Senate Inquiry, Hearing Program 4th Nov 2011
Senate PelAir report recommendations 2&3
Recommendations 2&3 deal with the ‘ATSB accident investigation processes’ including an extraordinary risk matrix that was commented on by the committee….
….“The ATSB's response notwithstanding, the committee remains concerned by the fact that the highest consequence the ATSB would attribute to the safety issues for those involved with emergency medical flights—in this particular case the patient, her family, the medical staff and flight crew—is 'moderate'. This would be the case even if all six on board had died in the accident”
There was also reference to an old chestnut CAR206…“It is important to note that current regulations include 'ambulance functions' under the category of 'aerial work', as outlined in Civil Aviation Regulation (CAR) 206. CAR 206 sets out what is referred to as the "classification of operations" and establishes three broad classes of commercial aviation: aerial work, charter and regular public transport (RPT).”
So R2 and R3 again from Phelan’s article:
PAIN R1-R3
….“The ATSB's response notwithstanding, the committee remains concerned by the fact that the highest consequence the ATSB would attribute to the safety issues for those involved with emergency medical flights—in this particular case the patient, her family, the medical staff and flight crew—is 'moderate'. This would be the case even if all six on board had died in the accident”
There was also reference to an old chestnut CAR206…“It is important to note that current regulations include 'ambulance functions' under the category of 'aerial work', as outlined in Civil Aviation Regulation (CAR) 206. CAR 206 sets out what is referred to as the "classification of operations" and establishes three broad classes of commercial aviation: aerial work, charter and regular public transport (RPT).”
So R2 and R3 again from Phelan’s article:
2.The committee recommends that the minister, in issuing a new statement of expectations to the ATSB, valid from 1 July 2013, make it clear that safety in aviation operations involving passengers (fare paying or those with no control over the flight they are on, e.g. air ambulance) is to be accorded equal priority irrespective of flight classifications.
3.The committee recommends that the ATSB move away from its current approach of forecasting the probability of future events and focus on the analysis of factors which allowed the accident under investigation to occur. This would enable the industry to identify, assess and implement lessons relevant to their own operations.
The ATSB and CASA have long been criticised on this issue. Proactive ATSB research and CASA safety education programs/publications appear to have an aversion for discussing current domestic air safety issues.
The issue has received scant attention over many years, because current regulation fails to provide equivalent regulatory protection for a huge variety of air passengers who are not protected by current airline regulation. They range from corporate executives, to fly-in-fly-out resource workers, to medevac and air rescue passengers, to police officers and prisoners (some not yet convicted.)
3.The committee recommends that the ATSB move away from its current approach of forecasting the probability of future events and focus on the analysis of factors which allowed the accident under investigation to occur. This would enable the industry to identify, assess and implement lessons relevant to their own operations.
The ATSB and CASA have long been criticised on this issue. Proactive ATSB research and CASA safety education programs/publications appear to have an aversion for discussing current domestic air safety issues.
PAIN R1-R3
Last edited by Sarcs; 17th Jun 2013 at 21:22.
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Frank and fearless reporting
For what it's worth, I sailed on the Rangatira just after the Wahine went down. I think that disaster blamed the God's/ weather/ sun spots and solar winds.
Erebus was a charter wasn't it?
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Its a big ask.
Master Sarcs presupposes the minister will empower the Senate recommendations made for ATSB and CASA and that change will be honestly embraced. To achieve that noble aim, the bloke (or blokette) who gets the job needs be made of pretty stern stuff, just to withstand the "Yes Minister" blarney, the mind numbing voodoo incantations (dripped over wax effigies) and to foil the dastardly, clandestine 'lobotomy plots'. That's the reason I like the idea of a 'junior' minister, someone like D. Fawcett esq. supported by a couple of attack dogs. Perhaps they could build a 'closed loop' system where things which need to be done, get done honestly, on time and within budget – or else.
For example: t'other day I imposed on P7 aka TOM (thanks mate) to have a look at the PAIN data on past coronial recommendations. When you see the numbers analysed like that, it is truly scary. I won't bore you with miles of data; my peregrinations through first 100 Coronial Recommendations (CR), made in good faith, by various coroners over the last ten years was a remarkable experience. For example: (and a Choccy frog) have a guess at the percentage of CR which were fobbed off by solemn promises that the chances of a repetition of a fatal accident would be reduced by brave, 'new' legislation; I'll give you a clue go beyond 50%. Then have a whack at the percentage of accepted CR and promised changes which have not actually been executed; you'll need to go better than 75% to win that Choccy frog. To end the misery think on this; the only CR that has been fully embraced since Lockhart is the MoU and even that was grabbed in self interest, then twisted and perverted out of any resemblance to the coroners intent.
Before our junior minister for matters aeronautical even mounts the starting blocks, there is a mountain to move, just to make good on broken promises made to honest, innocent coroners and families who expected that in return for lost lives, changes for the better would be made.
Before the most welcome recommendations of the Senate are executed, we need a transparent system which could track, soup to nuts, the implementation of change and ensure the spirit and intent of that change remains unsullied.
Ref 2&3 - The ATSB must first be extricated from the clammy grip of the DoIT executive and learn to stand alone once again. There are clever, talented people hidden beneath the surface dirt and rust who can and probably would willingly return to their previous standard of excellence, given half the chance. I wonder, can they be so fearful of having their rice bowls broken that they dare not speak out?; if so, then it's a hellish way to live a half life.
For example: t'other day I imposed on P7 aka TOM (thanks mate) to have a look at the PAIN data on past coronial recommendations. When you see the numbers analysed like that, it is truly scary. I won't bore you with miles of data; my peregrinations through first 100 Coronial Recommendations (CR), made in good faith, by various coroners over the last ten years was a remarkable experience. For example: (and a Choccy frog) have a guess at the percentage of CR which were fobbed off by solemn promises that the chances of a repetition of a fatal accident would be reduced by brave, 'new' legislation; I'll give you a clue go beyond 50%. Then have a whack at the percentage of accepted CR and promised changes which have not actually been executed; you'll need to go better than 75% to win that Choccy frog. To end the misery think on this; the only CR that has been fully embraced since Lockhart is the MoU and even that was grabbed in self interest, then twisted and perverted out of any resemblance to the coroners intent.
Before our junior minister for matters aeronautical even mounts the starting blocks, there is a mountain to move, just to make good on broken promises made to honest, innocent coroners and families who expected that in return for lost lives, changes for the better would be made.
Before the most welcome recommendations of the Senate are executed, we need a transparent system which could track, soup to nuts, the implementation of change and ensure the spirit and intent of that change remains unsullied.
Ref 2&3 - The ATSB must first be extricated from the clammy grip of the DoIT executive and learn to stand alone once again. There are clever, talented people hidden beneath the surface dirt and rust who can and probably would willingly return to their previous standard of excellence, given half the chance. I wonder, can they be so fearful of having their rice bowls broken that they dare not speak out?; if so, then it's a hellish way to live a half life.
Last edited by Kharon; 17th Jun 2013 at 22:48. Reason: Hells bells Minnie, look at the time.
The fact that Dolan allowed a "management by matrix" approach to classification, and by implication resourcing, implies that he knows nothing about Aviation safety.
I know what it feels like as a "know nothing manager" in a field I shouldn't have been in (Large IT systems) and my first response to the challenge of responding to highly complex and confusing situatoins was to try and build a set of rules like Dolans - with a little box into which to categorise each and every event. Other floundering managers will do likewise as they struggle to make sense of what is happening.
Unfortunately life isnt like that, as I found when one of my systems went down for only Four minutes at Three AM, and that "minor" event (in my stupid opinion) almost brought a chunk of Melbournes infrastructure to its knees, as I was later forcibly reminded.
All life is valuable and to categorise their implied value makes a mockery of the very reason the ATSB was established.
I know what it feels like as a "know nothing manager" in a field I shouldn't have been in (Large IT systems) and my first response to the challenge of responding to highly complex and confusing situatoins was to try and build a set of rules like Dolans - with a little box into which to categorise each and every event. Other floundering managers will do likewise as they struggle to make sense of what is happening.
Unfortunately life isnt like that, as I found when one of my systems went down for only Four minutes at Three AM, and that "minor" event (in my stupid opinion) almost brought a chunk of Melbournes infrastructure to its knees, as I was later forcibly reminded.
All life is valuable and to categorise their implied value makes a mockery of the very reason the ATSB was established.
Beancounter Beaker!
Sunny good point that you make:
Perhaps this highlights how ill equipped Beaker is for this particular bureaucratic position?? Beaker even tries to justify his position with this spin:
Again ‘beancounter’ Beaker takes the mickey bliss out of an excellent research paper by Dr Walker and Mr Bills ‘Analysis, causality and proof in safety investigations’ to support his main aim of fiscal discipline (for his Minister), again at the detriment of SAFETY….sheesh enough said!
:
I know what it feels like as a "know nothing manager" in a field I shouldn't have been in (Large IT systems) and my first response to the challenge of responding to highly complex and confusing situatoins was to try and build a set of rules like Dolans - with a little box into which to categorise each and every event. Other floundering managers will do likewise as they struggle to make sense of what is happening.
4.34 The committee put this proposition to the ATSB. Chief Commissioner Dolan responded:
That is a simplification of the purpose of that table. We will do a risk
assessment of an identified safety factor. This is not about assessment of
evidence, this is about assessment of safety issues—a safety factor that is
seen to have a continuing effect on risk to assess the likelihood and the
consequence of that factor coming into play in the future. That is our basis
for establishing the significance of a safety issue. It is not the basis on
which we will assess evidence.
If you are looking for the philosophical underpinnings of how we deal with
evidence and a range of other things, there is a document, Analysis,
causality and proof in safety investigations, which was a publication of
Dr Walker and Mr Bills in 2008. That shows the philosophical
underpinnings of how we deal with facts, evidence, analysis and so on. It is
reflected in our policies and procedures in the organisation. The risk
assessments largely draw on or are compressed versions of international
safety organisation risk management standards. We are trying to bring all
that to bear on a diverse range of operations, while bearing in mind the
guidance from the government that our attention should primarily be on the
safety of the travelling public.32
That is a simplification of the purpose of that table. We will do a risk
assessment of an identified safety factor. This is not about assessment of
evidence, this is about assessment of safety issues—a safety factor that is
seen to have a continuing effect on risk to assess the likelihood and the
consequence of that factor coming into play in the future. That is our basis
for establishing the significance of a safety issue. It is not the basis on
which we will assess evidence.
If you are looking for the philosophical underpinnings of how we deal with
evidence and a range of other things, there is a document, Analysis,
causality and proof in safety investigations, which was a publication of
Dr Walker and Mr Bills in 2008. That shows the philosophical
underpinnings of how we deal with facts, evidence, analysis and so on. It is
reflected in our policies and procedures in the organisation. The risk
assessments largely draw on or are compressed versions of international
safety organisation risk management standards. We are trying to bring all
that to bear on a diverse range of operations, while bearing in mind the
guidance from the government that our attention should primarily be on the
safety of the travelling public.32
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Sheik of tweak
Beaker is certainly a bureaucrat accountant, not much more than that. He can spin better than Shane Warne at his peak!
The inquiry hit the nail on the head when they noted that in future the Commisioner(s) ought to have a background skill set commensurate with the portfolio they are over sighting. A degree in spin, turd polishing, hypotheses, Ministers bodyguards, accounting, and mi mi mi no longer should be included in the Job PD. Mr Mrdak, do you understand the depth of that statement? Yes? Good, please pass this on to Teflon Tony.
It is ludicrous that Beaker could even pretend his knowledge, understanding or methodology is in the same league as someone like Kim Bills. And certainly he is not even on the same radar echo when it comes to a comparison with somebody like Alan Stray.
Sunfish, the clock is ticking closer to a smoking hole the longer this bureaucratic game continues. Care for a wager?
The inquiry hit the nail on the head when they noted that in future the Commisioner(s) ought to have a background skill set commensurate with the portfolio they are over sighting. A degree in spin, turd polishing, hypotheses, Ministers bodyguards, accounting, and mi mi mi no longer should be included in the Job PD. Mr Mrdak, do you understand the depth of that statement? Yes? Good, please pass this on to Teflon Tony.
It is ludicrous that Beaker could even pretend his knowledge, understanding or methodology is in the same league as someone like Kim Bills. And certainly he is not even on the same radar echo when it comes to a comparison with somebody like Alan Stray.
Sunfish, the clock is ticking closer to a smoking hole the longer this bureaucratic game continues. Care for a wager?
Last edited by 004wercras; 17th Jun 2013 at 23:05.
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casa and atsb - The waste and failure to meet ICAO requirements
The direction that has occurred in this thread, despite a few who seek to de-rail the open and frank discussion that has occurred, with almost 400, 000 views is certainly pointing at a system that is well and truly broken.
The Senate comes out with a report of over 170 pages, with very precise recommendations as to fixing the system. There is no joy for the two organisations being investigated by the honourable Senators. There is just a range of required directions made to the Australian parliament and in the first instance the Minister.
I am sure that the Minister has other things that he must focus on, considering the parlous current state of the Government.
It should not require a major accident, due to the failures of atsb and casa to focus his attention. This is a matter for all parliament and not for the department and it’s departmental incumbent Mr. Myrdac.
The direct responsibility is now for us, in the aviation community to keep up the pressure. I realise that many, including myself, are concerned about the regulator [casa] focussing on the man, not the game. We individually and as organisations should be concerned. I am aware of direct threats being made in this way [recently] in the past.
I am sure that the Honourable Senators, considering the amount of high quality work that they have done, will be able to recieve individual examples of aviation problems, even though the report is “in”, from those who have done so either for this inquiry or at all in the past.
To have MP’s suggesting that we should put individual matters on the table and “consult’ with casa or atsb, is at the very least naïve, and certainly just plain stupid.
There is no protection at all in these cases and it will place the informant in a difficult situation at that time and into the future.
Can we fix this??
This is the real question.
The answer – YES
In the US, all members and senators are routinely polled as to their attitudes on a series of issues on a routine basis. These are published and made public. Let’s do the same here, but we all must rise to the task.
Must we fix this – YES
For a start, there is an election looming, write to your local member about your concerns and make sure you get a reply and publish it on the site.
It will be worth while being specific:–
Ask the question:
“Following the current Senate investigation what do you intend doing to ensure there will be no repetition of breaches to aviation safety in Australia??”
I can supply e-mail addresses for all members and senators and will publish this list shortly.
The Senate comes out with a report of over 170 pages, with very precise recommendations as to fixing the system. There is no joy for the two organisations being investigated by the honourable Senators. There is just a range of required directions made to the Australian parliament and in the first instance the Minister.
I am sure that the Minister has other things that he must focus on, considering the parlous current state of the Government.
It should not require a major accident, due to the failures of atsb and casa to focus his attention. This is a matter for all parliament and not for the department and it’s departmental incumbent Mr. Myrdac.
The direct responsibility is now for us, in the aviation community to keep up the pressure. I realise that many, including myself, are concerned about the regulator [casa] focussing on the man, not the game. We individually and as organisations should be concerned. I am aware of direct threats being made in this way [recently] in the past.
I am sure that the Honourable Senators, considering the amount of high quality work that they have done, will be able to recieve individual examples of aviation problems, even though the report is “in”, from those who have done so either for this inquiry or at all in the past.
To have MP’s suggesting that we should put individual matters on the table and “consult’ with casa or atsb, is at the very least naïve, and certainly just plain stupid.
There is no protection at all in these cases and it will place the informant in a difficult situation at that time and into the future.
Can we fix this??
This is the real question.
The answer – YES
In the US, all members and senators are routinely polled as to their attitudes on a series of issues on a routine basis. These are published and made public. Let’s do the same here, but we all must rise to the task.
Must we fix this – YES
For a start, there is an election looming, write to your local member about your concerns and make sure you get a reply and publish it on the site.
It will be worth while being specific:–
Ask the question:
“Following the current Senate investigation what do you intend doing to ensure there will be no repetition of breaches to aviation safety in Australia??”
I can supply e-mail addresses for all members and senators and will publish this list shortly.
Senate PelAir report recommendations 4-6
Recommendation 4 goes to the ‘paper trail’ and transparency in the ATSB accident/incident investigation process and production of ‘Final Reports’. After all what should a, supposedly independent, Transport Safety Investigator have to hide??
R5&R6 covers the effects of the ATSB becoming a ‘multi-modal’ investigator and addressing the resultant shortfall in necessary expertise and investigator skills by benchmarking and training with international counterparts:
004 jumping the gun there a little bit
...oh well here is R7 :
Which was also covered by a PAIN 'birdsong' plus a 'link'....
4.The committee recommends that the ATSB be required to document investigative avenues that were explored and then discarded, providing detailed explanations as to why.
Such a measure would certainly have aided the committees deliberations: “The committee is concerned by the fact that no paper trail exists clearly documenting the ATSB’s decision to downgrade the issue [to a "minor safety issue"] should a similar accident a care in the future, this fact will surely be seen as a missed opportunity to enhance safety. The reasoning behind the downgrade, and the process and evidence leading to it, appears at the least unclear.”
The committee said it had considered a number of ways to encourage improvements in the conduct of safety investigations and production of reports, and foreshadows close scrutiny of issues that are causing daily increasing industry concern: “These resolve around the remit of the agency, the expertise of its leaders and quality control of its product.”
Such a measure would certainly have aided the committees deliberations: “The committee is concerned by the fact that no paper trail exists clearly documenting the ATSB’s decision to downgrade the issue [to a "minor safety issue"] should a similar accident a care in the future, this fact will surely be seen as a missed opportunity to enhance safety. The reasoning behind the downgrade, and the process and evidence leading to it, appears at the least unclear.”
The committee said it had considered a number of ways to encourage improvements in the conduct of safety investigations and production of reports, and foreshadows close scrutiny of issues that are causing daily increasing industry concern: “These resolve around the remit of the agency, the expertise of its leaders and quality control of its product.”
5.The committee recommends that the training offered by the ATSB across all investigator skills sets be benchmarked against other agencies by an independent body by, for example, inviting the NTSB or commissioning an industry body to conduct such a benchmarking exercise.
An aspect that attracted the committee’s scrutiny was the history of the ATSB’s formation with civil aviation as just one element of a multi-modal investigator that also covers the maritime and rail environments – an aspect that may have diluted the level of aviation expertise as air safety experts transferred from the regulator to the newly established ATSB. The committee comments: “to address these shortcomings, the committee was told that the theoretical internal investigator courses the ATSB conducts simply cannot replace technical experience, and should be supplemented with training offered by the NTSB [USA] and AAIB [UK]. The committee supports this view.”
6.The committee recommends that as far as available resources allow, ATSB investigators be given access to training provided by the agency’s international counterparts. When this does not occur, resultant gaps in training competence must be advised to the Minister and the Parliament.
Interaction with international counterparts has always been a popular concept at the workface both in regulation and accident investigation. The notion of learning from other agencies however has not been embraced to the same degree, and in some cases has been scornfully rejected. A senior NZCAA official once recounted to us that when both New Zealand and Australia were setting out on the path to regulatory reform and New Zealand was already leading by a couple of laps, the offer was made to the Australian regulator to sell us the entire NZ program on a floppy disk for $1 million. It is some time since the ongoing programme in Australia has been costed, but it must by now be close to $½ billion.
An aspect that attracted the committee’s scrutiny was the history of the ATSB’s formation with civil aviation as just one element of a multi-modal investigator that also covers the maritime and rail environments – an aspect that may have diluted the level of aviation expertise as air safety experts transferred from the regulator to the newly established ATSB. The committee comments: “to address these shortcomings, the committee was told that the theoretical internal investigator courses the ATSB conducts simply cannot replace technical experience, and should be supplemented with training offered by the NTSB [USA] and AAIB [UK]. The committee supports this view.”
6.The committee recommends that as far as available resources allow, ATSB investigators be given access to training provided by the agency’s international counterparts. When this does not occur, resultant gaps in training competence must be advised to the Minister and the Parliament.
Interaction with international counterparts has always been a popular concept at the workface both in regulation and accident investigation. The notion of learning from other agencies however has not been embraced to the same degree, and in some cases has been scornfully rejected. A senior NZCAA official once recounted to us that when both New Zealand and Australia were setting out on the path to regulatory reform and New Zealand was already leading by a couple of laps, the offer was made to the Australian regulator to sell us the entire NZ program on a floppy disk for $1 million. It is some time since the ongoing programme in Australia has been costed, but it must by now be close to $½ billion.
...oh well here is R7 :
7.The committee recommends that The Transport Safety Investigation Act 2003 be amended to require that the chief commissioner of the ATSB be able to demonstrate extensive aviation safety expertise and experience as a prerequisite for the selection process.
Two diversions to Mildura and VB allegedly very low on fuel landing below minima suggest that There might be a safety issue here regarding fuel policy and a rather abrupt (unforecast?) change of TAF to fog.
I note the Pel Air incident had the same ingredients - a rapidly changing forecast and fuel policy matter.
Shove that into your matrix Mr. Dolan.
Is the VB pilot going to be hung out to dry by CASA like Dominic James was?
Please explain, inquiring minds want to know. We have had at least Three warnings now that all is not well.
I note the Pel Air incident had the same ingredients - a rapidly changing forecast and fuel policy matter.
Shove that into your matrix Mr. Dolan.
Is the VB pilot going to be hung out to dry by CASA like Dominic James was?
Please explain, inquiring minds want to know. We have had at least Three warnings now that all is not well.
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Well under Beakers 'beyond Reason' methodology an emergency fuel diversion wouldn't raise a heckle anyway. Hell a smoking hole would only be classed as a low level incident!
Speaking of fuel, can anybody confirm whether VA have actually introduced new policy? I paxed 3 return sectors last week for business , 6 different aircraft for a total of 6 flights. Each aircraft was stinking hot, minimal to nil aircon until climb. No U/S APU's, just stinking hot onboard with plenty of pax whinging, including myself. I am curious whether a policy has been introduced? If it has it is not a good one. If my flights next week are a replica of last week I may go back to the Rat for a month or two.
Three weeks ago the flights felt cooler??
Speaking of fuel, can anybody confirm whether VA have actually introduced new policy? I paxed 3 return sectors last week for business , 6 different aircraft for a total of 6 flights. Each aircraft was stinking hot, minimal to nil aircon until climb. No U/S APU's, just stinking hot onboard with plenty of pax whinging, including myself. I am curious whether a policy has been introduced? If it has it is not a good one. If my flights next week are a replica of last week I may go back to the Rat for a month or two.
Three weeks ago the flights felt cooler??
Last edited by 004wercras; 18th Jun 2013 at 06:37.
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Hey sunny speaking about "diversions"
This event could be a very handy "diversion" from the senate estimates.
Shut them down!!!...........................
Well they shut Tiger down for a lot less!!
This event could be a very handy "diversion" from the senate estimates.
Shut them down!!!...........................
Well they shut Tiger down for a lot less!!
Last edited by thorn bird; 18th Jun 2013 at 07:54.
Pick the trend…???
Slight thread drift but there is relevance and as Sunny points out…perhaps a hole passing through a slice of Swiss cheese??
spelling nazi’s post on the thread dealing with this subject ‘spells’ it out best then Captain Claret brings in some ‘clarity’!
Captain Claret:
And 777 Steve makes a comment on Ben’s article that perhaps puts a better perspective on this tale:
Okay clear as mud yet??
No well perhaps we should look at the information that was available to the aircrew (other than the TTFs)and place it against the tracking info for the flight:
And the tracking info can be viewed ‘here’.
The TOPD time to YPAD appears to be 08:53 EST or 22:53 UTC and the amended TAF was issued at 2100 UTC and wetbulb temp=drybulb temp from at least 2030 UTC…so could you have picked the trend prior to TOPD?
Perhaps this incident is more relevant to the previous inquiry (Pilot Training and Airline Safety) and Mr Lyon’s 'submission 18' but there are definitely some similarities to the Norfolk ditching in the area of wx forecasts etc…but I’ve drifted enough and people can draw their own parallels (or not??). Oh well back to those recommendations...
By the way the ATSB investigation has started just don't hold your breath...
Investigation: AO-2013-100 - Low fuel diversion involving Boeing 737-8FE, VH-YIR, Mildura Airport, Victoria on 18 June 2013
Lefty can't track a YMIA TAF for yesterday maybe someone on the other thread can help you out...someone did mention YMIA had a prob of fog on at the time and that also seems to be fairly standard for this time of the year just look at today's TAF..??
spelling nazi’s post on the thread dealing with this subject ‘spells’
it out best then Captain Claret brings in some ‘clarity’! Captain Claret:
Just musing out loud...
I wonder if the airline's (collectively not just Virgin) bean counters had been on board enroute to the World Bean Counter's AGM in ADL, and had all had to go through the experience, including the BRACE, BRACE, BRACE; would they continue to advocate minimalist legal fuel "because statistically you'll just carry it for the sake of carrying it"?
Or would the experience, actually having some fear of the outcome, change their statistical outlook to permit the sensible carriage of an alternate, whether the current rules require it or not?
Hmmmm.
I wonder if the airline's (collectively not just Virgin) bean counters had been on board enroute to the World Bean Counter's AGM in ADL, and had all had to go through the experience, including the BRACE, BRACE, BRACE; would they continue to advocate minimalist legal fuel "because statistically you'll just carry it for the sake of carrying it"?
Or would the experience, actually having some fear of the outcome, change their statistical outlook to permit the sensible carriage of an alternate, whether the current rules require it or not?
Hmmmm.
Posted June 18, 2013 at 7:13 pm | Permalink
Aircraft operated under CASA oversight are legally entitled to dispatch without fuel to reach an alternate under IFR rules.
Australia is almost unique in this regard and as recent events have borne out, it trails the world in what is considered best practice with respect to flights operated with an alternate that is available. That is of course not to say that extra fuel isn’t uplifted to account for operational contingencies, I’m merely pointing out that in most circumstances a VH registered airliner flying domestically can legally commence its descent with no ability to, reach an alternate.
Why YSSY YBBN or YPPH don’t invest in CAT3 A or B is beyond me, but maybe that’s the point..it requires investment, investment that doesn’t provide a financial return..merely a higher level of operational flexibility, something the airport operators can’t make money off.
With respect to ATC Ben, having been in a similar circumstance when our destination was downgraded to CAT2 thanks to an equipment failure, I’d suggest the crew(s) most likely asked ATC what and where was still open and accepting arrivals, and then decided where to go. Unless you have an F18 off your wingtip, it remains the PIC’s decision…despite what many ATCO’s working for ASA would like to think.
Aircraft operated under CASA oversight are legally entitled to dispatch without fuel to reach an alternate under IFR rules.
Australia is almost unique in this regard and as recent events have borne out, it trails the world in what is considered best practice with respect to flights operated with an alternate that is available. That is of course not to say that extra fuel isn’t uplifted to account for operational contingencies, I’m merely pointing out that in most circumstances a VH registered airliner flying domestically can legally commence its descent with no ability to, reach an alternate.
Why YSSY YBBN or YPPH don’t invest in CAT3 A or B is beyond me, but maybe that’s the point..it requires investment, investment that doesn’t provide a financial return..merely a higher level of operational flexibility, something the airport operators can’t make money off.
With respect to ATC Ben, having been in a similar circumstance when our destination was downgraded to CAT2 thanks to an equipment failure, I’d suggest the crew(s) most likely asked ATC what and where was still open and accepting arrivals, and then decided where to go. Unless you have an F18 off your wingtip, it remains the PIC’s decision…despite what many ATCO’s working for ASA would like to think.
No well perhaps we should look at the information that was available to the aircrew (other than the TTFs)and place it against the tracking info for the flight:
TAF YPAD 171703Z 1718/1824 VRB05KT 9999 FEW030 SCT045 FM181000 VRB05KT CAVOK RMK
TAF AMD YPAD 172100Z 1721/1824 05005KT 9999 FEW025 FM180000 VRB05KT 9999 FEW030 SCT045 FM181000 VRB05KT CAVOK PROB30 1721/1724 0500 FG RMK
METAR YPAD 172030Z 08005KT 9999 FEW022 05/05 Q1019 NOSIG
METAR YPAD 172100Z 05004KT 9999 FEW022 05/05 Q1019 NOSIG
SPECI YPAD 172111Z 06005KT 9999 MIFG FEW022 SCT058 05/05 Q1020 NOSIG
METAR YPAD 172130Z 06004KT 9999 MIFG FEW022 05/04 Q1020 NOSIG
SPECI YPAD 172130Z 06004KT 9999 MIFG FEW022 05/04 Q1020 NOSIG
SPECI YPAD 172200Z 01006KT 9999 1000NW PRFG MIFG FEW022 05/05 Q1020 FM2200 01005KT 0500 FG FM2300 05005KT 9999 FEW025
SPECI YPAD 172205Z 01006KT 2000 0500N FG FEW022 05/04 Q1020 FM2205 01005KT 0500 FG FM2300 05005KT 9999 FEW025
SPECI YPAD 172215Z 02006KT 0500 0250N FG OVC001 05/04 Q1020 FM2300 05005KT 9999 FEW025
SPECI YPAD 172230Z 04005KT 0150 FG OVC001 06/05 Q1020 FM2300 05005KT 9999 FEW025
METAR YPAD 172230Z 04005KT 0150 FG OVC001 06/05 Q1020 FM2300 05005KT 9999 FEW025
SPECI YPAD 172300Z 04006KT 0150 FG OVC000 06/06 Q1021 FM2330 05005KT 9999 FEW025
METAR YPAD 172300Z 04006KT 0150 FG OVC000 06/06 Q1021 FM2330 05005KT 9999 FEW025
SPECI YPAD 172330Z 04005KT 0150 FG OVC000 07/07 Q1021 FM2400 05005KT 9999 FEW025
METAR YPAD 180000Z 01005KT 0150 FG OVC000 08/07 Q1021 FM0100 05005KT 9999 FEW025
SPECI YPAD 180000Z 01005KT 0150 FG OVC000 08/07 Q1021 FM0100 05005KT 9999 FEW025
SPECI YPAD 180030Z 01004KT 0150 FG OVC000 08/08 Q1022 FM0100 05005KT 9999 FEW025
SPECI YPAD 180100Z 03001KT 0500 0350N FG OVC001 09/09 Q1022 FM0130 05005KT 9999 FEW025
TAF AMD YPAD 172100Z 1721/1824 05005KT 9999 FEW025 FM180000 VRB05KT 9999 FEW030 SCT045 FM181000 VRB05KT CAVOK PROB30 1721/1724 0500 FG RMK
METAR YPAD 172030Z 08005KT 9999 FEW022 05/05 Q1019 NOSIG
METAR YPAD 172100Z 05004KT 9999 FEW022 05/05 Q1019 NOSIG
SPECI YPAD 172111Z 06005KT 9999 MIFG FEW022 SCT058 05/05 Q1020 NOSIG
METAR YPAD 172130Z 06004KT 9999 MIFG FEW022 05/04 Q1020 NOSIG
SPECI YPAD 172130Z 06004KT 9999 MIFG FEW022 05/04 Q1020 NOSIG
SPECI YPAD 172200Z 01006KT 9999 1000NW PRFG MIFG FEW022 05/05 Q1020 FM2200 01005KT 0500 FG FM2300 05005KT 9999 FEW025
SPECI YPAD 172205Z 01006KT 2000 0500N FG FEW022 05/04 Q1020 FM2205 01005KT 0500 FG FM2300 05005KT 9999 FEW025
SPECI YPAD 172215Z 02006KT 0500 0250N FG OVC001 05/04 Q1020 FM2300 05005KT 9999 FEW025
SPECI YPAD 172230Z 04005KT 0150 FG OVC001 06/05 Q1020 FM2300 05005KT 9999 FEW025
METAR YPAD 172230Z 04005KT 0150 FG OVC001 06/05 Q1020 FM2300 05005KT 9999 FEW025
SPECI YPAD 172300Z 04006KT 0150 FG OVC000 06/06 Q1021 FM2330 05005KT 9999 FEW025
METAR YPAD 172300Z 04006KT 0150 FG OVC000 06/06 Q1021 FM2330 05005KT 9999 FEW025
SPECI YPAD 172330Z 04005KT 0150 FG OVC000 07/07 Q1021 FM2400 05005KT 9999 FEW025
METAR YPAD 180000Z 01005KT 0150 FG OVC000 08/07 Q1021 FM0100 05005KT 9999 FEW025
SPECI YPAD 180000Z 01005KT 0150 FG OVC000 08/07 Q1021 FM0100 05005KT 9999 FEW025
SPECI YPAD 180030Z 01004KT 0150 FG OVC000 08/08 Q1022 FM0100 05005KT 9999 FEW025
SPECI YPAD 180100Z 03001KT 0500 0350N FG OVC001 09/09 Q1022 FM0130 05005KT 9999 FEW025
The TOPD time to YPAD appears to be 08:53 EST or 22:53 UTC and the amended TAF was issued at 2100 UTC and wetbulb temp=drybulb temp from at least 2030 UTC…so could you have picked the trend prior to TOPD?
Perhaps this incident is more relevant to the previous inquiry (Pilot Training and Airline Safety) and Mr Lyon’s 'submission 18' but there are definitely some similarities to the Norfolk ditching in the area of wx forecasts etc…but I’ve drifted enough and people can draw their own parallels (or not??). Oh well back to those recommendations...
By the way the ATSB investigation has started just don't hold your breath...
Investigation: AO-2013-100 - Low fuel diversion involving Boeing 737-8FE, VH-YIR, Mildura Airport, Victoria on 18 June 2013
Lefty can't track a YMIA TAF for yesterday maybe someone on the other thread can help you out...someone did mention YMIA had a prob of fog on at the time and that also seems to be fairly standard for this time of the year just look at today's TAF..??
TAF YMIA 190407Z 1906/1918
VRB05KT CAVOK
PROB30 1915/1918 0500 FG
RMK
T 13 09 05 04 Q 1023 1024 1025 1024
VRB05KT CAVOK
PROB30 1915/1918 0500 FG
RMK
T 13 09 05 04 Q 1023 1024 1025 1024
Last edited by Sarcs; 19th Jun 2013 at 06:41.
Would you also have the Mildura forecasts Sarcs?
A lot of parallels to the Norfolk incident. A tale of two crews really. Both crews find themselves at an airport with no fuel to go anywhere else and the weather is below the minima. A perfect discussion for a Command Ground School.
A lot of parallels to the Norfolk incident. A tale of two crews really. Both crews find themselves at an airport with no fuel to go anywhere else and the weather is below the minima. A perfect discussion for a Command Ground School.
Thanks Sarcs Given the ATSB states that they were holding:
The Mildura forecast takes on a whole new importance. I imagine that had their been any doubt about the mildura forecast then they would have continued to Adelaide and autolanded with more confidence.
Given the ATSB states that they were holding:
During the cruise, the weather at Adelaide deteriorated and the
aircraft commenced an extended holding pattern. While holding, the crew declared a fuel emergency and diverted to Mildura, Victoria.
aircraft commenced an extended holding pattern. While holding, the crew declared a fuel emergency and diverted to Mildura, Victoria.
Continued drift..Ben's latest!
Drifting along...oh well go with it...
Hmm maybe R25...
...should be amended to..."caution with regard to all Australian airport forecasts where the actual conditions can change rapidly and vary from forecasts"...
ATSB investigating Virgin Mildura fog incident
The ATSB has launched an inquiry into yesterday’s emergency landing at a fog bound Mildura airport by a Virgin Australia 737-800 which declared a fuel emergency after fog closed Adelaide airport.
It described the incident as ‘serious’.
This inquiry is understood to be among the very few cases that a serious fuel related incident involving an Australian airliner of size has come under scrutiny.
The ATSB will have the benefit of first person accounts of the incident not only from the pilots, but it is understood, from persons who were among the more than 90 passenger and crew onboard the flight from Brisbane to Adelaide.
It will also have recourse to a video taken on the ground at Mildura Airport of the incident and limited visibility that applied at the time, when the Virgin Australia 737 made two missed approaches prior to its landing.
Passengers were told to brace before the landing, an instruction consistent with preparation for a crash.
If the inquiry meets the expectations of concerned pilots and other interested parties it will ask questions about the Bureau of Meteorology forecasts for conditions at Adelaide which were taken into account by the pilots and flight planners affected by that airport’s unexpected closure, as well as advice that Mildura was clear when the Qantas and Virgin flights that then diverted to it found it seriously fog affected.
It will also need to address the fuel policies or rules which apply to flights like those which had already been affected by a series of serious and often unforecast fogs at SE Australia airports this autumn and early winter before yesterday’s Mildura incident.
Are these rules adequate if they leave airliners in a position where they have no alternative but to land in poor visibility because of insufficient fuel for longer holding patterns or a long return to airport of departure or a more distant alternative airport?
The spotlight will be on the ATSB for such questions and answers, in a winter which has only just started, and has been unusually foggy. It is an incident of significant safety importance.
The ATSB has launched an inquiry into yesterday’s emergency landing at a fog bound Mildura airport by a Virgin Australia 737-800 which declared a fuel emergency after fog closed Adelaide airport.
It described the incident as ‘serious’.
This inquiry is understood to be among the very few cases that a serious fuel related incident involving an Australian airliner of size has come under scrutiny.
The ATSB will have the benefit of first person accounts of the incident not only from the pilots, but it is understood, from persons who were among the more than 90 passenger and crew onboard the flight from Brisbane to Adelaide.
It will also have recourse to a video taken on the ground at Mildura Airport of the incident and limited visibility that applied at the time, when the Virgin Australia 737 made two missed approaches prior to its landing.
Passengers were told to brace before the landing, an instruction consistent with preparation for a crash.
If the inquiry meets the expectations of concerned pilots and other interested parties it will ask questions about the Bureau of Meteorology forecasts for conditions at Adelaide which were taken into account by the pilots and flight planners affected by that airport’s unexpected closure, as well as advice that Mildura was clear when the Qantas and Virgin flights that then diverted to it found it seriously fog affected.
It will also need to address the fuel policies or rules which apply to flights like those which had already been affected by a series of serious and often unforecast fogs at SE Australia airports this autumn and early winter before yesterday’s Mildura incident.
Are these rules adequate if they leave airliners in a position where they have no alternative but to land in poor visibility because of insufficient fuel for longer holding patterns or a long return to airport of departure or a more distant alternative airport?
The spotlight will be on the ATSB for such questions and answers, in a winter which has only just started, and has been unusually foggy. It is an incident of significant safety importance.
Recommendation 25
9.108 The committee recommends that the Aeronautical Information Package (AIP) En Route Supplement Australia (ERSA) is updated to reflect the need for caution with regard to Norfolk Island forecasts where the actual conditions can change rapidly and vary from forecasts.
9.108 The committee recommends that the Aeronautical Information Package (AIP) En Route Supplement Australia (ERSA) is updated to reflect the need for caution with regard to Norfolk Island forecasts where the actual conditions can change rapidly and vary from forecasts.
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Thorn bird
This page from the thread discussed the issues around reporting to the Atsb
http://www.pprune.org/australia-new-...011-a-104.html
The shocker is that Pel Air and Beaker has left the Atsb credibility questioned by many.
This page from the thread discussed the issues around reporting to the Atsb
http://www.pprune.org/australia-new-...011-a-104.html
The shocker is that Pel Air and Beaker has left the Atsb credibility questioned by many.
Last edited by halfmanhalfbiscuit; 19th Jun 2013 at 17:29.
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Where to begin.
To sort out the 'Mildura' issues is going to be a big job. Clearly there are major corporate, crew, meteorological and on the fringes, legislative issues. Although I feel the 'regs' are blameless this time – the Australian fuel policy is useful, flexible and with a little common sense tweaking works fine, for grown ups capable of taking responsibility and allowed to make decisions, although it does expect that the crews can look at the presented forecast, make an informed decision and order an extra few, discretionary drops of fuel – (to be sure, to be sure). Or to bugger off somewhere else before things get too 'tight'.
Once again, there are deep issues involved, BoM practice, methodology and policy. Corporate pressures, operational policy, pilot training, human factors; etc. in fact, all the parts of a crash puzzle except without body parts melded with aircraft parts, for the third time.
Mildura is a serious, but subtle event. Now, can our compromised ATSB sort it out before centuries end?. Will the report have any value?. Is the political will, savvy and interest required to make the recommendations stick there?. Or will we just end up with the 'company has amended their policy' etc; or, two crews re sitting their ATPL Met exams a' la the Chambers system. Or perhaps, McComic will just blame the whole shemozzle on the ills of society, con yet another minister and leave the spin to those who know how best to do it. One thing the Senate has achieved though, there will no disgustingly obvious cover up; not this time.
I don't know which concerns me the most: but close to the top of the list must be that two, not one, but two separate airlines finished up, operationally compromised, landing in less than ideal conditions, at Mildura. A foggy day should end with multiple complaints to management due to delays, missed connections, changes to crew rosters and a higher fuel bill; not with a full on declared fuel emergency and Brace, brace, brace.
Winter fog in Australia is not 'unusual', there are a few options available; delay, divert, hold and divert. All corporately unpalatable and operationally problematic; but, rock solid safe. A skipper has all of those options available, fully supported by law. The 'company' policy does not signify.
One concern, worthy of some consideration is 'crew attitude' and whether the ATSB has the balls to tackle the subliminal pressures to 'be on schedule', minimise fuel uplift and yet manage to not compromise or embarrass the company. Why did both crews not throw on 'gas for Mum'?. The little alarm bells of experienced crew, going south, early morning, in winter with the ambient weather conditions should ring, and a discreet, prudent 30 or even a big fat 60 minutes could be 'smuggled' inboard without adverse operational comment. Did two, not one, well fed, rested crews not 'see' the possibility of fog and take appropriate measures, I doubt it.. "One is unfortunate, two begins to look like carelessness". I believe we are allowed to ask why, just in case the nanny state or corporate dogma has managed to brainwash or bully a more politically correct generation of pilots, without denigrating the crews involved.
Three incidents, no bodies. Lucky country ? you bet.
Brace, brace, brace.
CP # 107......
..
Once again, there are deep issues involved, BoM practice, methodology and policy. Corporate pressures, operational policy, pilot training, human factors; etc. in fact, all the parts of a crash puzzle except without body parts melded with aircraft parts, for the third time.
Mildura is a serious, but subtle event. Now, can our compromised ATSB sort it out before centuries end?. Will the report have any value?. Is the political will, savvy and interest required to make the recommendations stick there?. Or will we just end up with the 'company has amended their policy' etc; or, two crews re sitting their ATPL Met exams a' la the Chambers system. Or perhaps, McComic will just blame the whole shemozzle on the ills of society, con yet another minister and leave the spin to those who know how best to do it. One thing the Senate has achieved though, there will no disgustingly obvious cover up; not this time.
I don't know which concerns me the most: but close to the top of the list must be that two, not one, but two separate airlines finished up, operationally compromised, landing in less than ideal conditions, at Mildura. A foggy day should end with multiple complaints to management due to delays, missed connections, changes to crew rosters and a higher fuel bill; not with a full on declared fuel emergency and Brace, brace, brace.
Winter fog in Australia is not 'unusual', there are a few options available; delay, divert, hold and divert. All corporately unpalatable and operationally problematic; but, rock solid safe. A skipper has all of those options available, fully supported by law. The 'company' policy does not signify.
One concern, worthy of some consideration is 'crew attitude' and whether the ATSB has the balls to tackle the subliminal pressures to 'be on schedule', minimise fuel uplift and yet manage to not compromise or embarrass the company. Why did both crews not throw on 'gas for Mum'?. The little alarm bells of experienced crew, going south, early morning, in winter with the ambient weather conditions should ring, and a discreet, prudent 30 or even a big fat 60 minutes could be 'smuggled' inboard without adverse operational comment. Did two, not one, well fed, rested crews not 'see' the possibility of fog and take appropriate measures, I doubt it.. "One is unfortunate, two begins to look like carelessness". I believe we are allowed to ask why, just in case the nanny state or corporate dogma has managed to brainwash or bully a more politically correct generation of pilots, without denigrating the crews involved.
Three incidents, no bodies. Lucky country ? you bet.
Brace, brace, brace.
CP # 107......
..
Last edited by Kharon; 19th Jun 2013 at 23:02.
I don't think some here understand the problem these incidents have created for CASA and ATSB and thus air safety in general.
That problem is that any safety report and / or regulatory action taken has to be seen to be absolutely consistent with the actions taken in the Pel Air case, otherwise ATSB and CASA become complete laughing stocks!
While there will no doubt be a great deal of hair splitting and drawing of fine distinctions to explain why this was a minor event of no great import, compared with the Norfolk ditching, the problem is the same even if the outcome is different - pilots (2 crews!) of Qantas and Virgin got caught with inadequate fuel and a fast changing weather forecast who had nowhere else to go. Both apparently landed below minima, at least Dominic James didn't try that!
The absence of candour at the ATSB and the lack of leadership, natural justice, procedural fairness and equity from CASA as revealed in the Senate report, is appalling.
That problem is that any safety report and / or regulatory action taken has to be seen to be absolutely consistent with the actions taken in the Pel Air case, otherwise ATSB and CASA become complete laughing stocks!
While there will no doubt be a great deal of hair splitting and drawing of fine distinctions to explain why this was a minor event of no great import, compared with the Norfolk ditching, the problem is the same even if the outcome is different - pilots (2 crews!) of Qantas and Virgin got caught with inadequate fuel and a fast changing weather forecast who had nowhere else to go. Both apparently landed below minima, at least Dominic James didn't try that!
The absence of candour at the ATSB and the lack of leadership, natural justice, procedural fairness and equity from CASA as revealed in the Senate report, is appalling.
Last edited by Sunfish; 19th Jun 2013 at 23:53.