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34R SYD Review ATSB

Old 16th Jan 2020, 00:13
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34R SYD Review ATSB




The design of standard instrument approaches and departures, air traffic control and flight crew actions and procedures, and the coding of aircraft flight management system navigation databases are among a number of the factors the ATSB is focusing on as part of the on-going investigation into a loss of separation event near Sydney Airport.

That investigation’s preliminary report, released on 16 January, details that separation between two Qantas aircraft, an Airbus A330-300 and a Boeing 737-800, was reduced to about 0.43 nautical miles (796 metres) laterally and about 500 feet (152 metres) vertically during the incident, which occurred at around 6:30pm on 5 August 2019.

The A330 had been cleared by air traffic control to take-off from Sydney Airport’s runway 34 Right, at the same time that the 737 was on final approach to land on the same runway.

While the A330 was commencing its takeoff run, the air traffic controller with responsibility for managing runway 34 Right, an otherwise experienced controller who was a trainee under supervision for the Aerodrome Controller – East (ADC-E) position, assessed that if the 737 continued to land, there would be insufficient runway spacing between the two aircraft, and so instructed the 737 to conduct a go around.

The preliminary report details that the loss of separation occurred as both aircraft turned to the right.

The preliminary report details that the loss of separation occurred as both aircraft turned to the right, with the A330 turning to the right following a standard instrument departure (SID) from runway 34R (the MARUB 6 SID) and the 737 turning to the right following the missed approach procedure for a GLS (a global navigation satellite system landing system) approach for a landing on runway 34R.

The ADC-E controller, who reported that he had both aircraft in sight, attempted to increase their separation by instructing the 737 to turn further right. As both aircraft converged, the A330 flight crew received a traffic advisory (TA) alert from their aircraft’s airborne collision avoidance system (ACAS).

The A330 first officer, who was pilot flying, then saw the 737 in close proximity and, in response, reduced the aircraft’s angle of bank to reduce the turn towards the 737.

The captain of the A330 radioed to advise the ADC-E controller that their proximity to the 737 was “very close”. The controller then issued an instruction to the A330 flight crew to turn left.

The A330 climbed to 5,000 feet and continued to Melbourne without further incident. The 737 climbed to 3,000 feet and was issued radar vectors for a second approach to runway 34R. It landed without further incident a short time later.

“Preliminary reports outline basic factual information established in the early phase of an investigation. They do not contain findings, identify contributing factors or outline safety issues and actions, which will be detailed in an investigation’s final report,” explained ATSB Director Transport Safety Dr Stuart Godley.

“The ATSB’s on-going investigation into this occurrence will focus on a range of factors including the design and risk assessment of MARUB standard instrument departures and missed approaches from Sydney Airport’s runway 34 Right; air traffic control procedures, controller training and controller actions; flight crew actions and the operator’s procedures for the 737 and A330; coding of flight management system navigation databases; and further analysis of flight data recordings and ATC recordings.”
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Old 16th Jan 2020, 00:24
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ATSB Incident status page: AO-2019-041 Loss of separation involving Airbus A330, VH-EBJ, and Boeing 737, VH-VZO, near Sydney Airport, New South Wales, on 5 August 2019


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Old 16th Jan 2020, 02:30
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Holy Snap, a few arse cheeks clenching and balls tingling.
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Old 16th Jan 2020, 11:16
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edited for unnecessary criticism.

Last edited by Paddleboat; 16th Jan 2020 at 22:20.
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Old 16th Jan 2020, 11:33
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I never paid much attention to Course Intercept 335 or direct to ENDEV. I do now .....
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Old 16th Jan 2020, 12:02
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How does one track to the Missed Approach point, presumably climbing, then "mandatory at 600ft turn right track 070"?
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Old 16th Jan 2020, 14:04
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Originally Posted by Capn Bloggs View Post
How does one track to the Missed Approach point, presumably climbing, then "mandatory at 600ft turn right track 070"?
It’s an interesting question, however the AIP does state:

A published missed approach procedure must not be flown unless commenced at the MAPT. If a missed approach climb is initiated before the MAPT, the aircraft must track to the MAPT before commencing the missed approach procedure.

So in this case the crew had no alternative but to continue straight ahead to the MAPT before commencing the turn (from the diagrams though it does look like the crew essentially continued to the far runway end before commencing the turn - and given the initial GA instruction was at 400’, the turn may possibly have been a little late). It’s also worth mentioning that the controllers efforts to vector the 737 resulted in them being vectored below radar lowest safe.

Perhaps with the benefit of hindsight the safest course of action would have been accepting that separation standards on the runway to be compromised and allow the 73 to land.

This is a bit like the LAHSO incident in ML several years ago, where the decision to make aircraft go around creates a greater safety risk.

Damned if you do, dammed if you don’t really.
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Old 16th Jan 2020, 15:56
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As I understand, the 737 crew should have maintained RWY track to 0.5Nm before the threshold (coincident with the 220’ DA) and then turned right (provided they were above 600’). According to the report the turn was recorded as starting at 0.8Nm beyond the threshold (1.5km).

Now I don’t know how long it would take between initiating a roll control input and a turn displaying on a radar trace but in this case the aircraft was turning 1.3 Nm beyond the MAP while moving at about 2.5 Nm per minute.

I don’t think it even remotely fair to label them ‘muppets’ or accuse them of not following the missed approach procedure even if the turn was delayed by 20-30 seconds. Let’s not forget the ridiculous 737 autopilot disconnects as soon as you push TOGA so it’s a pretty busy period.

Not saying it was textbook but the situation was bound to occur despite the variation in reaction time. To blame the crew overlooks all the procedural issues which made this an entirely likely outcome.
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Old 16th Jan 2020, 20:22
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Originally Posted by Colonel_Klink View Post

Perhaps with the benefit of hindsight the safest course of action would have been accepting that separation standards on the runway to be compromised and allow the 73 to land.

This is a bit like the LAHSO incident in ML several years ago, where the decision to make aircraft go around creates a greater safety risk.

Damned if you do, dammed if you don’t really.
I thought about this option too - but then what happens if the A330 aborts their takeoff? That would probably be a lot worse?
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Old 16th Jan 2020, 21:09
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GLS Rwy 34R (12-45) 14 JUN 19
The missed approach point is variously indicated on the chart as
1. RW34R (Fly Over Fix)
2. MAP at DA (Vertical Profile Strip)
3. MANDATORY 600' RT. (MISSED APCH: strip + Vertical Profile Strip)

The approach coding in the FMC is from the RW34R fly over fix (34R THLD)
According to the report graphic the 737 was turning right by less than half way along the runway.
ie. Turn commenced less than 12 seconds after coded MAP.
Less than 20 seconds from being instructed to GA from low level with configuration changes etc.

Muppets Paddleboat? You must be good!

Last edited by Back Seat Driver; 16th Jan 2020 at 21:46.
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Old 16th Jan 2020, 22:19
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Maybe I am being overly critical. But from the report old mate flew 2,5 km past the MAP without conducting the turn, a turn which is written in big bold, capital letters with MANDATORY scribbled on there..

Put another way, if they had followed the procedure as published, would there have been a breakdown in separation? What if they tried this kind of thing into ZQN?

Anyway, not saying they're solely to blame, ill retract my muppet comment.

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Old 16th Jan 2020, 22:48
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Originally Posted by Bloggs
How does one track to the Missed Approach point, presumably climbing, then "mandatory at 600ft turn right track 070"?
In my question I should have said "presumably climbing, already above 600ft". What are you expected to do if you execute a MA above 600ft? Turn immediately anyway, or continue on to the MAPt as per AIP?

As it turns out, the actual report says the 737 commenced it's GA at 400ft.
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Old 16th Jan 2020, 22:52
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The other more interesting nuanced sleeper trap lurking here is even if you keep the "To" waypoint updated with either a direct-to or a direct-to course intercept, for some approach codings, the LNAV armed (white below) VOR/LOC doesn't become visible until you cross the FAF. In other words, you can't tell if you will have TOGA to LNAV functionality until late in the approach (1600' in this case OLSOG). Most ILS approaches you get LNAV armed with or just after VOR/LOC capture.

If the To waypoint hasn't been updated you won't get it at all, It is difficult to notice something by its absence (LNAV). Even ff you have done everything correctly, you have to actively search for it to confirm it is available after crossing the FAF. That to me is one of the the big HF lessons I have taken away from this event.

This raises the old chestnut of what to set in the MCP for Boeings, the QDM or missed approach heading (070) in this case? We set the altitude, but we are divided on the HDG.
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Old 16th Jan 2020, 23:40
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When the 737’s got a missed approach track of 070, and the 330 ahead of it is turning onto about 105 to pick up the 075 radial - surely it’s a moot point whether the 737 turned at the MAPT or 12 seconds later. Things were going to get untidy regardless.
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Old 17th Jan 2020, 00:03
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Originally Posted by itsnotthatbloodyhard View Post
When the 737’s got a missed approach track of 070, and the 330 ahead of it is turning onto about 105 to pick up the 075 radial - surely it’s a moot point whether the 737 turned at the MAPT or 12 seconds later. Things were going to get untidy regardless.
They should be vertically separated at that point, the 737 at 2000 at the 330 at 3000.

If they had started the turn at the MAP, this would have looked rather different. Ie


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Old 17th Jan 2020, 00:27
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You might be assuming a bit much about the 330’s climb performance.
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Old 17th Jan 2020, 00:39
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Originally Posted by itsnotthatbloodyhard View Post
You might be assuming a bit much about the 330’s climb performance.
Sure, anythings possible.

I put it to you however that the 737 was at 920ft when the A330 rotated. Yet by the time the flightpaths converged, the A330 was higher. If it was struggling for climb performance, how'd that happen?
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Old 17th Jan 2020, 01:12
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Paddleboat.
possibly consider that after 800ft. AGL, the 737 was above acceleration altitude and accelerating, retracting flap etc. while the 330 was doing the noise abatement climb with an acceleration alt somewhat higher than the 737.
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Old 17th Jan 2020, 01:18
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Originally Posted by Back Seat Driver View Post
Paddleboat.
possibly consider that after 800ft. AGL, the 737 was above acceleration altitude and accelerating, retracting flap etc. while the 330 was doing the noise abatement climb with an acceleration alt somewhat higher than the 737.
Indeed! Certainly a possibility.

It was put to me that the reason a breakdown in separation was inevitable regardless of the 737's lateral track was due to the A330's lack of climb performance, at least relative to the 737. Your reasoning I believe supports my position. If the 737 had turned at the correct time and followed the path in my quick and dirty diagram, then there would have been more than sufficient time, given the A330 is back at 180kts until established on the radial, and the 737 is accelerating, for their to be vertical separation as provided by the respective procedures by the time their tracks intersected, if they would at all.

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Old 17th Jan 2020, 02:34
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A published missed approach procedure must not be flown unless commenced at the MAPT. If a missed approach climb is initiated before the MAPT, the aircraft must track to the MAPT before commencing the missed approach procedure.

So in this case the crew had no alternative but to continue straight ahead to the MAPT before commencing the turn (from the diagrams though it does look like the crew essentially continued to the far runway end before commencing the turn - and given the initial GA instruction was at 400’, the turn may possibly have been a little late). It’s also worth mentioning that the controllers efforts to vector the 737 resulted in them being vectored below radar lowest safe.
Except that is not what the chart says. By your logic if you were told to go-around at 1000' you would fly all the way to the runway end then start the right turn. By that time you would be level at 2000'.

By the looks of the ground track the crew flew the Missed Approach correctly as they started the go-around just above the minima. So they had to climb to 600' first before commencing the turn which took away some of their separation from the 330. They were a little late in the turn but as mentioned above the 737 is a handful in a unexpected go-around.

Maybe I am being overly critical. But from the report old mate flew 2,5 km past the MAP without conducting the turn, a turn which is written in big bold, capital letters with MANDATORY scribbled on there.
The turn is at 600' not at the MAP. If they started at turn at 220' then they would have turned straight into the cranes at the port. So they flew the MAP correctly as they were pretty close to the minima

Last edited by neville_nobody; 17th Jan 2020 at 03:09.
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