rot I've ever heard.

It took three years because it took that long to cover up. So those really responsible could get their ducks in a row. When the proposed report is sent to those that should have been held responsible for their comments and amendments such that any failings can be washed from the final report to save any embarrassment for the government agency or minister responsible. That's what takes three years.

The reason I suggest a maximum of 6 months is so any major occurrence is a "learning opportunity", not a history lesson.

I want my ATSB to be impartial, that is, unbiased, unprejudiced, neutral, non-partisan, non-discriminatory, dispassionate, objective, open-minded, equitable, even-handed, fair, fair-minded, just; without favouritism, free from discrimination, with no axe to grind, without fear or favour.

I want my ATSB to be properly resourced with sufficient qualified staff so that reports are released no later 6 months after the occurrence.

[IsDon]

IsDont
I want my ATSB to be impartial, that is, unbiased, unprejudiced, neutral, non-partisan, non-discriminatory, dispassionate, objective, open-minded, equitable, even-handed, fair, fair-minded, just; without favouritism, free from discrimination, with no axe to grind, without fear or favour.

You mean everything the ATSB currently isn't?

I want that too.

But if you think more money is going to fix the ATSB then you're delusional.

[PLovett]

The answer to the problem of an emasculated ATSB is to remove it from under the jurisdiction of the Dept of Transport, or whatever it goes under these days. The problem is that CASA and Airservices Australia come under the same umbrella and accordingly, you get that self-serving memorandum of understanding that neither will heap rubbish on the other, no matter how well deserved it may be. The only one to benefit from it is the Permanent Head of the department as he doesn't have to answer embarrassing questions to his/her Minister, but certainly not aviation.

[BuzzBox]

That said, expect the Monday morning quarterbacks (ATSB) to pillory whatever decision you make based upon airmanship and the best information you have available at the time. Especially if doing otherwise might actually find the route cause of the issue and that route cause may lay the blame squarely at the feet of Airservices Australia or BoM or some other government organisation that might be an embarrassment to some politician somewhere. How long has it taken for this report to come out, three years?

The crux is, whatever decision made by the crew, they will always be criticised by a regulator more concerned with deflecting blame from its cosy mates in other government agencies rather than finding and fixing the real causes.



As much as we all love to bag the ATSB and other government bodies, are you not overlooking one tiny, but very important point? According to ICAO Annex 13:

"The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability."

In my view, the ATSB didn't blame the aircrew involved in this incident. Indeed, the safety issues that were raised were directed squarely at ASA and the BoM. My biggest gripe is that it took them so bloody long to release the report. I suspect that's mainly a resources issue, as sunnySA said earlier.

[KABOY]

The only way forward from this is that the operator mandates far more operational requirements in operating to an airport (Non regulatory).

Destinations should carry an alternate with precision approach that requires generous viz and cloud ceiling forecasts. The reality is that some of those airports may be several hundred miles away, most international airlines operate this way. Oz airlines need to step back from the regulatory minimums and start carrying more fuel.

The cutbacks in the BOM and unreliable weather updates from operational staff will lead to another disaster. It is through sheer luck they haven't had and airliner off a runaway or floating in the sea.

CASA will regulate to to a minimum that doesn't upset QF, other airlines should work above that.

[Traffic_Is_Er_Was]

Unfortunately, BoM aviation forecasts have never been particularly accurate, but there has never been any studies or stats kept to see exactly how accurate/inaccurate they are. At the end of the day it is just educated guessing. Because the regs dictate that only BoM weather can be used operationally, airlines are hamstrung even if they want to use in-house forecasting. There is no competition, and no accountability. The regulator won't change anything, as they don't want different carriers using different interpretations to work out individual fuel requirements, and likely feel that airline's Met. Depts would always forecast a little more sympathetically, shall we say.
Part of the procedural problem also is that the system has not really adapted from the long ago abolition of Ops Control and Flight Service, in so far as their flight following duties went. Airlines have not had to develop their own dispatch/flight following (call it what you will), as they have always had the Service Provider do it for them. And frankly, there's not enough of them, and they are too busy doing what they are actually paid for - separating aircraft. That's probably why you only get weather updates an hour out. Either it's a tacit admission that the forecasts aren't much good outside that period, or they don't have the wherewithall to manage it more than that. Worrying about what the weather at your alternate is doing is probably not that high on the controllers priority list as he deals with the deteriorating traffic situation at your destination.
I guess the generally good weather in Australia has allowed this situation to develop, and the very rare "near miss " like this will probably not change it.

[framer]

Worrying about what the weather at your alternate is doing is probably not that high on the controllers priority list as he deals with the deteriorating traffic situation at your destination.
That is a good point. Inbound to Sydney with a thunderstorm passing through the controllers sound like they are working at maximum capacity just to stack everyone up and give them an estimate of onwards clearance time. To expect them to be monitoring diversion port weather trends at the same time is unrealistic in my view. That's from a line driver, any controllers care to comment?

[IsDon]

From my recent time on the 767 flying the MEL-SYD-BNE triangle, the normal fuel load was around 10T.

To carry an extra Tonne of fuel cost between 30-40Kg of extra fuel burn over the sector. Seems like cheap insurance to me.

Quite why dispatch calculated the fuel to the kilo, sometimes as low as 9T, based on the fact that the weather was forecast to be 100' above the alternate minima never ceased to amaze me. A classic case of measuring with a micrometer and cutting with an axe.

Obviously very few took flight planned fuel. With such a short sector length, and such a minuscule cost to carry, why would you?

[ozbiggles]

To play Devils advocate
I guess Qantas would fly more than 600 flights a day.
600 x $60 in extra fuel burn = $36000 a day x 365 days = $13,140,000 a year in extra fuel burn
Now it depends on if you are paying the bill or flying the aircraft how that affects you

Now if we were to put in fully capable ILS or GLS even at most big airports maybe that would be a cheaper solution in the long run.

[Willie Nelson]

Is Don,

You stated:Quite why dispatch calculated the fuel to the kilo, sometimes as low as 9T, based on the fact that the weather was forecast to be 100' above the alternate minima never ceased to amaze me.

With respect, perhaps your outfit is different but as for mine, if they published a larger figure when there was no legal necessity for an alternate to make me feel more comfortable where would it end?

The fuel they publish on the plan is a legal minimum, me and my offsider are paid the big money to decide to either take it or take more. If they didn't publish the minimum legal, what figure would they publish? (would it have a comfort factor scale next to it)

In the circumstances you describe our contingency fuel will be different to many others but would still be a valid figure if we have some to allow for unforecast options.

I've often heard pilots say "they want us to take X tonnes" (i.e. the minimum legal published on the plan) that is just not true, they want us to take what we believe we need to take to stay safe and satisfy the following criteria:

1) Is it legal?

2) is it safe?

3) Is it in the company's interest?

This third one is the catch all here if the minimum legal printed on the plan means you'll end up diverting then my mob will always want me to take more, they trust us to use discretion.

[Capn Bloggs]

600 x $60 in extra fuel burn = $36000 a day x 365 days = $13,140,000 a year in extra fuel burn. Now it depends on if you are paying the bill or flying the aircraft how that affects you
It's all relative; $13m on revenue of what, $8500m?

[The Bullwinkle]

600 x $60 in extra fuel burn = $36000 a day x 365 days = $13,140,000 a year in extra fuel burn
Now it depends on if you are paying the bill or flying the aircraft how that affects you

Why stop there? Why not say $131,400,000 over 10 years!
This is just the accountants way of making it sound so bad that they can apply pressure on us to take less fuel.

But do the math the other way.
Let's say those 600 flights carry an average of 180 passengers.
The additional $60 in extra fuel burn, divided by 180 passengers equates to only 33 cents extra per passenger.
That has to be the cheapest insurance in the world!!!

And on top of that, how about the bean counters actually calculate how much money was saved by those pilots who carried a little extra fuel and avoided the necessity to divert early, and all the associated costs that were avoided by using a little common sense (meals & accommodation, additional crew due to flight time limitations, additional fuel to actually get to the original destination.....)

[On eyre]

It sure is all relative Bloggs - that $13 million goes straight to the bottom line in a profit of say $500 million if you are lucky ! Becomes more significant when looked at that way.
But agreed safety is paramount - dare I say affordable safety - I know can, worms etc.

[ozbiggles]

I think Willie covered it nicely.
Using your logic on passengers paying for insurance....well they still fly Garuda, Air Asia and a few other airlines. As long as it's cheap and they can wear thongs...and there is the rub.
That's why a strong legislation is required for an even playing field. Unfortunately the ATSB report into Mildura ignored the dancing elephants in the room. It almost seems it was written by people who have no RPT experience, because people in that world get it. And I think it's why that world gets that this is such a poor report missing an opportunity to cover the big issues. But it only took 3 years....

[BuzzBox]

People keep talking about 'elephants' and 'big issues' without defining what they actually are in this case. Anyone care to recap?

[ozbiggles]

Fuel policy
Infrastructure ie ILS/GLS capability
AIr services provision of operational information
Airline provision of operational information
Bom capabilities and funding

Did you write the report Buzzie?

[Checklist Charlie]

Traffic_Is_Er_Was and many others.

Do not confuse Operations Control with Operational Control.

Two very different roles and responsibilities.

The former wholly belongs to the airline and the latter belongs as it should, with the Aircraft Commander.

CC

[BuzzBox]

Did you write the report Buzzie?

Nice try, but no, I did not. Nevertheless, I don't think it's as bad as some here are trying to make out. Some of the issues you mentioned were covered in the report. Others obviously weren't, but we'd probably be waiting another decade for a report if the ATSB had chosen to include infrastructure issues. As I said previously, I am disappointed they didn't talk about fuel policy, especially given the vagaries of the forecasting system.

[ozbiggles]

Sorry Buzzie couldn't resist!

I think we agree on more than we disagree probably but to say this report was a disappointment to me would be an understatement. This country was forced to land 2 RPT jets unplanned below landing minima at a regional airport. How did it get to this? We got a report that covers less than the interim report did 3 years later that adds nothing to the conversation this country needs to step up from its current state.

Fuel Ploicy
The CASA requirement when those aircraft dispatched was to have their fixed fuel remaining at touchdown, for those who don't know that's 30 minutes of fuel. Even the airlines think that is ridiculous and would of planned to have their aircraft there with 60 minutes. Then the pilots add on their discretionary ( the word that cannot be spoken). Surely the ATSB report could have as a safety recommendation suggested the CASA policy at the least needs reviewing? It is under Part 121 I believe but surely this report could have been used to reinforce that. Imagine if the aircraft had rocked up to ADL with CASAs fuel requirements. Most countries now I believe have recognised a 2nd option should always be available to RPT aircraft.

Infrastructure
Most if not all RPT aircraft can autoland, some for a long time. Every 5 years we have an RPT aircraft having a run in with unforecast fog. The airports won't pay for it because they will tell you the statistics don't make it worth the money they have to spend. Surely the ATSB report as a safety issue could have suggested the case for infrastructure needs to be made and funded. Maybe a small ticket safety surcharge on all airline tickets to pay for this. But again another dancing elephant

Bom
We all know forecasting is a dark art. But what happened on this day? Was it training, was it manpower, was it a mistake, was it cost cutting. I believe but may be wrong that Met guys now get 2 weeks training in AV Met and are expected to be a jack of all trades. Anyone here believe that met forecasting has improved in the last 10 years? We wouldn't know the first thing about it from this report.TTF vs TAF is a whole new subject.

Air Services
Where do you start? Who knew that air traffickers were marked down in their checks if they over serviced aircraft, ie giving them MET info that was available on the Internet or AWIS that don't work or if they do only if you are line of sight? WTF. Who and why were decisions made to cut this level of service to aircraft, why did the pilot world mostly not realise this had occured? Who made the safety case for this and why was it so inaccurate? The National Operational Centre, what role are they meant to play in this? They were not even aware it seems until both aircraft were almost on the ground.

Airlines
What level of training is required for their ops control centres, do they have the facilities and man power required?
Others will have many more points I'm sure.

It's not the ATSBs job to fix these things. It is their job to start the ball rolling and uncover things that need fixing before the next major incident. The What we knew very shortly after this incident. The how and why 3 years later we still don't know.

[Slippery_Pete]

QF fuel savings of $13m a year for ten years = $131mil for ten years.

The reality is that for that sort of money, every runway that Qantas operates to in Oz could be fitted with cat 2/3 ILS with autoland.

Airport owners like Melbourne airport, SACL, even Mildura Airport - they have no motivation to install infrastructure like ILS. They'll build shops and cafes and carparks - because that's how they make money. In fact, why install an ILS with autoland at Mildura? If aircraft are holding and diverting, you'll have big delays and you can sell more carparks and coffees in the terminal while they wait. How many new ILS have been built in Australia in the last 10-15 years? Less than five? Yet traffic has exploded.

GDP, STAAS, enroute holding, transition to GNSS - it's all bandaid solutions to crippled infrastructure.

This is the chickens coming home to roost after privatisation of federal airports. We have massively under resourced system - and no one with motivation to sink money into infrastructure. Airlines are expected to do more and more, with less and less. Eventually the holes in the cheese were going to line up.

[clakajak]

Ahhh, takes me back to this lively discussion that ensued back in 2009.....

http://www.pprune.org/pacific-general-aviation-questions/359918-senario-do-we-need-alternate.html

[Fieldmouse]

Agree with Slippery Pete's sentiments, if not his maths. Trying to get ASA interested in an AWIB and Baro VNAV approach design into a large regional, ILS and tower equipped aerodrome in Australia. ASA could care less. Can I hang a transmitter off some ASA infrastructure, that's already got a feed from the Met station? ? No way mate, that's ours, bugger off. ILS's everywhere?, Yeh right, $2-3million a pop and ASA set the price for maintenance. Plus the HIALs to make an ILS actually usable at $?? million.
ASA do the absolute minimum these days. Have no interest in aviation and are just lumbered with some historic obligations to provide ATC, RFS and a few Navaids. All these are obligations ASA would rather operate without.

[Old Akro]

ILS's everywhere?, Yeh right, $2-3million a pop and ASA set the price for maintenance.

I found the cost of installing ILS in the US a while back. I forget the number, but I think it was less than 1/5 the cost in Australia. Same hardware. Same installation process. The difference is AsA's charges. One day we need to get to examining what is really going on there. I'm sure the money is not going in controllers wages.

[Fieldmouse]

Akro, the guys at the point end have my sympathy. I have dealt with controllers and techs for nearly 40 years now and all are brilliant, dedicated professionals. But I will bet that the procedure and design office has 3 blokes who can do a design, and 57 managers.

[Slippery_Pete]

I found the cost of installing ILS in the US a while back. I forget the number, but I think it was less than 1/5 the cost in Australia. Same hardware. Same installation process. The difference is AsA's charges. One day we need to get to examining what is really going on there. I'm sure the money is not going in controllers wages.

Wagga to get ILS - Australian Flying (http://www.australianflying.com.au/news/wagga-to-get-ils)

According to this article, $1.6m from scratch. If done in bulk, the economy of scale would easily get it down to $1m per installation.

Given CASA have so far spent $300m on regulatory reform (mainly that Part 61 piece of crap), we could have had 300 ILS installed all over the country. Which would provide a better safety benefit I wonder?

[C441]

How much input does the PIC have on fuel loads for Qantas and Virgin?

As much as he/she wants (Qantas, imagine probably the same at Virgin). I've never once been questioned on a fuel decision - even after swapping freight for fuel.

[Traffic_Is_Er_Was]

And of course Wagga's ILS maintenance and running costs will be truly industry reflective, especially with their Tech college using it as a training tool.
How's that ILS going at the Gold Coast? That's infrastructure building these days in this country.
Checklist, I'm fully aware of whom is ultimately held responsible for the decisions which affect a flight, but on what information are those decisions being made?

[Checklist Charlie]

Operations Control has not been abolished and is still practised by mature airlines today.
Operational Control was transferred from an ATS/FS responsibility (approving flight plans and closing airports) to that of the Aircraft Commander in either the late 80's or early 90's. It was a ridiculous situation that existed where an ATC could close an airport whilst sitting in a tower with their eye line above the minima (as was the situation at Perth and the then new Brisbane towers). The only person who is in a position to decide whether they can continue an approach and land at the minima is the pilot themselves, not anybody else.

CC

[Capn Bloggs]

It was a ridiculous situation that existed where an ATC could close an airport
It hasn't happened here yet but the airports of the world are littered with the bodies of crew and pax that were being "operationally controlled" from Seat 0A, fog and thunderstorm prangs being examples. Operational Control would be even more appropriate today with the increased cost pressures... I'm not agreeing with it, just pointing out that around the world, hundreds of poeple would be alive today had our old "Operational Control" been in effect.

[Traffic_Is_Er_Was]

FS never exercised Operational Control. That was an ATC responsibility. No one is debating about whether or not the pilot can choose to try an approach. The discussion is whether you can expect or should plan to have to attempt one in the first place. If you plan using faulty information, then continue while using other faulty information, you are in for a world of hurt when you finally get there. I don't care if you have 12 bars on your shoulders, if you arrive without the fuel to get in or to go somewhere else, your options are pretty limited. A couple of 737 drivers got themselves nearly painted into a corner. I can't see a whole lot changing to prevent it maybe happening again, just a lot of finger pointing.

[Old Akro]

I don't care if you have 12 bars on your shoulders, if you arrive without the fuel to get in or to go somewhere else, your options are pretty limited.

I think its just too easy to blame the pilots or say the answer is to carry more fuel. At least the Virgin aircraft had sufficient fuel to divert to YMML. YMEN or YMAV, not to mention YPWR, or possibly even maybe YPED (although it probably had Adelaide's fog).

The pilots made the decision to go to Mildura based on a very favourable forecast that was issued by the BOM despite the BOM knowing or having the ability to know that fog was forming at the time they issuing a good forecast.

Clearly they made a decision to go somewhere that the forecast suggest was blue sky with broken cloud, had fuel and their own company handling services plus a nice passenger terminal that was close to Adelaide so they could finish the trip after the fog lifted with minimal delay. It was a good decision on the information they were supplied.

If the pilots had access to AWIS, a ground observer, an accurate forecast or information on the missed approach was passed to them, then they may have made a different decision.

The funny thing, is that this is a circumstance where a GA pilot might have done better. Because GA pilots don't have the same information resources a GA pilot would probably have pulled out the mobile phone and rung someone on the ground and gotten a higher quality answer than these pilots collectively got from our government air traffic and meteorological services.

[BuzzBox]

The pilots made the decision to go to Mildura based on a very favourable forecast that was issued by the BOM despite the BOM knowing or having the ability to know that fog was forming at the time they issuing a good forecast.


The report actually says something quite different:

"The 0358 amended TAF for Mildura that morning forecast light winds and scattered cloud at 3,000 ft and broken cloud at 6,000 ft. The TAF also included TEMPO periods between 0500 and 1000 in which the cloud base was forecast to reduce to 600 ft AGL.

A new routine TAF was issued for Mildura at 0902 that was valid from 1000. This TAF forecasted visibility in excess of 10 km and scattered cloud at 3,000 and 5,000 ft. No significant weather was listed on the TAF and no indication of low cloud or fog was given. Neither crew were aware of this TAF nor would they have been able to use this forecast in support of their decision to divert..."

"The METAR observation reports issued for Mildura at 0830 and 0900 showed light winds, visibility in excess of 10 km and the cloud lifting from broken at 3,400 to broken at 3,900 ft. These were the reports obtained by the crew of Velocity 1384 and Qantas 735 to assist their decision making about diverting to Mildura.

The BoM reported that their assessment of Mildura at around 0830 showed that low cloud was more likely to occur than fog. In addition, improved conditions could be expected from 1000 as the wind was forecast to tend southerly and both fog and low cloud were rare in a southerly flow at Mildura. Based on this information, the forecast for TEMPO conditions was continued.

At around 0900, weather recording instrumentation at Mildura started to indicate patches of low cloud at around 400 ft. A visual satellite image indicated a bank of low cloud south of Mildura indicating that the prediction of temporary (TEMPO) deteriorations was still appropriate."

With all due respect, it seems to me that it's quite wrong to suggest the aircraft based their diversion decisions on a 'very favourable forecast that was issued by the BOM despite the BOM knowing or having the ability to know that fog was forming at the time they issuing a good forecast'.

The first SPECI for low cloud at 200ft was issued at 0918, by which time both aircraft were already on their way to Mildura. That SPECI was not relayed to the aircraft and neither was an airborne report from an aircraft that departed Mildura at 0916. Thereafter, the visibility reduced rapidly from 28km to 1,000m between 0925 and 0931. Several SPECIS to that effect were issued between 0928 and 0932, the last of which was broadcast on the area frequency by the controller. However, CVR data showed that the crews were busy communicating on the CTAF frequency at the time, so it was probably not heard.

[Lead Balloon]

So if SPECIs are issued for e.g. Mildura, nobody is responsible for confirming that two RPT jets inbound to Mildura have received them? That seems odd to me. The funny thing, is that this is a circumstance where a GA pilot might have done better. Because GA pilots don't have the same information resources a GA pilot would probably have pulled out the mobile phone and rung someone on the ground and gotten a higher quality answer than these pilots collectively got from our government air traffic and meteorological services.That would be a dangerous practice, OA. Whenever I call the flying club's or refueller's number at my planned destination to find out what their eyes on the target are seeing, I aways give them comfort by saying: "As you will realise, I won't and can't believe anything you tell me." I of course only continue (or not) on the basis of official sources of information alone.

Funny thing is that the eyes on the target seem to be at least as reliable as the official sources ....

[Old Akro]

Neither crew were aware of this TAF nor would they have been able to use this forecast in support of their decision to divert..."

BUZZBOX I agree that my last post was in very black & white terms but the operative phrase is in your quote (above).

From memory, there was also a missed approach at YMIA that was not passed onto the crew. I also have a recollection that buried somewhere in the report is something to the effect that the BOM forecast the fog on the basis of satellite imagery rather than ground observation and that there was a ground observation that conflicted with one of the revised TAF's at the time of its issue.

My question would be, would we be better off if the BOM rang people for observations rather than looking at satellite photos & computer models.

But, the information that BOTH crews had available at the time of the decision to divert was that Mildura has vis > 10km with broken cloud in the mid 3,000ft range.

There was information that was on hand that conflicted with this, but it was not passed on to the crew by any of the BOM TAF's or METARS, or via ATC or via the company dispatchers for either airline.

If I was given a METAR that agreed with the TAF for an airport about 35 min flying away that easily allowed a VFR landing, I reckon I'd assume that I could rely to be an adequate IFR diversion.

Someone commented earlier that the big issue that we were all missing was that the ATSB was again attempting to deflect criticism for other government agencies.

The ATSB in the past has presented a timeline as part of the report. The drafting of this one makes it difficult to put all the pieces in correct order. I think it might be clearer if they has presented a chronological list of events.

[PLovett]

Now, where have I heard this before; that weather had deteriorated and was not passed on to the pilot? Even has more or less the same players with only the victims changed this time.

[megan]

PLovett, the same game has been in play for a long time. If anyone has access to RAAF records there was a Herc enroute Darwin to Richmond in the late 60s early 70s that got caught out by the same cockup as the two 737s.

[BuzzBox]

Old Akro:

From memory, there was also a missed approach at YMIA that was not passed onto the crew.

Yes, there was a missed approach at Mildura, by a Qantas Link Dash 8. The Virgin aircraft was already overhead Mildura at the time and Qantas wasn't far behind. In fact the Qantas aircraft started its approach about a minute later. The report states that the Virgin crew asked the Dash 8 for an appreciation of the weather and was told they 'couldn't see anything'.

I also have a recollection that buried somewhere in the report is something to the effect that the BOM forecast the fog on the basis of satellite imagery rather than ground observation and that there was a ground observation that conflicted with one of the revised TAF's at the time of its issue.

The report states the following:

For regional airports, such as Mildura, the BoM relied on satellite imagery, in addition to other data, to provide indications of fog. However, it can be difficult to differentiate between fog and low cloud when using satellite imagery. The BoM reported that their review of the forecasting used for Mildura on the day of the occurrence showed that the conditions (including wind direction) were not conducive to fog developing at that time of day and were more consistent with the possibility of low cloud. As such, the TAF that was valid at the time reflected a temporary period of low cloud that was expected to last between 30 and 60 minutes (TEMPO), rather than fog.

The 'other data' refers to observations recorded by the equipment and the observer at the airport. The revised TAFs that were issued were only valid from 0000Z, ie after both aircraft had arrived overhead Mildura. The TAF that was valid at the time of their arrival had a TEMPO for low cloud at 600ft, but no fog.

The 2230Z and 2300Z METARs both showed good conditions, with the lowest cloud at 3400ft. Shortly afterwards, the instruments at Mildura began to indicate patches of low cloud at around 400ft and a satellite image indicated a bank of low cloud south of Mildura. The report states that the BoM believed the forecast for TEMPO deteriorations was still appropriate, based on those observations.

About 10 minutes later, the weather began to deteriorate rapidly, starting with low cloud at about 200ft AGL, followed by reduced visibility and then fog. The first report of the deteriorating conditions came from an aircraft that departed Mildura at 2316Z. The Qantas and Virgin aircraft were on a different frequency at the time and the report was not subsequently passed to them. A SPECI showing the low cloud was issued at 2318Z, followed by three more SPECIs in rapid succession at about 2330Z. During that time period, the visibility dropped from greater than 10km to 2100m. According to the report, the observer "advised the forecasting office that the mist and subsequent fog arrived rapidly from the south".

I'm no meteorologist, but it seems to me that the weather conditions were quite good until shortly after 2300Z, with no indications of what was to come. The weather then deteriorated rapidly after about 2315Z. By that time, both the Virgin and Qantas aircraft had already diverted from Adelaide, on the assumption that the conditions at Mildura were still as reported at 2300Z. The BoM started issuing SPECIs as soon as the conditions began to deteriorate, but they were not relayed to either aircraft and neither was the airborne report from the aircraft that departed Mildura at 2316Z.

To be honest, I can't really pin the 'blame' on the BoM apart from the inaccuracy of the initial TAFs for Adelaide and Mildura, which did not predict fog. That said, in my experience, predictions of fog are rarely accurate at some airports, which is probably an indication of how difficult it is to forecast such conditions, rather than ineptness on the part of the BoM. I guess they're damned if they do and damned if they don't, in that they'll be pilloried for getting it wrong either way. In this case, it appears that everyone was caught out by the rapidly changing conditions.

In my view, the most easily solved causal factor in this incident is the lack of reports passed to the aircraft by ATC once the conditions started to deteriorate. If those reports had been relayed immediately, the crews might well have made a decision to return to Adelaide and attempt an autoland, which would obviously have been the lesser of the two evils. In that light, I believe the major problem lay with Airservices procedures, as highlighted by the ATSB's report.

I totally agree that a time line in the report would help readers to put a few things in perspective!

[BuzzBox]

Here's a time line, starting from 2230Z:

Timeline

2230Z: METAR YMIA 172230Z 27004KT 9999 BKN034 06/05 Q1019 RMK RF00.0/000.2

2300Z: METAR YMIA 172300Z 23004KT 9999 BKN039 07/06 Q1019 RMK RF00.0/000.2

2302Z: TAF YMIA 172302Z 1800/1812 20008KT 9999 SCT030 SCT050 RMK T 08 12 13 10 Q 1020 1019 1019 1021.

Not received by VA1384 or QF735 and not valid for their ETA

2304Z: VA1384 diverted to YMIA from YPAD. ETA YMIA 0932EST.

2313Z: QF735 diverted to YMIA from YPAD. ETA YMIA 0942EST.

2316Z: Air ambulance departed YMIA reported deteriorating conditions with low cloud at 400ft AMSL (approx 233ft AGL). Neither VA1384 or QF735 heard this report as they were on a different frequency. The report was not relayed to either aircraft by ATC.

2318Z: SPECI YMIA 172318Z 22004KT 9999 BKN002 SCT041 08/06 Q1019 RMK RF00.0/000.0

2328Z: SPECI YMIA 172328Z 21006KT 5000 BR BKN002 07/07 Q1019 RMK RF00.0/000.0

2330Z: SPECI YMIA 172330Z 21006KT 3300 BR BKN002 07/07 Q1019 RMK RF00.0/000.0

2332Z: SPECI YMIA 172332Z 20007KT 2100 BR BKN002 07/07 Q1019 RMK RF00.0/000.0

VA1384 overhead YMIA.

2336Z: 2332Z SPECI broadcast by ATC on the area frequency, but it was not heard by either aircraft as they were communicating on the CTAF frequency.

2339Z: Qantas Link Dash-8 conducted a missed approach at YMIA.

2340Z: QF735 commenced approach at YMIA.

2346Z: QF735 landed YMIA.

2348Z: SPECI YMIA 172348Z 19007KT 0900 FG OVC001 07/07 Q1019 RMK RF00.0/000.0

2352Z: TAF AMD YMIA 172352Z 1800/1812 20007KT 3000 BR SCT003 BKN040 BECMG 1800/1801 19006KT 9999 SCT030 SCT050 PROB30 1800/1802 0500 FG BKN002 RMK T 07 11 13 10 Q 1019 1019 1019 1020

VA1384 advised ATC they were still holding and did not have enough fuel to divert to another airport.

2354Z: Amended 2352Z TAF broadcast by ATC on the area frequency.

2358Z: ATC initiated an alert phase on VA1384 due to low fuel state.

0002Z: VA1384 commenced first approach at YMIA.

0004Z: VA1384 commenced a missed approach.

0012Z: ATC initiated a distress phase on VA1384 as the aircraft commenced its second approach.

0014Z: VA1384 landed YMIA.

[ozbiggles]

I take it back Buzzie, you should have written the report. That timeline would have made the report a bit easier to follow.

I wonder what happened on the ground at Mildura when the uncertainty and distress phase were issued? What facilities where available on the ground to respond and in what time frame. Something else not in the report. Surely an interesting question what response is available at airstrips like this that jets frequent even when it's not in an emergency.

[BuzzBox]

Ha, ha.

You're right, the report doesn't really say what happened on the ground, other than the following on pp. 20-21:

"At 0953, Velocity 1384 informed ATC that they would have to declare a fuel emergency in 10 minutes. In response, at 0958, the ATC operations room manager in Melbourne Centre contacted the Victorian Police coordination centre to activate the Mildura Airport emergency plan.

This resulted in local emergency services being contacted to initiate a response to the arrival of Velocity 1384."

[ozbiggles]

Obviously the Mildura Airport Emergency Plan worked perfectly as there was nothing of note to report on. I'd have to check but I thought that was an aspect of accident investigation that was meant to be reported on too.
It would be an interesting element of the story...another elephant maybe. Given the amount of RPT traffic into regional towns with no RFF at the airport how it should and did work on the day.
I believe there is a cost saving push onto to further increases the number of passengers before RFF is required at airports too. Even more reason this report should have taken the opportunities to lead the discussion.

[BuzzBox]

I could be wrong, but I think those aspects are only examined in detail in cases where the the services are actually used, eg fire or injuries/fatalities.

I agree with you though, it would be useful if that sort of stuff was included regardless. Under ICAO rules and the CASRs, they're supposed to conduct full-scale emergency exercises every two years, with partial exercises in between to make sure the plan actually works. The plan is also supposed to be reviewed in the event of an actual emergency, but I guess that's separate to any ATSB involvement.

[LeadSled]

It hasn't happened here yet but the airports of the world are littered with the bodies of crew and pax that were being "operationally controlled" from Seat 0A, fog and thunderstorm prangs being examples. Operational Control would be even more appropriate today with the increased cost pressures... I'm not agreeing with it, just pointing out that around the world, hundreds of poeple would be alive today had our old "Operational Control" been in effect.

Bloggsie, old mate,
In your case, that may very well be true, but for most real Captains, that is all part of command responsibility.
Funny thing, in the G.O.Ds of DCA Operational Control, it never did apply to Qantas, and it was Ansett various, TAA and EWA (on this side of the island) that had a somewhat spotty record.
Tootle pip!!

[topdrop]

2318Z: SPECI YMIA 172318Z 22004KT 9999 BKN002 SCT041 08/06 Q1019 RMK RF00.0/000.0
This should have been passed to the arriving aircraft. Do we know what time the SPECI was received by the relevant controller. With ETAs 14 and 24 mins later, would it have made any difference - could the crews have gone anywhere else? Maybe QF could as they had more fuel.

[BuzzBox]

The SPECIs weren't received by the controller, that was part of the problem. According to Airservicess procedures at the time, the SPECIs weren't automatically sent to the controller's console because Mildura had an AWIS. If aircraft wanted the information they had to either tune in to the AWIS (which wasn't working) or ask ATC, in which case the controller would retrieve the report from the system. As a result, the ATSB report says the ATC supervisors only became aware of the deteriorating conditions at about 2330Z, when the Mildura aerodrome reporting officer contacted them to ask why aircraft were diverting there when the weather was so bad.

The ATSB calculated that if the 2318Z SPECI had been disseminated immediately to the aircraft, they both would have had enough fuel to return to Adelaide and land with their fixed reserve intact.

[Slippery_Pete]

Your timeline is very helpful, thanks!

It is however missing the very first and last items....

1. Months earlier, AWIS breaks down, doesn't get fixed
....
99. Immediately after incident, AWIS gets fixed in blatant bum covering

Which ASA manager made their KPI by not fixing the AWIS?

ATSB report says the ATC supervisors only became aware of the deteriorating conditions when the Mildura aerodrome reporting officer contacted them to ask why aircraft were diverting there when the weather was so bad.

This is a monumental problem. It's 2016, and we have to wait for old mate in his airport ute to put two and two together and phone ATC about the weather?

[Traffic_Is_Er_Was]

ATC supervisors only became aware of the deteriorating conditions at about 2330Z

So why at least are the ATC supervisors not aware that the weather at one of the airports in their area of responsibility has gone bad? They don't tune in to the AWIS. Surely they don't just wait for amended TAFs to land on their desks? What is the point of SPECIs being issued to ATC if no one takes any notice of them? Does anybody actually carry the "big picture"?

It's 2016, and we have to wait for old mate in his airport ute to put two and two together and phone ATC about the weather?

20 years ago, this incident would never have happened. Ain't progress grand!

[BuzzBox]

So why at least are the ATC supervisors not aware that the weather at one of the airports in their area of responsibility has gone bad?

According to the report, it all came about as a result of changes to the AIP and MATS in 2009. Prior to the changes, ATC notified pilots about all SPECI reports and amendments to forecasts. After the changes, pilots were not to be alerted to the availability of a SPECI the could be obtained from an ABS. The reason for the change was the introduction of more automatic weather stations, which resulted in a flood of AUTO SPECI reports to ATC, all of which required review and broadcast to relevant traffic. That caused a huge increase in controller workload and conflicted with ATC's primary role of providing a traffic separation service.

The report states that these changes to MATS were subject to a Safety Case Assessment and Reporting Determination (SCARD). The SCARD determined that:

"...a safety case was not required as there was no change to the Air Traffic Services Provider Certificate. The size of the change was assessed as ‘small’ and the magnitude of the change as ‘reasonable’. In assessing the magnitude of the change, Airservices identified a potential failure of ‘the pilot does not obtain in-flight information’, with the effect that the ‘pilot is not aware of significant weather information’. The overall assessment was considered ‘minor’ and approved by the relevant managers."

In a nutshell, it became a pilot's responsibility to check the weather by requesting the information from ATC or by using other means such as the ABS; the information won't be provided automatically by ATC. Indeed, the controllers themselves may not know about deteriorating weather conditions, because the SPECIs are not automatically sent to them either. As an aside, this is not unique to Australia; the report notes that the US, Canada and New Zealand all have similar systems, whereby it is the pilot's responsibility to obtain the relevant weather information by requesting it if necessary.

Following this incident, the report says Airservices is working with BoM to "explore feasible options to provide information on significant deteriorations in weather conditions". Airservices has also updated MATS to ensure that information continues to be disseminated by ATC in cases where the ABS is out of service.

I certainly hope that the Airservices managers who assessed the 2009 changes as 'minor' now feel suitably chastised.

[ozbiggles]

In my mind a easy solution.
The NOC has a met guy and should have some SMEs. If they become aware of a critical change in forecast weather then they send it to the RPT operators and ATC to ensure the message gets out. Might mean they have to put their coffee down but if all they do at the NOC is figure out traffic flows the night before then what's the point.
The NOC should be a hub for all critical information, not just traffic management. Might mean someone has to put some thought and money into it.
Of course an investigation like this probably should have looked at that...but that would have been another elephant. Covered the big issues like a pilot not prefixing his report with Airep...I do go on.

[BuzzBox]

I've got another suggestion: With mandatory ADS-B just around the corner, 'Big Brother' will soon know where all the aircraft are and where they're headed at any given time. In this age of automation, perhaps 'Big Brother' can also be programmed to filter all the data Airservices receives from BoM and push anything relevant to the controller's console.

The ATSB report did say that Airservices would explore avenues to better disseminate relevant information, so it will be interesting to see what evolves, if anything. To be fair to the ATSB, is it their job to develop the solutions? My understanding is that they are tasked with determining the safety issues, but it's the relevant organisation's job to come up with the answers. If the ATSB isn't satisfied with the result, they can then issue a safety recommendation, as they did over one of the issues that was highlighted in the report. By law, the relevant organisation must then, within 90 days, either accept the recommendation and provide details of how the recommendation will be effected; or explain, for the public record, why the recommendation is not accepted.

[BuzzBox]

...and before anyone asks: No, I don't work for the ATSB!

[ozbiggles]

In a practical sense I see what you are saying Buzz...but I have a dream.

For too long the inmates have run the asylum in this country regarding aviation. Everything comes down to a cost benefit analysis. That has its place of course but things like an even playing field regarding a modern fuel,policy ( I'm thinking always having a 2nd bit of Tarmac) infrastructure such as Cat 2/3 ILS or GLS at least at capital city airports and a proper NOC controlling critical bits of information is where we should be going.

In my dream the safety world would be pro active and lead this discussion before we lose an aircraft because we didn't have one of these things in place. As they say if you think safety is expensive try having an accident. To pay for this all, a safety surcharge on all airline tickets. Not a hard sell for a good politician...not around in the current crop.It might be a dollar a ticket.

Instead after 3 years we got a report telling us the pilots should have got updated inaccurate met reports. The interim report had more in it. The Norfolk report showed us the capabilities of the ATSB, it could be the ATSB isn't funded enough or doesn't have the money to pay for the people it needs. It's the missed opportunities to lead a discussion that has to be had that disappoints me most in all of this. This should have been the wake up call...fate keeps knocking, soon it will open the door.

[BuzzBox]

Nice dream! Seriously though, I agree with you; the safety world should be out there leading the discussion on safety issues. The fact that doesn't happen more probably comes down to one thing: resources, as you and others have already pointed out. Sadly, I can't see things changing any time soon when there are so many other 'higher priority' programs competing for limited government funding. Perhaps a safety surcharge is the way to go, as you suggested.

[Icarus2001]

Thanks for the laugh Capn Bloggs.

So using your late forecast change with fog as an example, requiring an alternate as you said (was holding fuel okay?). There you are inbound to Perth in your B717, passing through transition on descent, flying the star. The Bumet in their wisdom add some requirements that you were not aware of when you departed Paraburdoo.

Q1 How are you going to know about it? Do you hear approach read out new TAFs very often?

Q2 If you did know by some method, ACARs etc, and you DO NOT have the extra fuel but you can see bloody field, what would you do?

Q3 If you land are you "legal"?

Q4 Will you report yourself.

Happy Days

Come on Capn Bloggs, questions are still on the table. Enlighten us.

[Derfred]

I think the elephant in the room that no-one seems to care about is that with a less than 30% chance of FG it won't even rate a mention on a forecast.

I'm sorry, but many seem to think pilots want accurate forecasts.

They don't. They want to know the worst case scenario, because that is what they have to plan for with fuel and contingencies.

I don't want to know the most likely weather at my destination, I want to know what could happen, even if unlikely.

So if it's 10% chance of FG at my destination, I want to know about it please.

Even if it's 1%.

[Capn Bloggs]

Bloggsie, old mate,
In your case, that may very well be true, but for most real Captains, that is all part of command responsibility.
Funny thing, in the G.O.Ds of DCA Operational Control, it never did apply to Qantas, and it was Ansett various, TAA and EWA (on this side of the island) that had a somewhat spotty record.
Sled, you never, ever let a chance go by to sledge domestic airline pilots, do you? You really should grow up.

[Icarus2001]

Slippery answer which has you nicely avoiding the question, well done.

So if it's 10% chance of FG at my destination, I want to know about it please.

Even if it's 1%.

What would you do with this knowledge of 1% chance of fog. It would be on there every day through winter, then what?

[Derfred]

I would have a contingency.

We seem to be constantly surprised by the regular occurrences of unforecast fog in this country.

We plan for engine failures every takeoff - that's about a 0.0001% chance.

[JamieMaree]

I think the elephant in the room that no-one seems to care about is that with a less than 30% chance of FG it won't even rate a mention on a forecast.



Defred,
This is exactly what code grey was all about ie to cover this possibility. If I remember correctly it has to do with Australia slavishly adopting ICAO standards. Before they used to give " prob 10% fog" and the view was forecast fog is fog is fog whether it is 100% or 10% forecast...... Adjust your fuel carriage accordingly.

[Icarus2001]

I would have a contingency.

Really? I would like to be a fly on the wall when the MFO/HFO/CP asks you why you are carrying around 30 minutes of extra fuel every day given a 1% probability of fog. As I said if the met guys could use this figure it would be on there almost every day in winter, in the south of the country.

[Angle of Attack]

There's a 0.000000000000000000000000000001% chance of a meteor hitting the threshold during your flare as well, that should be on every forecast from now on. But that's not having a go at you derfred, 10 or 20 percent probably should be included , but it still won't stop us forecast fog events. The main thing was that this Mildura event happened to GPS equipped aircraft, if it happened years ago pre GPS it could have been a precautionary search and landing event in a 737/727/DC9 Yikes!

[PLovett]

Does this raise a serious case for WAAS in Australia? Certainly cheaper than bunging in an ILS everywhere.

[Derfred]

Really? I would like to be a fly on the wall when the MFO/HFO/CP asks you why you are carrying around 30 minutes of extra fuel every day given a 1% probability of fog.

The MFO/HFO/CP of my airline would not. I feel sorry for you if you work for such an airline. Perhaps that explains your attitude.

Anyway, I didn't say I would carry around 30 minutes of extra fuel every day. I said I would have a contingency.

If there was a 1% chance of fog at my destination there are several different ways it could affect the way I operated that flight. For example:


Preflight, I may identify alternate airports that have zero chance of fog.
These airports may not necessarily be destination alternates, they may be enroute alternates, or TOD alternates, for example.
I may identify whether there is an alternate with an ILS, if my destination does not have an ILS.
I may use this 1% as a trigger to seek a second opinion, such as telephoning a Company MET department, or contacting someone with local knowledge at destination.
I may, as you say, carry more fuel. But not according to some pre-scripted policy. The extra fuel would be whatever I calculated I needed to mitigate the risk posed by this chance of fog. It would vary depending upon many factors.

Inflight, I would definitely be paying closer attention enroute to monitoring the weather at my destination and alternates, now that my attention has been drawn to this 1% chance of a problem.
I may also use this trigger inflight to pro-actively seek further information through Company or ATC channels, given that we now know they are not necessarily pro-actively seeking to help me.


There are a hell of a lot of mitigations available if the chance of a problem has been brought to your attention. It doesn't have to be as simple as just sticking on more fuel.

Fog generally will take at least 20 minutes from "first sign" to closing an airport (in my experience), so I would suggest that an airport with no reported fog at TOD could generally be committed to at that point. So a TOD alternate could be considered a viable mitigator.

As I said if the met guys could use this figure it would be on there almost every day in winter, in the south of the country.

It would most certainly not be on there almost every day in winter.

Fog requires certain meteorological conditions to occur. Predicting whether or not it will occur is difficult. Predicting a chance of it occurring is not difficult. Predicting zero chance is also not difficult. The problem is that the BoM will only admit a chance when it has a high probability of occurring (30% or greater).

Given a temperature, wet bulb depression, QNH, cloud cover and wind, some days in winter will have a chance of fog. Many will have no chance of fog. There are many forecast conditions that will preclude fog, such as temperature, rain, wind and cloud. (i.e. zero chance. Not 0.00001%, zero.)

Many pilots flying early morning arrivals into these ports on these kinds of days will make our own assessment of so-called "unforecast fog" and make contingencies anyway. Many of us save costly diversions, embarrassment or worse by doing so. Often these pilot decisions require experience and local knowledge, and will vary from pilot to pilot, so a little more information from the experts at the BoM would be handy for these decisions.


What I object to is this: The BoM appears to deliberately withhold information from the pilots who along with their passengers may live or die based on this information.

Only 20% chance of fog? Shhh... don't mention it.

5 days of 20% chance of fog? Statistically speaking, one of them will very likely end up with "unforecast fog". And that's ok?

If an engineer told you you had a cracked turbine blade, but there was only a 1% chance of it failing during this flight, you wouldn't leave the ground. But somehow, with fog, less than 30% chance is not even worth a mention. That's the most amazing risk management I've ever heard.

[josephfeatherweight]

Does this raise a serious case for WAAS in Australia?
Yes - it does. Cheap(ish), accurate, easy.

[le Pingouin]

Slippery Pete, Airservices isn't responsible for the Mildura AWIS - it belongs to the aerodrome operator. Refer to ESRA:

METEOROLOGICAL INFORMATION PROVIDED
1.TAF CAT B, METAR/SPECI.
2.AWIS PH 03 5023 3879 - Report faults to BoM.
3.AWIS FREQ 128.675 - Report faults to AD OPR.

[Slippery_Pete]

Hi Pengy.

Airservices were responsible at the time. The AWIS was provided via voice modulation on the VOR. The AWIS was fine, but the voice modulation on the aid had failed.

During the unserviceable period, the AWIS was available only by phone.

The day after the incident, ASA repaired the VOR, and AWIS services to airborne aircraft were resumed.

It is since then, that ASA are placing the AWIS responsibility onto airport owners. They are forcing airport owners to install and maintain their own VHF AWIS, as is the case now in Mildura.

Had they repaired the VOR AWIS in a timely manner, the affected crews could have accessed it at TOPC out of Adelaide and realised it was deteriorating quickly.

That statement of "report faults to BoM/aerodrome operator" is classic washing of hands by ASA. If they aren't responsible for any part of the AWIS infrastructure then they can't be blamed when it's not available.

[duncan_g]

Yes - it does. Cheap(ish), accurate, easy.

Do the current generation of MMRs fitted to the fleet support SBAS? It didn't used to be the case a few years ago...