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3 years later The Mildura report

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3 years later The Mildura report

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Old 4th Jun 2016, 07:28
  #101 (permalink)  
 
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Great to hear. All is not completely wrong with the world then
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Old 4th Jun 2016, 10:46
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Reactive forecasting was known as "pastcasting" in my day.
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Old 4th Jun 2016, 13:16
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Originally Posted by Chris2303
Reactive forecasting was known as "pastcasting" in my day.
Also know as "ass covering" Chris.

Can also be applied to fixing an AWIS, which was U/S for a month, the day after a major incident.
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Old 4th Jun 2016, 22:24
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A number of posts as well as the report mention the crew could have done an Autoland in the low vis conditions. Whilst it might be an absolute last resort option it carries a large risk.

There is a very good reason why an airport is only classified Cat 1 and not Cat 2/3. It is not a "free get out of jail card" as many pilots seem to think. It has a large risk associated with it, namely it is not guaranteed to deliver the aircraft to the correct position on the runway.

Australia is about the only country that I am aware of that allows "practice autolands" to Cat 1 runways. It was not permitted when I was operating O/S. All autolands in whatever met conditions were only permitted on certified Cat 2/3 runways.
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Old 4th Jun 2016, 22:45
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Quote...."Australia is about the only country that I am aware of that allows "practice autolands" to Cat 1 runways. It was not permitted when I was operating O/S. All autolands in whatever met conditions were only permitted on certified Cat 2/3 runways."

We do them Into KPHX Rwy 26..... Authorized in VFR conditions only.....there are about 5 others in the system.
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Old 4th Jun 2016, 23:21
  #106 (permalink)  
 
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Australia is about the only country that I am aware of that allows "practice autolands" to Cat 1 runways. It was not permitted when I was operating O/S. All autolands in whatever met conditions were only permitted on certified Cat 2/3 runways.
I work overseas and we have approvals for autolands at a good many airports that only have Cat I runways, and most of them AREN'T in Australia. In fact, our SOPs recommend an autoland any time the vis is below 1,500m or cloud base below 300ft, assuming the runway is autoland approved.
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Old 4th Jun 2016, 23:36
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If the crew had of decided upon an auto land in ADL (of course that option was taken away from them once they were misled by BoM, a U/S AWIS and ATC into a diversion to MIA) they would have no doubt been criticised, once again, by the Monday morning quarterback (ATSB).

While not technically legal, given the circumstances, an auto land off a Cat 1 ILS is a far better option than landing below minima off an RNAV non precision approach. Could you imagine the outcome of this incident had it happened during the days before runway aligned RNAV approaches? I doubt a landing off a VOR approach would have ended as well as it did. Although, in the days before GPS we also has a far more robust system of competent ATC/BoM and functioning infrastructure such that this incident probably wouldn't have happened in the first place.

The crux is, whatever decision made by the crew, they will always be criticised by a regulator more concerned with deflecting blame from its cosy mates in other government agencies rather than finding and fixing the real causes.

I think we here are all in agreement though that the crews of both aircraft did a remarkable job, in extremely stressful conditions which were not of their own making, to safely deliver their aircraft, crew and passengers to terra firma. I'm sure those on board are grateful of your skills.
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Old 5th Jun 2016, 07:22
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Well said IsDon.
It is good that Virgin recognised the good work their crew did.
Did QF do anything for their crew? Anyone know?
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Old 5th Jun 2016, 07:39
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Odd that the report was quite detailed about what happened in the Virgin 737 fuel-wise (and FDR/CVR) but not a word on the QF operation, save the original departure fuel and expected burn, unless I missed a bit...
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Old 5th Jun 2016, 07:56
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Pistenbroke,

I don't think anyone on this site or otherwise is advocating autoland on a cat 1/non autoland ILS is an inherently safe or good thing to do.

But it's many, many magnitudes safer than coupling an RNAV and flying it into the ground and hoping you hit the runway. It is not ideal, but a much better alternative to what eventually had to be done due to BoM and ASA shortcomings.

I can't believe ASA weren't destroyed by ATSB in this report for allowing AWIS unserviceability for so long, and then fixing it the day after.

Hello ATSB, anyone home???
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Old 5th Jun 2016, 08:28
  #111 (permalink)  
 
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I can't believe ASA weren't destroyed by ATSB in this report
Between this report and Norfolk ditching fiasco, any sane professional will have absolute surety that there is no longer an independent investigator in the industry.

CASA, ASA & the ATSB will collude, cover-up & throw you under the bus in a heartbeat to protect themselves from their own grave failings.

Fuel order & manage fatigue accordingly!
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Old 5th Jun 2016, 10:25
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IsDont
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.
The reason I suggest a maximum of 6 months is so any major occurrence is a "learning opportunity", not a history lesson.

I want my ATSB to be impartial, that is, unbiased, unprejudiced, neutral, non-partisan, non-discriminatory, dispassionate, objective, open-minded, equitable, even-handed, fair, fair-minded, just; without favouritism, free from discrimination, with no axe to grind, without fear or favour.

I want my ATSB to be properly resourced with sufficient qualified staff so that reports are released no later 6 months after the occurrence.
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Old 5th Jun 2016, 10:57
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Originally Posted by sunnySA
IsDont
I want my ATSB to be impartial, that is, unbiased, unprejudiced, neutral, non-partisan, non-discriminatory, dispassionate, objective, open-minded, equitable, even-handed, fair, fair-minded, just; without favouritism, free from discrimination, with no axe to grind, without fear or favour.
You mean everything the ATSB currently isn't?

I want that too.

But if you think more money is going to fix the ATSB then you're delusional.
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Old 5th Jun 2016, 10:58
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The answer to the problem of an emasculated ATSB is to remove it from under the jurisdiction of the Dept of Transport, or whatever it goes under these days. The problem is that CASA and Airservices Australia come under the same umbrella and accordingly, you get that self-serving memorandum of understanding that neither will heap rubbish on the other, no matter how well deserved it may be. The only one to benefit from it is the Permanent Head of the department as he doesn't have to answer embarrassing questions to his/her Minister, but certainly not aviation.
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Old 5th Jun 2016, 11:33
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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?
The crux is, whatever decision made by the crew, they will always be criticised by a regulator more concerned with deflecting blame from its cosy mates in other government agencies rather than finding and fixing the real causes.

As much as we all love to bag the ATSB and other government bodies, are you not overlooking one tiny, but very important point? According to ICAO Annex 13:
"The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability."
In my view, the ATSB didn't blame the aircrew involved in this incident. Indeed, the safety issues that were raised were directed squarely at ASA and the BoM. My biggest gripe is that it took them so bloody long to release the report. I suspect that's mainly a resources issue, as sunnySA said earlier.

Last edited by BuzzBox; 5th Jun 2016 at 13:31.
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Old 5th Jun 2016, 12:15
  #116 (permalink)  
 
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The only way forward from this is that the operator mandates far more operational requirements in operating to an airport (Non regulatory).

Destinations should carry an alternate with precision approach that requires generous viz and cloud ceiling forecasts. The reality is that some of those airports may be several hundred miles away, most international airlines operate this way. Oz airlines need to step back from the regulatory minimums and start carrying more fuel.

The cutbacks in the BOM and unreliable weather updates from operational staff will lead to another disaster. It is through sheer luck they haven't had and airliner off a runaway or floating in the sea.

CASA will regulate to to a minimum that doesn't upset QF, other airlines should work above that.
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Old 5th Jun 2016, 13:45
  #117 (permalink)  
 
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Unfortunately, BoM aviation forecasts have never been particularly accurate, but there has never been any studies or stats kept to see exactly how accurate/inaccurate they are. At the end of the day it is just educated guessing. Because the regs dictate that only BoM weather can be used operationally, airlines are hamstrung even if they want to use in-house forecasting. There is no competition, and no accountability. The regulator won't change anything, as they don't want different carriers using different interpretations to work out individual fuel requirements, and likely feel that airline's Met. Depts would always forecast a little more sympathetically, shall we say.
Part of the procedural problem also is that the system has not really adapted from the long ago abolition of Ops Control and Flight Service, in so far as their flight following duties went. Airlines have not had to develop their own dispatch/flight following (call it what you will), as they have always had the Service Provider do it for them. And frankly, there's not enough of them, and they are too busy doing what they are actually paid for - separating aircraft. That's probably why you only get weather updates an hour out. Either it's a tacit admission that the forecasts aren't much good outside that period, or they don't have the wherewithall to manage it more than that. Worrying about what the weather at your alternate is doing is probably not that high on the controllers priority list as he deals with the deteriorating traffic situation at your destination.
I guess the generally good weather in Australia has allowed this situation to develop, and the very rare "near miss " like this will probably not change it.
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Old 5th Jun 2016, 23:29
  #118 (permalink)  
 
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Worrying about what the weather at your alternate is doing is probably not that high on the controllers priority list as he deals with the deteriorating traffic situation at your destination.
That is a good point. Inbound to Sydney with a thunderstorm passing through the controllers sound like they are working at maximum capacity just to stack everyone up and give them an estimate of onwards clearance time. To expect them to be monitoring diversion port weather trends at the same time is unrealistic in my view. That's from a line driver, any controllers care to comment?
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Old 5th Jun 2016, 23:37
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From my recent time on the 767 flying the MEL-SYD-BNE triangle, the normal fuel load was around 10T.

To carry an extra Tonne of fuel cost between 30-40Kg of extra fuel burn over the sector. Seems like cheap insurance to me.

Quite why dispatch calculated the fuel to the kilo, sometimes as low as 9T, based on the fact that the weather was forecast to be 100' above the alternate minima never ceased to amaze me. A classic case of measuring with a micrometer and cutting with an axe.

Obviously very few took flight planned fuel. With such a short sector length, and such a minuscule cost to carry, why would you?
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Old 6th Jun 2016, 00:13
  #120 (permalink)  
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To play Devils advocate
I guess Qantas would fly more than 600 flights a day.
600 x $60 in extra fuel burn = $36000 a day x 365 days = $13,140,000 a year in extra fuel burn
Now it depends on if you are paying the bill or flying the aircraft how that affects you

Now if we were to put in fully capable ILS or GLS even at most big airports maybe that would be a cheaper solution in the long run.
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