CASA response to the ATSB report on Lockhart River
Registered User **
Join Date: Apr 2007
Location: Australia
Age: 68
Posts: 23
Likes: 0
Received 0 Likes
on
0 Posts
Geez Bloggs,
you are unbelievable.
Because an unqualified FO is on the flight deck with a captain flying faster than the REGULATED speeds for the Category of aircraft, of an aircraft conducting an RNAV(GNSS) approach you want to change the whole world wide accepted philosphy about how they are conducted.
you are unbelievable.
Because an unqualified FO is on the flight deck with a captain flying faster than the REGULATED speeds for the Category of aircraft, of an aircraft conducting an RNAV(GNSS) approach you want to change the whole world wide accepted philosphy about how they are conducted.
Registered User **
Join Date: Apr 2007
Location: Australia
Age: 68
Posts: 23
Likes: 0
Received 0 Likes
on
0 Posts
Howdy Leadsled,
Only 22% percent of RNAV rated pilots responded to the ATSB survey.
Because of the low response rate I wouldn't put any emphasis on the results and neither should have ATSB.
There are some very good points that should be encompassed by AsA and CASA into the design and presentation of RNAV approaches but the original design philosphy is sound and SAFE, when the pilot(s) conduct the approach according to the rules and their training and their experience.
Only 22% percent of RNAV rated pilots responded to the ATSB survey.
Because of the low response rate I wouldn't put any emphasis on the results and neither should have ATSB.
There are some very good points that should be encompassed by AsA and CASA into the design and presentation of RNAV approaches but the original design philosphy is sound and SAFE, when the pilot(s) conduct the approach according to the rules and their training and their experience.
Join Date: Aug 2004
Location: 45 South
Posts: 32
Likes: 0
Received 0 Likes
on
0 Posts
I thought that B1 was extreemly unconvincing and did a very poor effort in response to the report. He certainly does not justify his huge 6 figure salary. Rejecting the ATSB points and stating that he is implementing changes and improvements.................blah blah is pathetic from a man in his position. Opposition Memeber Martin Furguson is right.............CASA is a failed organisation! Fish rots from the head! 
Registered User **
Join Date: Apr 2007
Location: Australia
Age: 68
Posts: 23
Likes: 0
Received 0 Likes
on
0 Posts
Quote Boggs "Agreed that this was a multi-issue prang. The (lack of) CASA oversight of the Ops Manual, for example, makes me sick. No Stabilised Approach criteria? WTF?"
The only two issues with this prang BLOGGS was a cowboy in the front left seat not following the authorised procedure, either on the accident flight or during the RNAV approaches he conducted BEFORE HE WAS QUALIFIED to conduct them and an UNQUALIFIED and INEXPERIENCED co-pilot who probably didn't understand what was going on and should have been receiving guidance from a Captain following the rules.
Not even the FBI could catch AL CAPONE on anything other than a Tax evasion charge so give CASA a break, although they do need to get back to being to being the HITLERS that they should be and stop the cowboys getting commands with fare paying pax in the back.
I feel sad for the families of the pilots who have lost their loved ones, but I understand the plight of the families of the innocent passengers who can't cuddle their loved ones because of the actions of a pilot and a company that allowed an UNQUALIFIED crewmember to operate a high performance aircraft on a route with a high workload RNAV approach to one of the runways.
The only two issues with this prang BLOGGS was a cowboy in the front left seat not following the authorised procedure, either on the accident flight or during the RNAV approaches he conducted BEFORE HE WAS QUALIFIED to conduct them and an UNQUALIFIED and INEXPERIENCED co-pilot who probably didn't understand what was going on and should have been receiving guidance from a Captain following the rules.
Not even the FBI could catch AL CAPONE on anything other than a Tax evasion charge so give CASA a break, although they do need to get back to being to being the HITLERS that they should be and stop the cowboys getting commands with fare paying pax in the back.
I feel sad for the families of the pilots who have lost their loved ones, but I understand the plight of the families of the innocent passengers who can't cuddle their loved ones because of the actions of a pilot and a company that allowed an UNQUALIFIED crewmember to operate a high performance aircraft on a route with a high workload RNAV approach to one of the runways.
"on a route with a high workload RNAV approach to one of the runways"
Maybe I am missing something here, but how is the LHR Rwy 12 RNAV Appr a higher workload than any other RNAV approach?
Dr
Maybe I am missing something here, but how is the LHR Rwy 12 RNAV Appr a higher workload than any other RNAV approach?
Dr
Registered User **
Join Date: Apr 2007
Location: Australia
Age: 68
Posts: 23
Likes: 0
Received 0 Likes
on
0 Posts
Quote FO BLOGGS "The crux of what he is saying, and I agree is- you need to have something to increase situational awareness when you dont have a flash ND, and having a fix that references distance to go to the field so that one can easily calculate descent profiling surely is the way to go."
Who cares what happens half way down the approach?
Descent planning is about the start point and the end point.
For the YLHR RWY 12 RNAV(GNSS) approach the descent point is 1.7 prior to LHRWF and the angle is 3.49 degrees. Work off your GS and you have a rate of descent that keeps you above the steps.
Get it wrong or don't do it at all for an RNAV approach or an ILS or an NDB?DME or a VOR/DME and "DEATH COMES UNEXPECTEDLY", unfortunatley not just for the pilot who made the mistake, but everyone else on board.
Who cares what happens half way down the approach?
Descent planning is about the start point and the end point.
For the YLHR RWY 12 RNAV(GNSS) approach the descent point is 1.7 prior to LHRWF and the angle is 3.49 degrees. Work off your GS and you have a rate of descent that keeps you above the steps.
Get it wrong or don't do it at all for an RNAV approach or an ILS or an NDB?DME or a VOR/DME and "DEATH COMES UNEXPECTEDLY", unfortunatley not just for the pilot who made the mistake, but everyone else on board.
Registered User **
Join Date: Apr 2007
Location: Australia
Age: 68
Posts: 23
Likes: 0
Received 0 Likes
on
0 Posts
Quote the Doctor, and I love Fish-tail Bonanza's. "Maybe I am missing something here, but how is the LHR Rwy 12 RNAV Appr a higher workload than any other RNAV approach?"
Fair point, it is no busier than many other RNAV approaches throughout Australia.
But if you conduct it faster than required then you get real busy real quick.
Death happens at the same rate though: INSTANTLY.
Fair point, it is no busier than many other RNAV approaches throughout Australia.
But if you conduct it faster than required then you get real busy real quick.
Death happens at the same rate though: INSTANTLY.
Registered User **
Join Date: Apr 2007
Location: Australia
Age: 68
Posts: 23
Likes: 0
Received 0 Likes
on
0 Posts
Quote Chimbu: "The characterisation of the PIC and the manner in which he was flying the approach in question is a disgrace...how can anyone not on board know how he was flying the approach?"
We know that the PIC or the FO was flying the approach in a manner other than prescribed because of the FLIGHT DATA RECORDER.
We know that the FO did not have an RNAV endorsement.
We know that there is another approach available at LHR that both pilots were qualified to conduct.
We don't know why the PIC elected to conduct an approach outside of the regulations other than speculation shown by his past actions that he regularly operated outside of the rules and was not caught doing it until after he killed everyone else on board.
Lots of pilots and ops people knew this Captain was a regular breacher of the regulations but no-one "dobbed him in" and therefore his life was not saved.
We know that the PIC or the FO was flying the approach in a manner other than prescribed because of the FLIGHT DATA RECORDER.
We know that the FO did not have an RNAV endorsement.
We know that there is another approach available at LHR that both pilots were qualified to conduct.
We don't know why the PIC elected to conduct an approach outside of the regulations other than speculation shown by his past actions that he regularly operated outside of the rules and was not caught doing it until after he killed everyone else on board.
Lots of pilots and ops people knew this Captain was a regular breacher of the regulations but no-one "dobbed him in" and therefore his life was not saved.
Join Date: Jan 2006
Location: Around
Posts: 58
Likes: 0
Received 0 Likes
on
0 Posts
Who cares what happens half way down the approach?
The implimentation of GPS/GNSS has greatly reduced the workload of pilots (as it was designed to do). But on the other hand increased complacency.
These sort of systems were supposed to increase a pilots situational awareness not just make life easier!
having a fix that references distance to go to the field so that one can easily calculate descent profiling surely is the way to go.
Bugsmasherdriverandjediknite
Join Date: Jul 2000
Location: Bai, mi go long hap na kisim sampla samting.
Posts: 2,849
Likes: 0
Received 0 Likes
on
0 Posts
wouldn't you still have to do that calculation though...... but working it backwards to know you were at the waypoint, and the next decent step and maintain situational awareness (know exactly where you were)?.
**Nm from my destination - **Nm to the waypoint to continue decent?.
**Nm from my destination - **Nm to the waypoint to continue decent?.
Check Attitude
Join Date: Nov 2001
Location: Queensland, Australia
Posts: 476
Likes: 0
Received 0 Likes
on
0 Posts
For those who haven't seen the ATSB Final Report, heres the link.
There are a number of files to download, the report is 10Mb,
the appendix is 13Mb, and there is also an animation plus a lnk to the driver for the animation.
If you don't have broadband, you can order the Hard Copy of the report, including a CD Rom.
http://www.atsb.gov.au/publications/...200501977.aspx
Given that this is Australia's worst Air Disaster in 40 + years, the ATSB have done a thorough job, including linking CASA's contribution to the tragedy.
There are a number of files to download, the report is 10Mb,
the appendix is 13Mb, and there is also an animation plus a lnk to the driver for the animation.
If you don't have broadband, you can order the Hard Copy of the report, including a CD Rom.
http://www.atsb.gov.au/publications/...200501977.aspx
Given that this is Australia's worst Air Disaster in 40 + years, the ATSB have done a thorough job, including linking CASA's contribution to the tragedy.
Last edited by Mainframe; 6th Apr 2007 at 21:18.
Join Date: Apr 2002
Location: Oz
Posts: 331
Likes: 0
Received 0 Likes
on
0 Posts
The RNAV is a breeze with the right gear, ala moving map, autopilot combined with glide slope information, etc, but for those without that type of gear,those that are stuck with the first generation type RNAV approved GPS’s it is not so easy, And there is a lot of aircraft out there that still have that type of equipment.
For those who reckon this approach is just fine and beaut without any significantly higher workload than other approaches, here is a little cut and past paste (of that that refers to the RNAV approach) from the findings.
(Scource: ATSB 200501977)
The Lockhart River Runway 12 RNAV (GNSS) approach probably
created higher pilot workload and reduced position situational awareness
for the crew compared with most other instrument approaches. This was
due to the lack of distance referencing to the missed approach point
throughout the approach, and the longer than optimum final approach
segment with three altitude limiting steps.
Based on the available evidence, the Lockhart River Runway 12 RNAV
(GNSS) approach design resulted in mode 2A ground proximity warning
system alerts and warnings when flown on the recommended profile or at
the segment minimum safe altitudes. (Safety Issue)
The Australian convention for waypoint names in RNAV (GNSS)
approaches did not maximise the ability to discriminate between waypoint
names on the aircraft global positioning system display and/or on the
approach chart. (Safety Issue)
There were several design aspects of the Jeppesen RNAV (GNSS)
approach charts that could lead to pilot confusion or reduction in
situational awareness. These included limited reference regarding the
‘distance to run’ to the missed approach point, mismatches in the vertical
alignment of the plan-view and profile-view on charts such as that for the
Lockhart River runway 12 approach, use of the same font size and type for
waypoint names and ‘NM’ [nautical miles], and not depicting the offset in
degrees between the final approach track and the runway centreline.
Jeppesen instrument approach charts depicted coloured contours on the
plan-view of approach charts based on the maximum height of terrain
relative to the airfield only, rather than also considering terrain that
increases the final approach or missed approach procedure gradient to be
steeper than the optimum. Jeppesen instrument approach charts did not
depict the terrain profile on the profile-view although the segment
minimum safe altitudes were depicted. (Safety Issue)
Airservices Australia’s instrument approach charts did not depict the
terrain contours on the plan-view. They also did not depict the terrain
profile on the profile-view, although the segment minimum safe altitudes
were depicted. (Safety Issue)
For those who reckon this approach is just fine and beaut without any significantly higher workload than other approaches, here is a little cut and past paste (of that that refers to the RNAV approach) from the findings.
(Scource: ATSB 200501977)
The Lockhart River Runway 12 RNAV (GNSS) approach probably
created higher pilot workload and reduced position situational awareness
for the crew compared with most other instrument approaches. This was
due to the lack of distance referencing to the missed approach point
throughout the approach, and the longer than optimum final approach
segment with three altitude limiting steps.
Based on the available evidence, the Lockhart River Runway 12 RNAV
(GNSS) approach design resulted in mode 2A ground proximity warning
system alerts and warnings when flown on the recommended profile or at
the segment minimum safe altitudes. (Safety Issue)
The Australian convention for waypoint names in RNAV (GNSS)
approaches did not maximise the ability to discriminate between waypoint
names on the aircraft global positioning system display and/or on the
approach chart. (Safety Issue)
There were several design aspects of the Jeppesen RNAV (GNSS)
approach charts that could lead to pilot confusion or reduction in
situational awareness. These included limited reference regarding the
‘distance to run’ to the missed approach point, mismatches in the vertical
alignment of the plan-view and profile-view on charts such as that for the
Lockhart River runway 12 approach, use of the same font size and type for
waypoint names and ‘NM’ [nautical miles], and not depicting the offset in
degrees between the final approach track and the runway centreline.
Jeppesen instrument approach charts depicted coloured contours on the
plan-view of approach charts based on the maximum height of terrain
relative to the airfield only, rather than also considering terrain that
increases the final approach or missed approach procedure gradient to be
steeper than the optimum. Jeppesen instrument approach charts did not
depict the terrain profile on the profile-view although the segment
minimum safe altitudes were depicted. (Safety Issue)
Airservices Australia’s instrument approach charts did not depict the
terrain contours on the plan-view. They also did not depict the terrain
profile on the profile-view, although the segment minimum safe altitudes
were depicted. (Safety Issue)
Gorn,
That is not the way I'd do it. Firstly, the slower your aircraft, the more affected by the H/T wind component on the approach getting quickly to the point where a couple of hundred feet error in your "worked out rate of descent" will either put you into a limiting step or make you miss out because you get to the MApt too high.
Also, flying level until only 7-odd nm to touch is not the ideal way to get stabilised by a reasonable height (~1000ft AGL). I my experience, it is better to start descent earlier from higher. That allows more time to get the descent profile under control.
The simplest and safest way (to do any NPA) is to fly the chart profile, a bit like an ILS. Provided you make each chart profile altitude point eg 5 Mike, 4 Mike 3 Mike you CANNOT hit anything. Even if you are a bit erratic and miss a profile point by 100ft, you are not going to run into anything. If all has turned to worms, it is very easy for PNF/support pilot to call out out "4 Mike 1950!". Instantly, we know where we should be (and hopefully where we are).
Of course, the big spanner in the works doing this is Foxtrot. The distance reference you use changes right in the middle of the approach! When you are doing this type of approach without a graphical display of where you are, the potential for misinterpreting your position increases greatly.
That is exactly what I am suggesting, unbelievable as it may seem to you.
I agree. Higher than it needs to be.
Jet A Knight,
Except that if it had been a VOR/DME, the PNF would have had a simpler, single distance reference all the way to the runway (as would have the PF) and would therefore have been more likely to work out that something was terribly amiss. Even though the approach was flown fast (perhaps because the PF thought he had already passed Foxtrot and was therefore quite high, poking the nose down?) provided he stayed on or near the altitude profile the aeroplane isn't going to come to grief until he pops out and tries to land too fast.
For the YLHR RWY 12 RNAV(GNSS) approach the descent point is 1.7 prior to LHRWF and the angle is 3.49 degrees. Work off your GS and you have a rate of descent that keeps you above the steps.
Also, flying level until only 7-odd nm to touch is not the ideal way to get stabilised by a reasonable height (~1000ft AGL). I my experience, it is better to start descent earlier from higher. That allows more time to get the descent profile under control.
The simplest and safest way (to do any NPA) is to fly the chart profile, a bit like an ILS. Provided you make each chart profile altitude point eg 5 Mike, 4 Mike 3 Mike you CANNOT hit anything. Even if you are a bit erratic and miss a profile point by 100ft, you are not going to run into anything. If all has turned to worms, it is very easy for PNF/support pilot to call out out "4 Mike 1950!". Instantly, we know where we should be (and hopefully where we are).
Of course, the big spanner in the works doing this is Foxtrot. The distance reference you use changes right in the middle of the approach! When you are doing this type of approach without a graphical display of where you are, the potential for misinterpreting your position increases greatly.
you want to change the whole world wide accepted philosophy about how they are conducted.
a high workload RNAV approach to one of the runways.
Jet A Knight,
So far as Foxtrot is concerned, lots of relevant points, but in this case, even a VOR/DME flown like that would have resulted in a crash.
"Except that if it had been a VOR/DME, the PNF would have had a simpler, single distance reference all the way to the runway (as would have the PF) and would therefore have been more likely to work out that something was terribly amiss"
The PNF (assuming he wasn't the PF) being endorsed on the approach being flown may have helped also!
Dr
The PNF (assuming he wasn't the PF) being endorsed on the approach being flown may have helped also!
Dr
All,
I fully accept that that this accident was caused by all sorts of cockups and stuffups, not just Foxtrot. However, if even ONE of the holes in the slices had been misaligned, 19 people would be alive today. It behoves the system to fix ALL the slices so they don't line up again.
We can "blame" the PIC but is that going to stop the same thing happening again? Or do we just accept all these systemic deficiencies and forget about it, hoping that Cowboy Joe (no offence intended; I don't know the names of the crew) isn't replaced by another?
I fully accept that that this accident was caused by all sorts of cockups and stuffups, not just Foxtrot. However, if even ONE of the holes in the slices had been misaligned, 19 people would be alive today. It behoves the system to fix ALL the slices so they don't line up again.
We can "blame" the PIC but is that going to stop the same thing happening again? Or do we just accept all these systemic deficiencies and forget about it, hoping that Cowboy Joe (no offence intended; I don't know the names of the crew) isn't replaced by another?
Is there a need for some regulation over these more remote, low density RPT services?
I realise that the trend today is for free enterprise and market forces to sort these things out, but .....
.... whenever I have flown into Bamaga it has seemed odd that at least two companies were fighting for market share on this route. I suspect the end result was that nobody was making a reasonable return on their investment.
Dr
I realise that the trend today is for free enterprise and market forces to sort these things out, but .....
.... whenever I have flown into Bamaga it has seemed odd that at least two companies were fighting for market share on this route. I suspect the end result was that nobody was making a reasonable return on their investment.
Dr
Don Quixote Impersonator
Thread Starter
Join Date: Jul 1999
Location: Australia
Age: 77
Posts: 3,403
Likes: 0
Received 0 Likes
on
0 Posts
ForkTailedDrKiller
Ping, underlying the whole 300 odd pages is that simple fact.
AND in those regions it will NEVER work without some form of Government support or subsidy.
Game set and match on that one.
Ping, underlying the whole 300 odd pages is that simple fact.
AND in those regions it will NEVER work without some form of Government support or subsidy.
Game set and match on that one.
Join Date: Apr 2007
Location: Australia
Posts: 8
Likes: 0
Received 0 Likes
on
0 Posts
Responsbility
Ok - We have determined that the flight crew's approach was outside nominal values as stipulated in the AIP, the aircraft was a definite CFIT and there is a level of conjecture over the RNAV GNSS at YLHR.
What I wish to find a little more about is was there any benefit in operating this aircraft as a multi crew operation? I understand the CVR was U/S but surely the reports taken from other flight crew would have provided some insight into the incorporation of the FO into the 'team' or was it a single pilot accident? Surely this aspect would have been either covered during a check or flights with other crewmembers.
It seems that the chief pilot, CEO and head of training and checking was selective in his hearing of reports about the conduct of operations at this base. Does this sound fishy to others or is it just me? If the checks were completed then the approach profiles would have been examined? What roles did the check pilot take when conducting flights? It has been documented that he was selective in his completion of the CASA approved syllabus items in intial training so did this also flow into the checks and tests required by the CAR 217 organisation?
What was the standard that was applied during the conducted of CASA delegated flight tests by the ATO - manager of Training and checking? What was the standard of checking afforded the ATO by others in the CAR 217 organisation or CASA?
Was the requirements as stipulated in the CASA ATO Delegates handbook completed, or do we find we have a number of flight crew who have 'never' been checked properly?
I hope the coronial enquiry does follow on from where the ATSB report has ended?
I for one want to know whether CASA intend on following up any breeches in procedures that the Delegate conducted? I have no bones with the flight crew but the management of the flight standards department - seems abysmal. I for one cannot close on 'pilot error' - it was an 'airline' so the responsibility of the managers in authorising this pilot are very much to blame (company error). Refer to section 28BE Act.
Considering the 'airline' is closed - are we not entitled to see what recommendations the ATSB would have made against the company? Would it not be in the interest of safety in releasing the specifics. Or is that for the Coroner to determine?
The ASIC records indicate the company is now in administration ! Does that indicate a financial problem ? Does that mean that the financial viability of the organisation was compromised - When ? before the accident ? Does CASA conduct an ongoing financial viability assessment ? Should it?
Did this financial position affect the CAR 217 operation? Was proper company surveillance conducted or was it a paper exercise?
I dunno guys (and Gals) there is much much more to this. After Monarch, Seaview, Whyalla and numerous other enquiries surely it is time to put the 'rougues' out of the game.
What I wish to find a little more about is was there any benefit in operating this aircraft as a multi crew operation? I understand the CVR was U/S but surely the reports taken from other flight crew would have provided some insight into the incorporation of the FO into the 'team' or was it a single pilot accident? Surely this aspect would have been either covered during a check or flights with other crewmembers.
It seems that the chief pilot, CEO and head of training and checking was selective in his hearing of reports about the conduct of operations at this base. Does this sound fishy to others or is it just me? If the checks were completed then the approach profiles would have been examined? What roles did the check pilot take when conducting flights? It has been documented that he was selective in his completion of the CASA approved syllabus items in intial training so did this also flow into the checks and tests required by the CAR 217 organisation?
What was the standard that was applied during the conducted of CASA delegated flight tests by the ATO - manager of Training and checking? What was the standard of checking afforded the ATO by others in the CAR 217 organisation or CASA?
Was the requirements as stipulated in the CASA ATO Delegates handbook completed, or do we find we have a number of flight crew who have 'never' been checked properly?
I hope the coronial enquiry does follow on from where the ATSB report has ended?
I for one want to know whether CASA intend on following up any breeches in procedures that the Delegate conducted? I have no bones with the flight crew but the management of the flight standards department - seems abysmal. I for one cannot close on 'pilot error' - it was an 'airline' so the responsibility of the managers in authorising this pilot are very much to blame (company error). Refer to section 28BE Act.
Considering the 'airline' is closed - are we not entitled to see what recommendations the ATSB would have made against the company? Would it not be in the interest of safety in releasing the specifics. Or is that for the Coroner to determine?
The ASIC records indicate the company is now in administration ! Does that indicate a financial problem ? Does that mean that the financial viability of the organisation was compromised - When ? before the accident ? Does CASA conduct an ongoing financial viability assessment ? Should it?
Did this financial position affect the CAR 217 operation? Was proper company surveillance conducted or was it a paper exercise?
I dunno guys (and Gals) there is much much more to this. After Monarch, Seaview, Whyalla and numerous other enquiries surely it is time to put the 'rougues' out of the game.