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3 years later The Mildura report

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3 years later The Mildura report

Old 6th Jun 2016, 11:51
  #141 (permalink)  
 
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FS never exercised Operational Control. That was an ATC responsibility. No one is debating about whether or not the pilot can choose to try an approach. The discussion is whether you can expect or should plan to have to attempt one in the first place. If you plan using faulty information, then continue while using other faulty information, you are in for a world of hurt when you finally get there. I don't care if you have 12 bars on your shoulders, if you arrive without the fuel to get in or to go somewhere else, your options are pretty limited. A couple of 737 drivers got themselves nearly painted into a corner. I can't see a whole lot changing to prevent it maybe happening again, just a lot of finger pointing.
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Old 6th Jun 2016, 23:35
  #142 (permalink)  
 
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I don't care if you have 12 bars on your shoulders, if you arrive without the fuel to get in or to go somewhere else, your options are pretty limited.
I think its just too easy to blame the pilots or say the answer is to carry more fuel. At least the Virgin aircraft had sufficient fuel to divert to YMML. YMEN or YMAV, not to mention YPWR, or possibly even maybe YPED (although it probably had Adelaide's fog).

The pilots made the decision to go to Mildura based on a very favourable forecast that was issued by the BOM despite the BOM knowing or having the ability to know that fog was forming at the time they issuing a good forecast.

Clearly they made a decision to go somewhere that the forecast suggest was blue sky with broken cloud, had fuel and their own company handling services plus a nice passenger terminal that was close to Adelaide so they could finish the trip after the fog lifted with minimal delay. It was a good decision on the information they were supplied.

If the pilots had access to AWIS, a ground observer, an accurate forecast or information on the missed approach was passed to them, then they may have made a different decision.

The funny thing, is that this is a circumstance where a GA pilot might have done better. Because GA pilots don't have the same information resources a GA pilot would probably have pulled out the mobile phone and rung someone on the ground and gotten a higher quality answer than these pilots collectively got from our government air traffic and meteorological services.
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Old 7th Jun 2016, 01:02
  #143 (permalink)  
 
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The pilots made the decision to go to Mildura based on a very favourable forecast that was issued by the BOM despite the BOM knowing or having the ability to know that fog was forming at the time they issuing a good forecast.

The report actually says something quite different:
"The 0358 amended TAF for Mildura that morning forecast light winds and scattered cloud at 3,000 ft and broken cloud at 6,000 ft. The TAF also included TEMPO periods between 0500 and 1000 in which the cloud base was forecast to reduce to 600 ft AGL.

A new routine TAF was issued for Mildura at 0902 that was valid from 1000. This TAF forecasted visibility in excess of 10 km and scattered cloud at 3,000 and 5,000 ft. No significant weather was listed on the TAF and no indication of low cloud or fog was given. Neither crew were aware of this TAF nor would they have been able to use this forecast in support of their decision to divert..."
"The METAR observation reports issued for Mildura at 0830 and 0900 showed light winds, visibility in excess of 10 km and the cloud lifting from broken at 3,400 to broken at 3,900 ft. These were the reports obtained by the crew of Velocity 1384 and Qantas 735 to assist their decision making about diverting to Mildura.

The BoM reported that their assessment of Mildura at around 0830 showed that low cloud was more likely to occur than fog. In addition, improved conditions could be expected from 1000 as the wind was forecast to tend southerly and both fog and low cloud were rare in a southerly flow at Mildura. Based on this information, the forecast for TEMPO conditions was continued.

At around 0900, weather recording instrumentation at Mildura started to indicate patches of low cloud at around 400 ft. A visual satellite image indicated a bank of low cloud south of Mildura indicating that the prediction of temporary (TEMPO) deteriorations was still appropriate."
With all due respect, it seems to me that it's quite wrong to suggest the aircraft based their diversion decisions on a 'very favourable forecast that was issued by the BOM despite the BOM knowing or having the ability to know that fog was forming at the time they issuing a good forecast'.

The first SPECI for low cloud at 200ft was issued at 0918, by which time both aircraft were already on their way to Mildura. That SPECI was not relayed to the aircraft and neither was an airborne report from an aircraft that departed Mildura at 0916. Thereafter, the visibility reduced rapidly from 28km to 1,000m between 0925 and 0931. Several SPECIS to that effect were issued between 0928 and 0932, the last of which was broadcast on the area frequency by the controller. However, CVR data showed that the crews were busy communicating on the CTAF frequency at the time, so it was probably not heard.
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Old 7th Jun 2016, 05:01
  #144 (permalink)  
 
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So if SPECIs are issued for e.g. Mildura, nobody is responsible for confirming that two RPT jets inbound to Mildura have received them? That seems odd to me.
The funny thing, is that this is a circumstance where a GA pilot might have done better. Because GA pilots don't have the same information resources a GA pilot would probably have pulled out the mobile phone and rung someone on the ground and gotten a higher quality answer than these pilots collectively got from our government air traffic and meteorological services.
That would be a dangerous practice, OA. Whenever I call the flying club's or refueller's number at my planned destination to find out what their eyes on the target are seeing, I aways give them comfort by saying: "As you will realise, I won't and can't believe anything you tell me." I of course only continue (or not) on the basis of official sources of information alone.

Funny thing is that the eyes on the target seem to be at least as reliable as the official sources ....
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Old 7th Jun 2016, 05:08
  #145 (permalink)  
 
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Neither crew were aware of this TAF nor would they have been able to use this forecast in support of their decision to divert..."
BUZZBOX I agree that my last post was in very black & white terms but the operative phrase is in your quote (above).

From memory, there was also a missed approach at YMIA that was not passed onto the crew. I also have a recollection that buried somewhere in the report is something to the effect that the BOM forecast the fog on the basis of satellite imagery rather than ground observation and that there was a ground observation that conflicted with one of the revised TAF's at the time of its issue.

My question would be, would we be better off if the BOM rang people for observations rather than looking at satellite photos & computer models.

But, the information that BOTH crews had available at the time of the decision to divert was that Mildura has vis > 10km with broken cloud in the mid 3,000ft range.

There was information that was on hand that conflicted with this, but it was not passed on to the crew by any of the BOM TAF's or METARS, or via ATC or via the company dispatchers for either airline.

If I was given a METAR that agreed with the TAF for an airport about 35 min flying away that easily allowed a VFR landing, I reckon I'd assume that I could rely to be an adequate IFR diversion.

Someone commented earlier that the big issue that we were all missing was that the ATSB was again attempting to deflect criticism for other government agencies.

The ATSB in the past has presented a timeline as part of the report. The drafting of this one makes it difficult to put all the pieces in correct order. I think it might be clearer if they has presented a chronological list of events.
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Old 7th Jun 2016, 11:12
  #146 (permalink)  
 
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Now, where have I heard this before; that weather had deteriorated and was not passed on to the pilot? Even has more or less the same players with only the victims changed this time.
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Old 7th Jun 2016, 11:34
  #147 (permalink)  
 
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PLovett, the same game has been in play for a long time. If anyone has access to RAAF records there was a Herc enroute Darwin to Richmond in the late 60s early 70s that got caught out by the same cockup as the two 737s.
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Old 8th Jun 2016, 02:56
  #148 (permalink)  
 
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Old Akro:

From memory, there was also a missed approach at YMIA that was not passed onto the crew.
Yes, there was a missed approach at Mildura, by a Qantas Link Dash 8. The Virgin aircraft was already overhead Mildura at the time and Qantas wasn't far behind. In fact the Qantas aircraft started its approach about a minute later. The report states that the Virgin crew asked the Dash 8 for an appreciation of the weather and was told they 'couldn't see anything'.

I also have a recollection that buried somewhere in the report is something to the effect that the BOM forecast the fog on the basis of satellite imagery rather than ground observation and that there was a ground observation that conflicted with one of the revised TAF's at the time of its issue.
The report states the following:
For regional airports, such as Mildura, the BoM relied on satellite imagery, in addition to other data, to provide indications of fog. However, it can be difficult to differentiate between fog and low cloud when using satellite imagery. The BoM reported that their review of the forecasting used for Mildura on the day of the occurrence showed that the conditions (including wind direction) were not conducive to fog developing at that time of day and were more consistent with the possibility of low cloud. As such, the TAF that was valid at the time reflected a temporary period of low cloud that was expected to last between 30 and 60 minutes (TEMPO), rather than fog.
The 'other data' refers to observations recorded by the equipment and the observer at the airport. The revised TAFs that were issued were only valid from 0000Z, ie after both aircraft had arrived overhead Mildura. The TAF that was valid at the time of their arrival had a TEMPO for low cloud at 600ft, but no fog.

The 2230Z and 2300Z METARs both showed good conditions, with the lowest cloud at 3400ft. Shortly afterwards, the instruments at Mildura began to indicate patches of low cloud at around 400ft and a satellite image indicated a bank of low cloud south of Mildura. The report states that the BoM believed the forecast for TEMPO deteriorations was still appropriate, based on those observations.

About 10 minutes later, the weather began to deteriorate rapidly, starting with low cloud at about 200ft AGL, followed by reduced visibility and then fog. The first report of the deteriorating conditions came from an aircraft that departed Mildura at 2316Z. The Qantas and Virgin aircraft were on a different frequency at the time and the report was not subsequently passed to them. A SPECI showing the low cloud was issued at 2318Z, followed by three more SPECIs in rapid succession at about 2330Z. During that time period, the visibility dropped from greater than 10km to 2100m. According to the report, the observer "advised the forecasting office that the mist and subsequent fog arrived rapidly from the south".

I'm no meteorologist, but it seems to me that the weather conditions were quite good until shortly after 2300Z, with no indications of what was to come. The weather then deteriorated rapidly after about 2315Z. By that time, both the Virgin and Qantas aircraft had already diverted from Adelaide, on the assumption that the conditions at Mildura were still as reported at 2300Z. The BoM started issuing SPECIs as soon as the conditions began to deteriorate, but they were not relayed to either aircraft and neither was the airborne report from the aircraft that departed Mildura at 2316Z.

To be honest, I can't really pin the 'blame' on the BoM apart from the inaccuracy of the initial TAFs for Adelaide and Mildura, which did not predict fog. That said, in my experience, predictions of fog are rarely accurate at some airports, which is probably an indication of how difficult it is to forecast such conditions, rather than ineptness on the part of the BoM. I guess they're damned if they do and damned if they don't, in that they'll be pilloried for getting it wrong either way. In this case, it appears that everyone was caught out by the rapidly changing conditions.

In my view, the most easily solved causal factor in this incident is the lack of reports passed to the aircraft by ATC once the conditions started to deteriorate. If those reports had been relayed immediately, the crews might well have made a decision to return to Adelaide and attempt an autoland, which would obviously have been the lesser of the two evils. In that light, I believe the major problem lay with Airservices procedures, as highlighted by the ATSB's report.

I totally agree that a time line in the report would help readers to put a few things in perspective!
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Old 8th Jun 2016, 03:09
  #149 (permalink)  
 
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Here's a time line, starting from 2230Z:

Timeline

2230Z: METAR YMIA 172230Z 27004KT 9999 BKN034 06/05 Q1019 RMK RF00.0/000.2

2300Z: METAR YMIA 172300Z 23004KT 9999 BKN039 07/06 Q1019 RMK RF00.0/000.2

2302Z: TAF YMIA 172302Z 1800/1812 20008KT 9999 SCT030 SCT050 RMK T 08 12 13 10 Q 1020 1019 1019 1021.
Not received by VA1384 or QF735 and not valid for their ETA
2304Z: VA1384 diverted to YMIA from YPAD. ETA YMIA 0932EST.

2313Z: QF735 diverted to YMIA from YPAD. ETA YMIA 0942EST.

2316Z: Air ambulance departed YMIA reported deteriorating conditions with low cloud at 400ft AMSL (approx 233ft AGL). Neither VA1384 or QF735 heard this report as they were on a different frequency. The report was not relayed to either aircraft by ATC.

2318Z: SPECI YMIA 172318Z 22004KT 9999 BKN002 SCT041 08/06 Q1019 RMK RF00.0/000.0

2328Z: SPECI YMIA 172328Z 21006KT 5000 BR BKN002 07/07 Q1019 RMK RF00.0/000.0

2330Z: SPECI YMIA 172330Z 21006KT 3300 BR BKN002 07/07 Q1019 RMK RF00.0/000.0

2332Z: SPECI YMIA 172332Z 20007KT 2100 BR BKN002 07/07 Q1019 RMK RF00.0/000.0
VA1384 overhead YMIA.
2336Z: 2332Z SPECI broadcast by ATC on the area frequency, but it was not heard by either aircraft as they were communicating on the CTAF frequency.

2339Z: Qantas Link Dash-8 conducted a missed approach at YMIA.

2340Z: QF735 commenced approach at YMIA.

2346Z: QF735 landed YMIA.

2348Z: SPECI YMIA 172348Z 19007KT 0900 FG OVC001 07/07 Q1019 RMK RF00.0/000.0

2352Z: TAF AMD YMIA 172352Z 1800/1812 20007KT 3000 BR SCT003 BKN040 BECMG 1800/1801 19006KT 9999 SCT030 SCT050 PROB30 1800/1802 0500 FG BKN002 RMK T 07 11 13 10 Q 1019 1019 1019 1020
VA1384 advised ATC they were still holding and did not have enough fuel to divert to another airport.
2354Z: Amended 2352Z TAF broadcast by ATC on the area frequency.

2358Z: ATC initiated an alert phase on VA1384 due to low fuel state.

0002Z: VA1384 commenced first approach at YMIA.

0004Z: VA1384 commenced a missed approach.

0012Z: ATC initiated a distress phase on VA1384 as the aircraft commenced its second approach.

0014Z: VA1384 landed YMIA.
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Old 8th Jun 2016, 04:31
  #150 (permalink)  
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I take it back Buzzie, you should have written the report. That timeline would have made the report a bit easier to follow.

I wonder what happened on the ground at Mildura when the uncertainty and distress phase were issued? What facilities where available on the ground to respond and in what time frame. Something else not in the report. Surely an interesting question what response is available at airstrips like this that jets frequent even when it's not in an emergency.
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Old 8th Jun 2016, 05:03
  #151 (permalink)  
 
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Ha, ha.

You're right, the report doesn't really say what happened on the ground, other than the following on pp. 20-21:
"At 0953, Velocity 1384 informed ATC that they would have to declare a fuel emergency in 10 minutes. In response, at 0958, the ATC operations room manager in Melbourne Centre contacted the Victorian Police coordination centre to activate the Mildura Airport emergency plan.

This resulted in local emergency services being contacted to initiate a response to the arrival of Velocity 1384."
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Old 8th Jun 2016, 05:15
  #152 (permalink)  
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Obviously the Mildura Airport Emergency Plan worked perfectly as there was nothing of note to report on. I'd have to check but I thought that was an aspect of accident investigation that was meant to be reported on too.
It would be an interesting element of the story...another elephant maybe. Given the amount of RPT traffic into regional towns with no RFF at the airport how it should and did work on the day.
I believe there is a cost saving push onto to further increases the number of passengers before RFF is required at airports too. Even more reason this report should have taken the opportunities to lead the discussion.
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Old 8th Jun 2016, 05:56
  #153 (permalink)  
 
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I could be wrong, but I think those aspects are only examined in detail in cases where the the services are actually used, eg fire or injuries/fatalities.

I agree with you though, it would be useful if that sort of stuff was included regardless. Under ICAO rules and the CASRs, they're supposed to conduct full-scale emergency exercises every two years, with partial exercises in between to make sure the plan actually works. The plan is also supposed to be reviewed in the event of an actual emergency, but I guess that's separate to any ATSB involvement.
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Old 8th Jun 2016, 06:19
  #154 (permalink)  
 
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It hasn't happened here yet but the airports of the world are littered with the bodies of crew and pax that were being "operationally controlled" from Seat 0A, fog and thunderstorm prangs being examples. Operational Control would be even more appropriate today with the increased cost pressures... I'm not agreeing with it, just pointing out that around the world, hundreds of poeple would be alive today had our old "Operational Control" been in effect.
Bloggsie, old mate,
In your case, that may very well be true, but for most real Captains, that is all part of command responsibility.
Funny thing, in the G.O.Ds of DCA Operational Control, it never did apply to Qantas, and it was Ansett various, TAA and EWA (on this side of the island) that had a somewhat spotty record.
Tootle pip!!
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Old 8th Jun 2016, 12:27
  #155 (permalink)  
 
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2318Z: SPECI YMIA 172318Z 22004KT 9999 BKN002 SCT041 08/06 Q1019 RMK RF00.0/000.0
This should have been passed to the arriving aircraft. Do we know what time the SPECI was received by the relevant controller. With ETAs 14 and 24 mins later, would it have made any difference - could the crews have gone anywhere else? Maybe QF could as they had more fuel.
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Old 8th Jun 2016, 12:54
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The SPECIs weren't received by the controller, that was part of the problem. According to Airservicess procedures at the time, the SPECIs weren't automatically sent to the controller's console because Mildura had an AWIS. If aircraft wanted the information they had to either tune in to the AWIS (which wasn't working) or ask ATC, in which case the controller would retrieve the report from the system. As a result, the ATSB report says the ATC supervisors only became aware of the deteriorating conditions at about 2330Z, when the Mildura aerodrome reporting officer contacted them to ask why aircraft were diverting there when the weather was so bad.

The ATSB calculated that if the 2318Z SPECI had been disseminated immediately to the aircraft, they both would have had enough fuel to return to Adelaide and land with their fixed reserve intact.

Last edited by BuzzBox; 8th Jun 2016 at 16:01.
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Old 8th Jun 2016, 15:06
  #157 (permalink)  
 
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Your timeline is very helpful, thanks!

It is however missing the very first and last items....

1. Months earlier, AWIS breaks down, doesn't get fixed
....
99. Immediately after incident, AWIS gets fixed in blatant bum covering

Which ASA manager made their KPI by not fixing the AWIS?

ATSB report says the ATC supervisors only became aware of the deteriorating conditions when the Mildura aerodrome reporting officer contacted them to ask why aircraft were diverting there when the weather was so bad.
This is a monumental problem. It's 2016, and we have to wait for old mate in his airport ute to put two and two together and phone ATC about the weather?
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Old 8th Jun 2016, 21:19
  #158 (permalink)  
 
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ATC supervisors only became aware of the deteriorating conditions at about 2330Z
So why at least are the ATC supervisors not aware that the weather at one of the airports in their area of responsibility has gone bad? They don't tune in to the AWIS. Surely they don't just wait for amended TAFs to land on their desks? What is the point of SPECIs being issued to ATC if no one takes any notice of them? Does anybody actually carry the "big picture"?

It's 2016, and we have to wait for old mate in his airport ute to put two and two together and phone ATC about the weather?
20 years ago, this incident would never have happened. Ain't progress grand!
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Old 8th Jun 2016, 23:32
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So why at least are the ATC supervisors not aware that the weather at one of the airports in their area of responsibility has gone bad?
According to the report, it all came about as a result of changes to the AIP and MATS in 2009. Prior to the changes, ATC notified pilots about all SPECI reports and amendments to forecasts. After the changes, pilots were not to be alerted to the availability of a SPECI the could be obtained from an ABS. The reason for the change was the introduction of more automatic weather stations, which resulted in a flood of AUTO SPECI reports to ATC, all of which required review and broadcast to relevant traffic. That caused a huge increase in controller workload and conflicted with ATC's primary role of providing a traffic separation service.

The report states that these changes to MATS were subject to a Safety Case Assessment and Reporting Determination (SCARD). The SCARD determined that:

"...a safety case was not required as there was no change to the Air Traffic Services Provider Certificate. The size of the change was assessed as ‘small’ and the magnitude of the change as ‘reasonable’. In assessing the magnitude of the change, Airservices identified a potential failure of ‘the pilot does not obtain in-flight information’, with the effect that the ‘pilot is not aware of significant weather information’. The overall assessment was considered ‘minor’ and approved by the relevant managers."
In a nutshell, it became a pilot's responsibility to check the weather by requesting the information from ATC or by using other means such as the ABS; the information won't be provided automatically by ATC. Indeed, the controllers themselves may not know about deteriorating weather conditions, because the SPECIs are not automatically sent to them either. As an aside, this is not unique to Australia; the report notes that the US, Canada and New Zealand all have similar systems, whereby it is the pilot's responsibility to obtain the relevant weather information by requesting it if necessary.

Following this incident, the report says Airservices is working with BoM to "explore feasible options to provide information on significant deteriorations in weather conditions". Airservices has also updated MATS to ensure that information continues to be disseminated by ATC in cases where the ABS is out of service.

I certainly hope that the Airservices managers who assessed the 2009 changes as 'minor' now feel suitably chastised.

Last edited by BuzzBox; 8th Jun 2016 at 23:52.
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Old 9th Jun 2016, 00:00
  #160 (permalink)  
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In my mind a easy solution.
The NOC has a met guy and should have some SMEs. If they become aware of a critical change in forecast weather then they send it to the RPT operators and ATC to ensure the message gets out. Might mean they have to put their coffee down but if all they do at the NOC is figure out traffic flows the night before then what's the point.
The NOC should be a hub for all critical information, not just traffic management. Might mean someone has to put some thought and money into it.
Of course an investigation like this probably should have looked at that...but that would have been another elephant. Covered the big issues like a pilot not prefixing his report with Airep...I do go on.
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