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3 years later The Mildura report

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3 years later The Mildura report

Old 2nd Jun 2016, 04:20
  #61 (permalink)  
 
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Relax, it was a general statement, not intended to cast aspersions about the fuel state of the aircraft involved in this incident.
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Old 2nd Jun 2016, 04:37
  #62 (permalink)  
 
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Seriously though, I think this incident was a big wake up call for the 'system'.
You reckon? This morning, the joint had fog until 00. Then, at 2330 (us and others already enroute), BoM amends the TAF and puts on an Alternate until 0100! Not good enough! Reactive forcasting at it's best, just like Mildura.

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

Last edited by Capn Bloggs; 2nd Jun 2016 at 10:51. Reason: Spelling
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Old 2nd Jun 2016, 05:28
  #63 (permalink)  
 
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Bloggs,

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

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

So what's the solution? Should we always carry an alternate like they do overseas? Frankly, I'm disappointed the ATSB didn't at least consider that aspect during its investigation.
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Old 2nd Jun 2016, 05:31
  #64 (permalink)  
 
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hopefully we've all learnt to be a bit more sceptical about the absolute accuracy of weather forecasts
This is probably the most appropriate practical lesson for pilots.

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

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

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

Reactive forcasting at it's best
Agreed!

DIVOSH!
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Old 2nd Jun 2016, 05:49
  #65 (permalink)  
 
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Think unions / associations should approach virgin cpt to see if he would be interested in giving some talks to pilot groups ( Sully style ) about company flight plan fuel and how he feels about it ?
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Old 2nd Jun 2016, 05:59
  #66 (permalink)  
 
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the new non-pilot Dir of Flight Operations @ virgin will fix this
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Old 2nd Jun 2016, 06:17
  #67 (permalink)  
 
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Did it say somewhere in the ATSB report the aircraft experienced fuel exhaustion?
If fuel exhaustion damages the fuel system, how do aircraft with multiple fuel tanks get by when they run tanks down. In fact, doesn't the 737 have an auxiliary tank?

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

Think back to https://en.wikipedia.org/wiki/TWA_Flight_800 - since this event, centre fuel tanks of the early 747 series are never run dry. Somewhat relevant.
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Old 2nd Jun 2016, 07:12
  #68 (permalink)  
 
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Not relevant at all squawky. Any pumps that were dry on this landing would have been dry on a normal landing. The pumps that were working were just a bit shallower than normal. Your mate told you porkies.
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Old 2nd Jun 2016, 07:28
  #69 (permalink)  
 
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On the NG we run the Center tank pumps until the low pressure lights flicker of the gauge reads zero. It causes no damage.
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Old 2nd Jun 2016, 08:56
  #70 (permalink)  
 
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Buzzbox, thank you for the link, I am making my way through it, and this section caught my eye:
The use of en-route weather reports for updating operational decisions as a potential risk mitigant was examined to assess their capacity to provide a timely en-route warning that the destination weather would prevent a safe landing from being assured, thereby enabling an early diversion to an alternate airport.

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

The assumption that "timely en-route warnings" will be passed on to crew(s) as a mitigator goes to the heart of this incident, I also note this document was published in 2006.
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Old 2nd Jun 2016, 10:00
  #71 (permalink)  
 
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I learnt that the reliability of forecasts in this country were somewhat dubious after departing for an aerodrome with only a TEMPO for rain on it, and after my second missed approach after waiting about 45mins between approaches, to then have the forecast on it and all my other alternates around it, be changed to require an alternate and neither of them any better than my destination aerodrome, even though they all had a very similar forecast to begin with.

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

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

morno
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Old 2nd Jun 2016, 11:27
  #72 (permalink)  
 
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Thanks for the laugh Capn Bloggs.

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

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

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

Q3 If you land are you "legal"?

Q4 Will you report yourself.

Happy Days
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Old 2nd Jun 2016, 11:34
  #73 (permalink)  
 
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A forecast is based on probabilities. Just like at Randwick the low probability event occurs a commensurate amount of the time.
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Old 2nd Jun 2016, 12:14
  #74 (permalink)  
 
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CurtainTwitcher:

You're welcome! That Research Report has some interesting findings that are as relevant today as they were 10 years ago. Of all the risk mitigators they analysed, it's probably no surprise that the requirement to always carry an alternate provided a significant reduction in risk. From page 29:
"The requirement to always carry fuel to fly to at least one alternate was tested, and demonstrated a marked increase in safety. However, the numbers of events that met the criteria were sufficiently low that it was not possible to make any statistically significant analysis beyond stating that this requirement does create a significant reduction in risk.

The Australian operating environment is different from many parts of the world where a similar operational requirement is used, both because of its more benign operating environment, and because of the larger distances than normally exist between suitable alternate airports. These factors could both reduce the perceived need to make a requirement for the mandatory carriage of fuel for an extra alternate, and to make such a requirement more onerous with a greater fuel uplift."
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Old 2nd Jun 2016, 20:03
  #75 (permalink)  
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Surprised nobody has commented on this:

In order to use Mildura Airport as an alternate, the forecast cloud and visibility were required to be above the alternate minima. The alternate minima for runway 27 at Mildura for large jet aircraft were 1,233 ft and 6 km if the forecast QNH was used. This could be reduced to 1,133 ft if the actual aerodrome QNH was used (see below), although the visibility requirement remained at 6 km.
WTF? - if I flight plan to an airport and look up the current actual QNH then I can reduce the alternate minima by 100 feet? I plan alternate minima based on runway I might be using? Who writes this crap?

UTR

Last edited by UnderneathTheRadar; 3rd Jun 2016 at 01:28.
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Old 2nd Jun 2016, 21:19
  #76 (permalink)  
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As a non-RPT pilot who regularly makes the decision to stay home on crappy days (not that this would have been one of those days), I was thinking about the decision process regarding a) do I go to Mildura or b) autoland below minima at Adelaide.

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

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

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

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

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

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

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

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

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

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

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

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

UTR
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Old 2nd Jun 2016, 23:48
  #77 (permalink)  
 
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WTF? - if I flight plan to an airport and look up the current actual QNH then I can reduce the alternate minima by 1000 feet? I plan alternate minima based on runway I might be using? Who writes this crap?
No. Only 100 feet.
I think what a lot of people who write these reports, and many who comment on the reports don't have is an understanding of the mental processes going on real time for the crews when a situation like this is unfolding. It is fine and dandy to sit at a desk and flick through the regs to confirm that the crew should have technically made diversion decisions based on the TAF not on the observation.
It is a completely different thing to be doing 450kts across the ground using two tonne an hour and realising that the forecasts you based your fuel load on have been wrong and that your Plan A is not going to happen. When developing plan B information is gathered and options considered. Both crews were presented with information ( the Mildura met observation) that suggested a safe landing could be made at Mildura. At this point in time, when 'the system' is not working as advertised, real likely outcomes are more important to the crew than regulations. So they should be too, the crew have to make whatever decisions are necessary to keep their aircraft safe.
If this situation was presented to a new Captain in a simulator as a LOFT and the new Captain decided that holding in the hope that the unforecast fog cleared was a more appropriate decision than diverting to a field nearby that was reported as being open, many check Captains would debrief that as a new Captain, don't forget your primary role is to keep the aircraft safe and if you have to break the regs to do that,my then so be it.
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Old 2nd Jun 2016, 23:53
  #78 (permalink)  
 
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donpizmeov et al, replacement fuel system components were flown out the next day with a tech crew. Ask anyone at VA, it was hardly an internal secret at the time and was also mentioned in threads on this topic elsewhere.

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

I also heard a "rumour" that ditching was seriously contemplated...
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Old 3rd Jun 2016, 00:56
  #79 (permalink)  
 
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I also heard a "rumour" that ditching was seriously contemplated...
What!!!!! In the River Murray? About the most ridiculous suggestion made, ditching that is.

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

Last edited by megan; 3rd Jun 2016 at 01:20. Reason: FSU
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Old 3rd Jun 2016, 01:22
  #80 (permalink)  
 
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If I remember correctly at least one of the jets flew past Mildura on the way to Adelaide and at the time of passing was clear.

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

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

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

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