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3 years later The Mildura report

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3 years later The Mildura report

Old 3rd Jun 2016, 00:32
  #81 (permalink)  
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Originally Posted by framer View Post
No. Only 100 feet.
My mistake - yes 100 feet - the point being, that the alternate minima can't be reduced with actual QNH - only the approach minima.
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Old 3rd Jun 2016, 00:51
  #82 (permalink)  
 
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UTR, you sure about that?

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

If the AWIS is NOTAMed out then obviously alternate minima can't be reduced. If it can be reasonably expected to be available, why not?
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Old 3rd Jun 2016, 01:07
  #83 (permalink)  
 
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When the flight service units were removed it is said that there was a marked reduction in the accuracy of weather reports, with attendant necessity to carry additional fuel to cover exigencies. And Mildura used to have a FSU.
MIldura had better than that during this event, a person actually trained in the weather:

Originally Posted by Page 18 of the report
...In response the forecaster contacted the BoM observer located at Mildura Airport.
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Old 3rd Jun 2016, 01:17
  #84 (permalink)  
 
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My interpretation of ditching = land or body of water

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

Perhaps I should have said out-landing.

Either way the aircraft would be pretty much screwed.
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Old 3rd Jun 2016, 01:25
  #85 (permalink)  
 
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MIldura had better than that during this event, a person actually trained in the weather...
True, but in this case the 'system' got in the way and made the observer's input all but useless by the time the information was relayed to the aircraft. I'm willing to bet that information about the deteriorating weather conditions would have been passed along a darn sight quicker back in the good old days of FSUs.
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Old 3rd Jun 2016, 01:43
  #86 (permalink)  
 
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A met observer can be anybody delegated by BOM. It may be your local baker or candle stick maker, not someone trained in meteorology, but able to read the gauges and dials. Just down the road it's a station owner.
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Old 3rd Jun 2016, 01:58
  #87 (permalink)  
 
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It may be your local baker or candle stick maker, not someone trained in meteorology, but able to read the gauges and dials. Just down the road it's a station owner.
Megan,
Don't downplay the knowledge and ability of the BoM observers, they have all completed BoM courses successfully. There is significant meteorological knowledge required, probably not much different to a PPL standard, plus the specific training to be an accredited BoM observer.
Tootle pip!!
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Old 3rd Jun 2016, 01:59
  #88 (permalink)  
 
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No one wants to take on my question?

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

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

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Old 3rd Jun 2016, 03:33
  #89 (permalink)  
 
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Originally Posted by *Lancer* View Post
No one wants to take on my question?

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

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

That because there isn't a hard answer Lancer.

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

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

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

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

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

Time for the ATSB to go.

Last edited by IsDon; 3rd Jun 2016 at 06:02.
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Old 3rd Jun 2016, 05:12
  #90 (permalink)  
 
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When can you commit?
Men don't like to commit, so the girls say.

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

Remember when we had operational control? Departed with a CAVOK report in hand, only to be told enroute the destination had been closed due weather, and what were the intentions re an alternate. No fuel for an alternate, nor holding, and FSU was told so. What are your intentions was the reply. Continue to destination was the only option open, and land in the crap weather was the answer, and duly executed.
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Old 3rd Jun 2016, 07:26
  #91 (permalink)  
 
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I must be too young to remember that Megan.
What was operational control? What is FSU?
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Old 3rd Jun 2016, 11:24
  #92 (permalink)  
 
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This incident, and the Norfolk Is debacle, have demonstrated that the ATSB has a way too cosy relationship with other government entitities and will seek to deflect blame from them at all costs. Including destroying the reputations and careers of the crews involved.

Time for the ATSB to go.
No, its time that ATSB was resourced correctly. The workload to complete such a comprehensive reports is time consuming. Time = money, more staff to share the workload. Then investigations such as this (and many others) are completed within a realistic and meaningful time period (i.e. 6 months maximum). I'm not privy to the number of ATC/Pilot investigators are employed by ATSB but if this report took 3 years then this means a large increase in investigators (x6).
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Old 3rd Jun 2016, 14:28
  #93 (permalink)  
 
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Do the Australian airlines have dispatchers that are required to monitor these changes and keep crews updated for every flight?

Itís a while since I flew in oz and we didnít really have such a system back then but I assumed things had evolved?
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Old 4th Jun 2016, 02:14
  #94 (permalink)  
 
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Originally Posted by sunnySA View Post
No, its time that ATSB was resourced correctly. The workload to complete such a comprehensive reports is time consuming. Time = money, more staff to share the workload. Then investigations such as this (and many others) are completed within a realistic and meaningful time period (i.e. 6 months maximum). I'm not privy to the number of ATC/Pilot investigators are employed by ATSB but if this report took 3 years then this means a large increase in investigators (x6).
What? So more money will stop the collusion?

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

It took three years because it took that long to cover up. So those really responsible could get their ducks in a row. When the proposed report is sent to those that should have been held responsible for their comments and amendments such that any failings can be washed from the final report to save any embarrassment for the government agency or minister responsible. That's what takes three years.
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Old 4th Jun 2016, 03:32
  #95 (permalink)  
 
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Are both crews still with their respective employers?

Last edited by gettin' there; 4th Jun 2016 at 03:32. Reason: Spelling
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Old 4th Jun 2016, 03:50
  #96 (permalink)  
 
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The VA Capt retired after a long and distinguished career.
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Old 4th Jun 2016, 04:33
  #97 (permalink)  
 
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This report is a complete joke.

The discussions here so far have missed the main point of this incident. I find a lot of similarities with the ATSBs handling of the disgraced Norfolk Is investigation and report on this incident. In both cases the ATSB has deliberately attempted to deflect any blame from BoM, CASA, Airsevices or any other government agency and has tried, and failed, to blame the crew.
Completely agree. Government departments spending three years getting each others' backsides covered before finally releasing the report and hanging the crew out to dry. Same as Pelair.

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

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

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

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

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

ATSB - complete joke, have lost all respect, in bed with regulator.
BOM - give them the money they need to get the forecasts right
ASA - stop wasting money on bullshit and spend it on infrastructure, like ILS and AWIS and maintenance
Pilots - do exactly what we were doing thirty years ago, with half the support, half the navaids, half the fuel - with the knowledge that if all the holes line up, you'll get hung out to dry by the ATSB.
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Old 4th Jun 2016, 04:43
  #98 (permalink)  
 
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oicur - in regards to dispatch in Oz, both QF and VA(and TT) are the only operators with 'real dispatch' in the full sense of the word in that it's a department that does both flight planning, and flight watch. JQ used to have it, but they now have a mixed model where their flight plans are done by a contractor in the Phillipines, and they have a Co-Ordinator in Oz that does any late min changes, and flight watches the EDTO flights. All other operators as far as I am aware, their pilots do their own planning, and they have no form of flight watching.

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

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

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

As stated in the report also - both VA and QF have their own Met department as well.
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Old 4th Jun 2016, 06:41
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Did either of these crews receive any sort of recognition of a job well done?

I've had a quick read of the report but will go through it more slowly next week, from what I have read there were several statements that could be read as an admonishment of the crews actions but no statements recognising that they achieved a safe outcome despite being set up by years of cost cutting projects in various departments and a dose of bad luck.
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Old 4th Jun 2016, 06:54
  #100 (permalink)  
 
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Yes, framer, they received much recognition. They won the CEO award for safety and the overall CEO award, and were flown to London (or was it Necker Island) for a function with Sir Richard and similar award recipients from other Virgin businesses.
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