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ATSB Report: QF B737 838 VH VXF

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ATSB Report: QF B737 838 VH VXF

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Old 19th May 2005, 11:06
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ATSB Report: QF B737 838 VH VXF

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

http://www.atsb.gov.au/aviation/occu...ail.cfm?ID=659
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Old 19th May 2005, 12:17
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Bloody Hell! 10°! I would've melted long before they had got to CBR.

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

I was impressed with the gallant promise from the operator that they would ensure "ensure earliest rectification".
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Old 19th May 2005, 14:58
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It is not immediately apparent to me how the activation of the contingency procedure for TCU staff shortage would have had any effect on the incident. Do they infer that the aircraft wouldn't have held in the first place? Is the tower able to determine the a/c has descended below the lowest safe? Would the tower have instigated an arrival other than an ILS? ie; how does the tower at CB transition the a/c from en-route to an arrival?
Anyone care to enlighten me on this aspect?
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Old 20th May 2005, 00:47
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Mate, anything that goes into the FMS needs to verified before inserting. Failure to do so kills people. (AA B757 Cali, for instance..)
 
Old 20th May 2005, 06:18
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Interesting...

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

I would have thought that by this point in time a cadet would have had his/her ATPL. Am I missing something here?!?!?!?
 
Old 20th May 2005, 07:49
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ATPL is not required for short haul FO's in QF because they, unlike their LH counterparts, are never required to act in command of the aircraft i.e. when the captain is on a break.
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Old 20th May 2005, 08:11
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Yes well, from the hours that the Capt had on the aircraft, obviously BOTH of them were ex L/H. Need we say more. !!!
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Old 20th May 2005, 08:57
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Well that didn't take long.
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Old 20th May 2005, 12:57
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Ferris,
Would the tower have instigated an arrival other than an ILS? ie; how does the tower at CB transition the a/c from en-route to an arrival?
My understanding (from my "location") is that when the TCU is manned you get a radar control service down to wherever you want: I would say down to the LLZ with a radar descent. Mind you, the only time I go to CBR is in the SIM, and the slack-o "ATC" that looks after us just tells us to "join the holding pattern"! Unionistic @#$%^ (sorry cinders! )
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Old 23rd May 2005, 06:57
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I heard that Tower controllers are not allowed to be trained in approach control techniques because ASA does not want to lose TCU airspace when/if the government allows airports to operate their own towers.

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

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

Short answer is that any TWR controller with appropriate training could have provided the Class C service in the absence of the radar controller.
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Old 23rd May 2005, 13:04
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Fatigue? maybe.
but this could have been one of the worst aviation disasters in modern australia times. !!!! thank god it wasnt

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

Role : Co-Pilot/1st Officer

Class of Licence Hours: Commercial

Hours on Type: 530.0

Hours Total : 1992

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

With a lot of cadets now becoming FO's after moving from their highly experienced SO roles ( ), after moving straight out of there $100 000 + paid cadetships where NO real practical command/decision making, raw flying experience has been gained, lets hope to god these ace pilots dont ever lose their captain and "MAP" mode.
I would hate to think of them flying on a dark and stormy night attempting an approach with no FMC.
There is still a lot to be said for experience.
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Old 23rd May 2005, 13:24
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Pure Risk - there are ALOT of people that will tell you that TRAINING in an AIRLINE ENVIRONMENT makes up for (lack of) EXPERIENCE.

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

Go figure.
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Old 23rd May 2005, 13:33
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PureRisk, what a load of BS.

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

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


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

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

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

Last edited by blueloo; 23rd May 2005 at 13:58.
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Old 23rd May 2005, 14:02
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Blueloo: The argument that says that plenty of experienced pilots have crashed planes is true - plenty of high time pilots have made errors.

BUT

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

Those who know - understand.

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

But what would I know - after all, I'm just an old fart and no match for a psych/skills/ hotshot - hotdog - jet jockey - SO/FO who has seen it all ' on the line ' .
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Old 23rd May 2005, 14:08
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Kurtz - The argument can easily go full circle....


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


Those who know - understand.
Those that don't - don't believe it or don't care
....and there are those that live with the blinkers on and live with tunnel vision.



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

All of these incidents keep reminding me of Fate is the Hunter.
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Old 23rd May 2005, 14:35
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Awww Gee come on you blokes, give the poor cadet a break.

She's only a girl................
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Old 24th May 2005, 00:04
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To all the smart arses, have a look at the Jeppesen ILS page for CBR. The holding pattern limit is shown as D 14 with no mention of it being a dme limit unlike the MEL holding pattern limits for example. In the heat of the moment this could have happened to anybody at 5 in the morning when this is the last thing you expected! And for the anti cadet bashing, most of you would never have flown with one. Nearly all can outfly and out think some of the more seasoned ex GA pilots of which I am one. Do not believe for moment that experience in one facet of aviation is transferable to another.
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Old 24th May 2005, 00:34
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Mr Approach, (and if anyone else is interested)

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

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

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

Cheers.

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Old 24th May 2005, 05:04
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schlond hauler you are an idiot and no doubt this could/will happen to you.

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

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

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

of course, situational awareness is not in the fam.



Four days holiday for flaming another user!!!



Woomera

Last edited by Woomera; 26th May 2005 at 05:56.
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Old 24th May 2005, 06:12
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En-root, I believe your assumption to be correct but your logic does not follow. Why consolidate the radar TCUs if they are not profitable? They probably are and will be moreso as staff are cut and positions eliminated.

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