Australia, New Zealand & the Pacific Airline and RPT Rumours & News in Australia, enZed and the Pacific

WA: Push on or Pull Out?

Old 7th Feb 2021, 11:04
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WA: Push on or Pull Out?

Seems to be ongoing investigations from the regulator out in the West in regards to PIC decision making around diverting to the nearest suitable, or continuing on to destination/engineering base. The opinions on this out there also seems divided in terms of landing at whatever is closest vs flying on for an hour.

Air Asia 237, Air Asia 221, and most recently Virgin 1788. Not sure if Network 2658 is another.

The ATSB usually does not push the blame on any crew as such, however they clearly did not approve of the decision making in last weeks release of Virgin 1778.


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Old 7th Feb 2021, 22:21
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From the ATSB’s report:

What happened

On 9 July 2019, a Fokker F100 aircraft, registered VH-FWI, was being operated by Virgin Australia Regional Airlines (VARA) as regular public transport flight VA1788 from Geraldton to Perth, Western Australia.

During climb at about 13,000 ft, the left engine flamed out. Due to a pre-existing fault with the autothrottle system the pilot was required to manually select climb thrust on the remaining (right) engine. The crew elected to maintain the incidental speed (250 knots). Due to a desire not to ‘strain’ the right engine the pilot flying also elected not to increase thrust from climb to maximum continuous, and/or reduce the aircraft’s speed towards the recommended single engine climb speed (155–170 knots). Consequently, the crew adopted a cruise level about 6,500 ft below the maximum engine out altitude.

The crew maintained their cleared track to Perth and conducted an approach and landing via the runway 21 instrument landing system, using single engine procedures. The aircraft was accompanied from the touchdown point to the domestic terminal by airport emergency vehicles.
😳

Some pretty poor decision making on that flight deck.
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Old 7th Feb 2021, 22:41
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With an engine shut down on a twin, if you land at the nearest suitable airport you have covered your backside. I can’t recall a single instance where a regulatory authority have taken the position that a crew should have pressed on to the destination on one engine.

If you are going to continue past a suitable alternate, you had better have a good reason and be prepared for lengthy questioning on your decision making process.
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Old 8th Feb 2021, 00:00
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With an engine shut down on a twin, if you land at the nearest suitable airport you have covered your backside. I can’t recall a single instance where a regulatory authority have taken the position that a crew should have pressed on to the destination on one engine.
According to the ATSB you can fly for as long as you like on one engine if you are a foreign carrier. However VH aircraft have to land at the nearest suitable airport.

Interesting that they are suddenly all so concerned about glide range yet if you read the multiple Air Asia reports where they flew for hundreds of miles past numerous suitable airports it doesn't even rate a mention. Why does the glide range matter in this incident yet not in the other ones?? Since when has glide range in a multi engine jet even been a legal consideration anyway??

I agree they should have landed at Geraldton but the ATSB need to find some consistency in their reports and start applying the same standard to all carriers.

Last edited by neville_nobody; 8th Feb 2021 at 00:12.
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Old 8th Feb 2021, 00:12
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In 2005, flight BA268 a B747 from LAX to LHR, had an engine failure soon after departure and continued across the Atlantic on 3 engines. They had to divert to Manchester due insufficient fuel to make Heathrow. There was a difference of opinion between the FAA and the CAA as to whether the decision was correct.

No one would have criticised the crew if they had returned to LAX.
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Old 8th Feb 2021, 02:34
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Or refer back to the Air Asia A330 that passed several suitable airports, by-passed Learmonth on the way back to Perth after losing a part of one engine.

One description at the time "I have not read all posts on this thread but I was a passenger on the plane and can clarify a few things first hand.
First, there was an initial loud bang followed quickly by the vibration. I imagined that a cargo door had blown off. The vibration did last the entire return flight except for the approach to landing when it all but stopped. Presumably lower airspeed reduced the windmilling force.

The vibration was fairly constant and low frequency - maybe 5 to 8 Hz I am guessing. It did seem so wane and surge. During the surging it was extremely unnerving. The toilet block behind me was wobbling so much that the noise prevented me from always hearing properly whatever was being said. In fact, during the emergency briefings from the crew they had to deliver it in person to a couple of rows at a time so we could hear them.

At times the vibration of my seat back was too much to be able to rest against. I had to sit forward in the seat.

The captain did suggest we pray on two occasions. I was not upset that he said that except that I hoped it did not mean that he was substituting reliance on a higher being over his own effort. He did sound emotional on one of his announcements when he appeared to have to stop mid sentence and then compose himself to continue. Then again it could have been something else that diverted his attention".

But press on they did.
And, if I remember correctly, the final report said nothing about the decision to return to Perth despite the captain being motivated to recommend prayer.

Last edited by WingNut60; 8th Feb 2021 at 02:53.
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Old 8th Feb 2021, 02:51
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Not much emphasis in the report about length of runway at YPPH compared to YGEL, width of runway at YPPH compared to YGEL, ARFF at YPPH but not YGEL, medical assistance at YPPH versus very little at YGEL but plenty of analysis of glide range.
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Old 8th Feb 2021, 03:00
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There was a difference of opinion between the FAA and the CAA as to whether the decision was correct
I know there was much discussion at the time about so called differences between FAA and CAA policy at the time, originating from where I know not, of course it was subject to much discussion on the forum. Essentially no difference between the two authorities by my reading. The report says,
Operational Policy - Flight Continuation

The aircraft manufacturer did not provide guidance as to the acceptable period of continued flight following an IFSD. The crew was subject to the operator’s written policy for flight continuation which was that, once certain considerations have been satisfied, the flight should continue to destination or to an operator-served destination as close as possible to it. This policy had been approved by the UK CAA. The following factors were to be reviewed before making the decision to continue:

1. The circumstances leading to the engine failure should be carefully considered to ensure that the aircraft is in a safe condition for extended onward flight.

2. The possibility of a second engine failure should be considered. This would require evaluation of performance considerations, diversion requirements and range and endurance on two engines.

The USA Federal Aviation Regulations (FAR Part 121.565) requires a landing at the nearest suitable airport following an engine failure or IFSD, except for an aircraft with three or more engines. In this case, the commander ‘may proceed to an airport he selects if he decides that this is as safe as landing at the nearest suitable airport’, having considered a number of factors. These included the nature of the malfunction and possible mechanical difficulties, fuel requirements, weather, terrain and familiarity with the chosen airport. The commander is required to keep ATC informed and the operator is required to inform subsequently their airworthiness authority of the event.

As part of this investigation a review was also made of other UK and overseas operating companies to determine the guidance given to their crews in the event of an engine failure on a 4‑engined aircraft. One operator required that the aircraft land at the nearest suitable airport. Another had no policy and left it as a commander’s decision. One operator required the aircraft to return to the airfield of departure if the engine failure occurred prior to reaching cruise altitude and the conditions at that airfield were suitable; otherwise, the commander could continue to an airfield of his selection. Three other operators had policies similar to that of G-BNLG’s operator. All of the continuation policies emphasised that any continuation was dependent on the aircraft being in ‘a safe condition for flight’.
They had to divert to Manchester due insufficient fuel to make Heathrow
Just prior to the diversion fuel on landing London was estimated at 6.5 tonnes, required minimum being 4.5 tonnes. The aircraft landed Manchester because the crew lacked confidence in being able to access the remaining fuel, the airlines balance procedures differed from Boeings and after this incident the airline reverted to Boeings procedure.
there were indications of deficiencies in the training regarding fuel management provided to the flight crew. The three qualified pilots were not confident that all the fuel was available and their difficulties with fuel management indicated that their knowledge of the fuel system with three engines operating was insufficient. The fuel balancing procedures used by the operator, while suitable for normal operations, was a factor in the diversion involving G-BNLG. Following the incident, the operator provided guidance to crews that was more extensive, whilst progressing discussions with the airframe manufacturer. This has resulted in the operator reverting to the fuel handling procedures recommended by the manufacturer.
https://assets.publishing.service.go...BNLG_06-06.pdf
No one would have criticised the crew if they had returned to LAX
There's always someone who'll complain, missed wedding, dumping 70 tonnes of fuel etc etc
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Old 8th Feb 2021, 03:06
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And little ATSB discussion on the time required to secure and brief the approach. They were so close to GEL that they would likely have had to hold (I'm not F100 rated so not sure how how long it takes to run the EF checklist and brief).

I'd imagine the time delta between touchdown and Perth and GEL would be just several minutes by the time the holding to prepare the GEL would have been taken into account vs doing it enroute to PER.

There were definitely some decisions that were not optimal, but if the time delta was indeed a few minutes, I don't think deciding to fly to Perth was necessarily one of them.
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Old 8th Feb 2021, 03:15
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But press on they did.
And, if I remember correctly, the final report said nothing about the decision to return to Perth despite the captain being motivated to recommend prayer.
The report agreed with the decision making in the return to Perth due to a variety of reasons. I mean the engine was practically jumping on the wing, however great job on continuing. Now if it fell off, or severe airframe damage occurred as a result, then I guess they would throw them under the bus.

The crews who essentially failed their own engine due to incompetence near Alice Springs, rightly so got crucified for the decision to press on both in the internal and the atsb report.


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Old 8th Feb 2021, 04:41
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CAO 20.6 allows continuing to an airport that is not “the nearest suitable”.


3.2 The pilot in command of a multi-engine aircraft in which 1 engine fails or its rotation is stopped, may proceed to an aerodrome of his or her selection instead of the nearest suitable aerodrome if, upon consideration of all relevant factors, he or she deems such action to be safe and operationally acceptable. Relevant factors must include the following:

(a) nature of the malfunctioning and the possible mechanical difficulties which may be encountered if the flight is continued;

(aa) the nature and extent of any city, town or populous area over which the aircraft is likely to fly;

(b) availability of the inoperative engine to be used;

(c) altitude, aircraft weight, and usable fuel at the time of engine stoppage;

(d) distance to be flown coupled with the performance availability should another engine fail;

(e) relative characteristics of aerodromes available for landing;

(f) weather conditions en route and at possible landing points;

(g) air traffic congestion;

(h) type of terrain, including whether the flight is likely to be over water;

(i) familiarity of the pilot with the aerodrome to be used.

If all those are on the day an event happens all properly considered, and the outcome is safe, then it’s not “wrong” to have bypassed the nearest airport.

Is it smart? Well that’s a different argument.
its why captains are paid the big bucks isn’t it, to make these decisions?

and nearest doesn’t need to be the closest physically. Time comes in to it too.
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Old 8th Feb 2021, 22:53
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Originally Posted by wheels_down View Post
Seems to be ongoing investigations from the regulator out in the West in regards to PIC decision making around diverting to the nearest suitable, or continuing on to destination/engineering base. The opinions on this out there also seems divided in terms of landing at whatever is closest vs flying on for an hour.

Air Asia 237, Air Asia 221, and most recently Virgin 1788. Not sure if Network 2658 is another.

The ATSB usually does not push the blame on any crew as such, however they clearly did not approve of the decision making in last weeks release of Virgin 1778.
The armchair experts at the ATSB should butt out on this one.
It is apparent from the report that the PIC was well aware of the risks, possible mitigations and how best to manage workload during an abnormal event. The crew displayed good CRM and the PIC had (rare) empathy for the health of the remaining engine.

Consider that by the time they identified and dealt with the problem, completed all checklists, attempted a relight and re-secured the dud engine they would have been about a third of the way to destination. It is only a 200nm sector. It would not be usual to start a turn-back or diversion until all the abnormal procedures had been completed. You'd look like a goose if the relight had been successful (now where should we go?), and any diversion from the planned track is workload best avoided until priority activites are completed.
With a situation nicely under control, turning back to an uncontrolled airport with a less easy 2D approach and fewer emergency facilities versus a straight-in 3D approach to an international airport and two other military aerodromes close to on-track is a no-brainer.
As for the ATSB comments about OEI climb speeds and maximum OEI altitude; really this is nit-picking. If weather, terrain or range are not limiting, the pilot should be free to select whatever provides adequate performance. Lower and faster is often safer than nibbling at the limits of the envelope.

Well done that crew, I say.

Last edited by Mach E Avelli; 8th Feb 2021 at 23:06. Reason: typo
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Old 8th Feb 2021, 23:45
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Originally Posted by Mach E Avelli View Post
The armchair experts at the ATSB should butt out on this one.
It is apparent from the report that the PIC was well aware of the risks, possible mitigations and how best to manage workload during an abnormal event. The crew displayed good CRM and the PIC had (rare) empathy for the health of the remaining engine.

Consider that by the time they identified and dealt with the problem, completed all checklists, attempted a relight and re-secured the dud engine they would have been about a third of the way to destination. It is only a 200nm sector. It would not be usual to start a turn-back or diversion until all the abnormal procedures had been completed. You'd look like a goose if the relight had been successful (now where should we go?), and any diversion from the planned track is workload best avoided until priority activites are completed.
With a situation nicely under control, turning back to an uncontrolled airport with a less easy 2D approach and fewer emergency facilities versus a straight-in 3D approach to an international airport and two other military aerodromes close to on-track is a no-brainer.
As for the ATSB comments about OEI climb speeds and maximum OEI altitude; really this is nit-picking. If weather, terrain or range are not limiting, the pilot should be free to select whatever provides adequate performance. Lower and faster is often safer than nibbling at the limits of the envelope.

Well done that crew, I say.
^
I agree with everything you have said. I truly wonder whether the ATSB actually employs any experienced ex-airline pilots
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Old 9th Feb 2021, 00:34
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ETOPs certification could be a factor to consider in the decision making process. If you’re in an aircraft which it’s alright to be 2 or 3 hours over the ocean from a suitable airport, then continuing to destination should be a lower risk factor than a non ETOPs aircraft. Obviously not applicable in the AirAsia case with an engine shaking itself to pieces.

I believe QF have a number of airports in Indonesia which they don’t approve for emergency use and would overfly in the event of an engine shutdown. PIC would make his own decision in the event of an un extinguishable engine fire or something similar.
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Old 9th Feb 2021, 01:01
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I agree with everything you have said. I truly wonder whether the ATSB actually employs any experienced ex-airline pilots
well the ATSB report contains all the information about the operating crew, not identified of course, perhaps at the introduction to the report the lead investigator should have to state their qualifications and experience? As I asked above, are they considered "expert witness" status in court? CASA has got caught out with this a few times.
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Old 9th Feb 2021, 02:43
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I would guess that the next time they advertise for investigators that they will be spoiled for choice. Don't forget that one of the Commissioners is Chris Manning and he gets a say in the release of the report.
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Old 9th Feb 2021, 03:57
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Originally Posted by Mach
You'd look like a goose if the relight had been successful (now where should we go?)
No you wouldn't. The flipping thing stopped. Who's to say what is going to happen next even if you did get it re-lit?
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Old 9th Feb 2021, 06:48
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Bloggsie I hear ya, but in this specific case - it being such a short sector - by the time it carked it again they could just as likely be at the half way point anyways.
Second guessing the tea and bickies with certain 'you can't win' chief pilots if they had got it re-lit then turned around and gone back to a non-engineering base, em tasol.
All the above waffle about ETOPS is irrelevant to this particular flight.
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Old 9th Feb 2021, 08:54
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How many times in the last 2 decades has a jet engine failed for no reason? Even those poxy old rollers don't fail for no reason (notwithstanding severe turbulence, bad or no fuel, excessive water ingestion). Saying that they'd be over half way by the time they'd secured the engine is clutching at straws and defending the indefensible. A half decent crew would have the engine secure and an approach brief done in 15 minutes not the 40 that it would take to get to the CP at reduced engine out speeds. You can try and polish a turd all you like...........
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Old 9th Feb 2021, 10:34
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From the ATSB report:
The captain conducted two flights the previous day and had completed office‑based work in the four days prior to that.
I wonder if this has any relevance to events?
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