3 years later The Mildura report
 

3 years later the ATSB final report finally appears.
Cover page - First safety message. Pilots are reminded of their responsibility for collecting all relevant information to support inflight decision making...
Qantas did that and ended up in the situation they did.
The report says the forecast was inaccurate in terms of significance and length of the fog at Adelaide and the Mildura met wasn't accurate either.
I have a feeling this report will make the Norfolk report look like a Shakespearian classic.

Link:

Investigation: AO-2013-100 - Landing below minima due to fog involving Boeing 737s, VH-YIR and VH-VYK Mildura Airport, Victoria on 18 June 2013

Nothing to see here.

The VA 737 landed with less than 15 mins of fuel and essentially no one stuffed up (not BOM, not ATC, not Crew, not Ops Control/Dispatch). :cool: - and if it wasn't for the QF skipper taking extra fuel they would have been in the same boat...

What is wrong with the ATSB?!!

http://i.imgur.com/hRJpFy4.jpg

When will we be like the rest of real world and carry technical alternates.:ok:

Well the fact is that the QF captain DID take extra fuel so he was not in the same boat!

From the report:
How are code grey forecasts promulgated?
Can a crew look at them on the internet or is it only available to Airlines?

3 years to tell us what the aircraft did, nothing new from the interim report.

This was an opportunity for a top down dissection of how business Is done in this country. Two aircraft from different companies ended up on a country airstrip conducting emergency landings and the conclusion is they should have been getting more regular updates on inaccurate forecasts?

What about the infrastructure? All modern jet aircraft can auto land, in fact the report mentions when emergency autolands have saved us in the past. No recommendation to mandate it at capital airports at least? The bean counters will tell you it's not statiscally significant to warrant the expense but how many times has it saved the day already?

The NOC, National Operations Centre. What the hell does it do, it seems to have got involved right about the time both aircraft were in the circuit area at Mildura. Shouldn't the NOC be the centre of knowledge and information for these types of unfolding events or is it just somewhere in Canberra to sit and drink coffee? Surely we should have a central point for ASA,BOM, major airlines to co-ordinate unfolding scenarios so all the missed opportunities that occured here don't happen?if not why not?

ASA who the hell decided that not passing on SPECIs wasn't going to cause any real problems? That if they can only get that information within visual range it wouldn't be an issue. What the hell is going on there with risk mangement and what other chocolate eggs are hidden?

How did it happen the AIP didn't reflect the intent of the change at ASA? Where else is this a problem. How come the majority of the pilot group didn't know this was the intent?

This just on the first read, I'm sure there is more

How did it happen they had to ask CASA for an interpretation of inflight fuel requirements? Haven't we sorted that out in 100 years of flying.

Nothing on if current fuel policy is appropriate or what other countries might use.

We did cover the big issue that the air ambulance pilot didn't start his radio call with Airep, glad that made it in.

Probably when parasitic corporate bean counters stop running flt ops. :rolleyes: I would advise not to hold your breath.

This report should have been a good chance to begin a move to mandate it. But it didn't touch that elephant in the room. That would have been a bit bold. Unless it's mandated the inmates will continue to run the asylum charging $1 tickets....checked baggage not included. Surely fuel policy and facilities should have been the main thrust of this report. Forecasting is a black art, getting lost in the aviation world. It will never be 100% therefore the risk controls would be fuel, facilities and timely supply of bad news...but we did find out the air ambulance pilot didn't say Airep....

They did.....Mildura

Forget it, Framer, AIP SUPP 65/16 finishes off Code Grey, that forecast that shall not be mentioned... Come to think of it, a coincidence? As is the push to turf the TTF?

Given what's gone on here (inadequate forecasting), a technical alternate should be an airport with an ILS. Then at least you've got a chance of getting in doing an autoland somewhere.

TBM-Legend, do you have level 6 English?

Hotnhigh - a technical alternate doesn't get you there with 15 mins of fuel. They didn't have an alternate of any sort & used contingency, FR, and any extra above the plan that they loaded.

What alternate do you suggest they should have carried?

out of interest, when a 380 arrives in Sydney, Perth, Brisbane do they carry an alternate all the way to the destination or do they plan to a decision point and then give the alternate away if the conditions suit?

Code Grey covers the situation where all the met criteria does not generate the forecast of fog neither real or the possibility thereof. If there is a remote chance of fog occurring based on aches in grannies bones or the ants are stirring or any other meteorological condition, then a cOde Grey is issued by BOM. (In the old days BOM used to issue forecasts with prob 5% or 10% fog to cover grannies bones but these days the criteria is that if the chance is less than I think 30% then fog is not mentioned).
The concept was introduced by QF and fuel policy dictates that fuel for an alternate must be carried from a pre- flight point of view when there is a code grey.
Not sure how many other airlines use it , if any.
QF uses it because lots of flights don't carry alternate fuel if the weather forecast doesn't demand it.

For that airport, at that time of day, at that time of year = MEL + fixed reserve at a minimum. (and that's before I check the WX and NOTAMS)

Totally inexcusable!

QF doesn't use code grey anymore. We use OPRISK instead. Different criteria but in this sort of event the intent is the same.

By the looks of the report these crews carried the fuel that the regulator and their own companies required them to carry or in the case of the QF crew even more, but then we're faced with the situation where the forecasts and the observations were not accurate for not one but two airports. Even being set up like that they both got their aircraft safely on the ground. You can bet your bottom dollar that the next time they see a one degree split with less than five knots of wind they will take full alternate fuel regardless of what the met guys and flight planning guys say. Hopefully many others will too.
In spite of the ATSB folk preaching to pilots about getting weather updates most would have to agree that the system failed and the pilots successfully dealt with the unusual situation.

If Australian Capital city airports had CAT II or III facilities like every other capital city airport in the world it would have been a non starter. Given the amount of money generated by airports in fees and charges this woeful lack of infrastructure is ridiculous.

How do you know MEL will stay available as an alternate? You just cannot plan for every contingency.
If the flights involved had continued to Adelaide, it would not have been an issue.