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Mid-air collision involving Piper PA-44-180 Seminole, VH-JQF, and Beech D95A Travel A

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Mid-air collision involving Piper PA-44-180 Seminole, VH-JQF, and Beech D95A Travel A

Old 19th Feb 2022, 03:59
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Originally Posted by Squawk7700 View Post
No doubt Covid will get a mention as a reason for the delay.
Yes Covid has proven very convenient for governments and corporations.
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Old 19th Feb 2022, 04:57
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Covid the convient excuse.
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Old 19th Feb 2022, 14:33
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Has been numerous reports over the years in that the ‘due date’ stated online had passed by two quarters and it still wasn’t finished, it wasn’t until I emailed them that they replied ‘ohhhh sorry about that, errr no it’s not quite finished yet, estimated completion is later this year’. Staff shortages I have been told for the best past of the last decade.

However they always try to reassure me that staffing issues does not reduce risk. ‘If we find any safety related issues throughout the investigation we won’t hesitate to take immediate action with xx parties in the event of safety’.
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Old 3rd Mar 2022, 00:29
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I have found some references to a Mangalore Airspace Study.
  • CASA advised on 3 Sep 2021 that they were conducting such a study <https://consultation.casa.gov.au/stakeholder-engagement-group/mangalore-aeronautical-study/consult_view/>, consultation for which ended on 30 Sep 2021 <https://www.avsef.gov.au/all-consultations?title=Mangaloreso>
  • I would have assumed it would be published by now, but there is nothing on the CASA website.

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Old 3rd Mar 2022, 10:22
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If you can find anything on the new CASA website, you will be doing extremely well! Describing it as a "dog's breakfast" is an understatement (& would be insulting to dogs)...
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Old 7th Mar 2022, 01:34
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The ATSB is investigating the breakaway and grounding of a ship - the product tanker CSC Friendship - at the Port of Brisbane in Queensland on 27 February 2022. I found this comment on linkedin to be interesting:
This will be the most watched investigation in Australian Maritime industry this century.

Why?

Brisbane was in flood for the 3rd time in 10 years which occurred on the Sunday morning before this event occurred close to midnight. Flood Port Procedures would be well established and utilised until now?

Noted no pilots onboard, so they can’t be the useall scapegoats for groundings but with a change in pilotage providers in Brisbane just a month before this incident it maybe a touchy point for some.

Safe port questions to be raised by P&I clubs, which is a fair question.

Noting the last floods no brisbane ferries were lost yet this time one sank, ten reported damaged to put it into perspective, which won’t be investigated by ATSB.

And than the closeness of Australian industry! will there by any conflict of interest in this incident investigation? ATSB is managed by the ex Manager Maritime safety Queensland ? Which is In charge of these port procedures.

The report and critical safety issues raised will definitly be a must read in the Maritime industry.

Hopefully it can be published soon before the next flood to avoid repeat events this being a tanker at critical Queensland infrastructure.
Methinks the author of that post may be in for some disturbing surprises.
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Old 31st Mar 2022, 07:03
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Final Report from the ATSB is now available.
https://www.atsb.gov.au/publications...r/ao-2020-012/

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Old 31st Mar 2022, 09:02
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What a report! I have been highly critical of recent ATSB reports, but this one seems to have done a very good, even handed job of going through all the issues. This accident highlights the severe problem of lack of training instrument aids in the Melbourne basin. If there had been a slot at Moorabbin, this accident would not have happened.

I need to re-read it but the swiss cheese holes seem to be:

While the pilots did everything that was required, although didn't initiate aircraft to aircraft comms for separation. They were both training, with the workload (and possibly belief that they were under IFR traffic separation conditions), its understandable. that they may have placed higher reliance than they should have for either another ATC warning or some clear direction.

The controller seems to have acted correctly in accordance with procedures, although I bet the poor guy lies awake wishing he'd done something extra at one of the STCA instances.

The ridiculousness of the CASA see & be seen concept.

Ambigous and poorly written CASA regulations.

Overloaded training aids in the Melbourne basin after the closure of Cowes, Wonthaggi

Maybe a failure of the AsA traffic system to determine STCA alarms according to flight plan rather than trajectory.
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Old 31st Mar 2022, 09:44
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While the pilots did everything that was require
Except arrange vertical separation in IMC.

The controller seems to have acted correctly in accordance with procedures
Not much more the controller could have done. If as a pilot you are not going to arrange vertical on the trajectories involved...............

Overloaded training aids in the Melbourne basin after the closure of Cowes, Wonthaggi
CASA specifies an aid in the initial issue of an Instrument Rating, ASA rips most of them out, well done, not.

Maybe a failure of the AsA traffic system to determine STCA alarms according to flight plan rather than trajectory.
Has nothing to do with it. STCA is short term, predictive on radar trajectories which is far more accurate than a flight plan trajectory.

Yes, it's a good report AND ONLY A BIT OVER TWO YEARS. But still skirts around the airspace issue. Would not have happened in Class E. That piece of airspace is extremely busy at times, why? Where's the closest VOR that training can be done apart from MNG? The sectorisation there is extremely challenging for the ATC. But don't worry, a bullshit remedy has been implemented that will do nothing to make it safer.

The ridiculousness of the CASA see & be seen concept.


C'monnnn, it's the vibe, so totally safe in 21st century aviation, worked for the Wright Bros.
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Old 31st Mar 2022, 10:39
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Originally Posted by tossbag View Post
But don't worry, a bullshit remedy has been implemented that will do nothing to make it safer.
There is quite a bit to digest out of this report.

But at the risk of brining up something that has been discussed in another thread, as soon as I saw that an SFIS might be on the cards at MNG, I started to wonder just how this incident may very well have occurred at BNA with a far greater loss of life.
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Old 31st Mar 2022, 10:51
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The reason the report takes so long to come out is that there is a 2 year Statute of Limitations on claims for accident compensation. This report has been released one month after the 2 year limit. Think about it? The detailed draft was completed around 12 months ago. It is fair to say it has has been heavily worked over to limit liability issues. The final report was released today and is available for download off the ATSB website. It identifies failures identified and discussed in this forum. You need to read the report and not just read the summary as the summary attempts to transfer all blame to the pilots.
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Old 31st Mar 2022, 11:40
  #32 (permalink)  
 
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Originally Posted by Tossbag
Would not have happened in Class E. That piece of airspace is extremely busy at times, why? Where's the closest VOR that training can be done apart from MNG? The sectorisation there is extremely challenging for the ATC.
Oh come on Tossbag. Extremely busy is it? You're dreaming if you think Class E ie full-blown controlled airspace for IFR (regardless of the weather) will "work". There were two near-misses recently at Mangalore, according to the report; essentially dogfights in the holding pattern. If you think Class E would solve that you're dreaming. All that would do is make Mangalore one-in, one-out. And, of course, as per the other thread, Class E would not stop a VFR running into an IFR (and good luck, LB, forcing every VFR in the country to fit a transponder so E airspace will work).

Originally Posted by Tossbag
The sectorisation there is extremely challenging for the ATC
Precisely the reason that JQF didn't get traffic on AEM. AEM had been airborne, heading for Mangalore, for 27 minutes before being passed to JQF. JQF should have got traffic on AEM on taxi. Not good enough. Getting late-notice traffic (6 miles, 12 o'clock!) in a full radar/ADS-B environment is not good enough. Do you have any idea what workload the pilots are under just after takeoff (and approaching the airfield when doing an instrument approach?).

And the elephant in the room is the CTAF. Monitoring/calling on the CTAF while all this jibber is going on simultaneously on the ATC freq is a recipe for a disaster.

In this context, I think the SFIS would work well. It removes the fundamental, deadly flaw of the new-age airspace rationale: having to operate on two freqs simultaneously. A bit like a supercharged CAGRO with legal position info: providing info when required but otherwise letting the pilots sort it out and get on with it. I have always said you simply cannot run two, concurrent airspace systems together (ATC+E and CTAF+others) without pilot workload going through the roof.

The report also said multiple pilots heard the broadcasts from AEM and JQF on the CTAF. Just how busy was the CTAF? These were experienced pilots (albeit training students). How is it that multiple broadcasts and at least one traffic statement from ATC to each (meaning both aircraft should have heard it) were all missed? Comms overload. Would that have happened if FS had been in place, such as at Port Hedland? No (or the chance would have been very very much reduced).

And the first STCA occurred 1min 38sec before the collision. I've had a traffic alert from ATC when I've already switched to the CTAF. In this case, ATC was still talking to the aircraft, with no "changing to the CTAF" call yet made. You wouldn't let a person walk out into an incoming car if you could stop them, even though it's not your responsibility...
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Old 31st Mar 2022, 14:30
  #33 (permalink)  
 
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You're dreaming if you think Class E ie full-blown controlled airspace for IFR
These two aircraft would not have collided in Class E airspace.

All that would do is make Mangalore one-in, one-out
Yes, yes it would. In IMC that's exactly what it means.

Class E would not stop a VFR running into an IFR
In IMC conditions it would, that's how Class E works. If a VFR ran into an IFR in IMC in Class E then there's a different problem isn't there? But you're letting your 'Tossbag obsession' turn you into a ranting loon.

AEM had been airborne, heading for Mangalore, for 27 minutes before being passed to JQF. JQF should have got traffic on AEM on taxi.
ATC expert now? You haven't got all of the ATC picture here, you've got air/ground comms only, on one aerodrome, not the 20 or 30 other that this person was looking after plus the en-route traffic plus the internal co-ord that needs to be done. Class E in these sectors and there wouldn't be one controller looking after this debacle.

Rant, rant, rant. You've got 10% of the picture but you're a 100% expert, well done you

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Old 31st Mar 2022, 14:55
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Maths 101, 6 miles in your 12 o'clock, unless they were on reciprocal tracks then the aircraft shouldn't have collided.

ATC 101, vector the aircraft at the current position of the other aircraft and they'll never hit.

There seems to be an inconsistency between Figure 13: Recreation of STCA display at 1122:29 and Figure 20: Aircraft position for AEM and JQF

These aircraft were under pilot navigation. Figure 13 there appears to be about 150 (160?) degrees between the relative flight paths, figure 20 there appears to be about 100 degrees between the relative flight paths. JQF must've turned further left to intercept their outbound track to LACEY.

[edit: Figure 24: Estimated collision aspect based on ADS-B data and wreckage assessment shows the angle as being about 135 degrees]

AIP GEN 3.3 para 2.16.7 h. "any other data which may enhance the value of the information". For JQF "traffic right to left", not sure that 12 o'clock was accurate. Why is that ATSB needed to do a recreation of the STCA display? Surely there was a TAAATS replay available including all the HMI actions of the controller, use of route display, use of Bearing and Range tools, movement of the labels, use of highlight function, use of text areas, which strip windows were open.

Figure 12: STCA activation and vertical profiles for AEM and JQF is interesting as it shows that the controller changed their display range (ASD range) a number of times, zoomed in, zoomed out, zoomed in and zoomed in further. When your sector extends across two states, from south of (abeam) Melbourne to north of Canberra and Wagga, to have a range of just 23NM demonstrates that the controller was focused on the STCA alert.

How is that Eurocat still has STCA issues? How is it that STCA's have been inhibited in Class G airspace in the BN FIR below 4500ft and not in the ML FIR? Interestingly ATSB doesn't explore this discrepancy.

Linking to ATSB publication A pilot’s guide to staying safe in the vicinity of non-towered aerodromes - such a dated document. Published 2013. Quotes statistics from 2003 and 2008 where there were 709 occurrences in the vicinity of non-towered aerodromes were reported to the ATSB relating to airspace use, operations and procedural compliance. Do we have more up-to-date information? What has changed since 2013?

I am pleased that the Department of Infrastructure is partially funding the installation of ADS-B transponder technology. I'd much rather than it was 100% funding.

Last edited by sunnySA; 1st Apr 2022 at 02:39. Reason: typo, added [edit]
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Old 31st Mar 2022, 15:04
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You're dreaming if you think Class E ie full-blown controlled airspace for IFR
These two aircraft would not have collided in Class E airspace.
That is NOT what I said. Quote me completely or not at all. I said "work". I did not say Class E would have not prevented this prang. Of course it would have.

In IMC conditions it would, that's how Class E works. If a VFR ran into an IFR in IMC in Class E then there's a different problem isn't there? But you're letting your 'Tossbag obsession' turn you into a ranting loon.
I never mentioned "in IMC". Stop adding red herrings to your argument.

Given you are allegedly a multi-decade experienced IFR trainer AND controller (according to the CV you PMed me), instead of ranting, I assume you would have at least thought of the two-comm issues of E and CTAFs. And just to circumvent a VMC tangent, please don't suggest all the IFRs simply switch to VFR to make it all work. As we saw at Ballina, looking out the window doesn't always work. Unless of course you think I am speaking nonsense.

not the 20 or 30 other that this person was looking after plus the en-route traffic plus the internal co-ord that needs to be done.
Oh, so it's ok to have so little time to consider what they are looking at on the screen may well go pearshaped. Right. What I'm seeing is a lack of service. What you're saying I can't get that service because the controller is too busy (or the ATC system is set up badly). One doesn't need to be an expert to see there is a major problem here.

Class E in these sectors and there wouldn't be one controller looking after this debacle.
You said in your ranting PM that I don't know how many VOR approaches I've done there, 5 IFR at a time is routine at MNG. That would immediately stop in E, would it not, or how would all that navaid training work then?





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Old 31st Mar 2022, 16:33
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Thread drift, yes, I've been guilty of one or two but why are pilots required to train on a piece of kit that they will rarely use - VOR? I understand an ILS approach, I understand a NDB approach, but really isn't this all old school.

Is it a case of "I had to do it, so you have to do it too"? Is it a rite of passage that marks entrance or acceptance into a group or society, in this case a pilot fraternity?
Why not RNP or GLS approaches?

Could an entrepreneur make a $ by setting up an VOR in a paddock and charging for use? Same for a NDB? ILS might be a bit expensive if AUSCAL needed to fly it flight test every 3 months but if the minima was pretty high, or the approach was practiced from 5000ft to 2000ft then accuracy should be must of a problem.
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Old 31st Mar 2022, 19:47
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There was a section in the report that stated the possibility that each aircraft was transmitting on one frequency when the opportunity to hear the traffic was on the other....

Bad luck in the timing.
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Old 31st Mar 2022, 21:08
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Originally Posted by David Sutcliffe View Post
The reason the report takes so long to come out is that there is a 2 year Statute of Limitations on claims for accident compensation. This report has been released one month after the 2 year limit. Think about it? The detailed draft was completed around 12 months ago. It is fair to say it has has been heavily worked over to limit liability issues. The final report was released today and is available for download off the ATSB website. It identifies failures identified and discussed in this forum. You need to read the report and not just read the summary as the summary attempts to transfer all blame to the pilots.
I don't think you've read the Transport Safety Investigation Act 2003. And if the ATSB is delaying the release of investigation reports because of potential liability issues and compensation claims arising from the accident under investigation, it would be worth the ATSB reading the Transport Safety Investigation Act 2003, again. I think you're confusing correlation for causation, David.

(Of course it's all the pilots' fault. OAR and Air Services have stuck a band aide over the running sore. Job done. Move on, nothing to see here.)
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Old 31st Mar 2022, 21:35
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[G]ood luck, LB, forcing every VFR in the country to fit a transponder so E airspace will work.
I see your point, Capn. No piece of equipment has ever been mandated for VFR aircraft in Australia. CASA would never impose new costs on anyone. (BTW: Not all VFR aircraft have to be fitted with transponders for E airspace to work. VFR aircraft without transponders just have to stay out of it. That's kinda the point...)

We know what will happen if an RPT aircraft full of passengers collides with a non-transponder equipped aircraft in G.

It's the 21st century, FFS. We have hand-launched drones flying around with transponders in them. That there are still highly intelligent, highly experienced people attempting to justify the operation of passenger-carrying RPT aircraft in airspace where non-transponder equipped aircraft may operate, completely astonishes me. That the operators and PICs of those RPT aircraft choose to do it, completely astonishes me. As if the opinion of the mutual protection racket comprising CASA, Air Services and ATSB that it's 'not unsafe' makes it so.

Last edited by Lead Balloon; 31st Mar 2022 at 21:47.
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Old 31st Mar 2022, 22:44
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Ranting? I don't think so mate. It's pretty clear who's engaging in that. It's clear to me there are multiple factors at play here, if you want to cherry pick some of the simpler causes, do so, there are answers to every point. But the real cause here is that a 1970's-80's airspace system is being used despite having a 2000's onward radar/surveillance system. The equipment has evolved but the procedures and airspace has not, and it won't. Not until Ballina happens or elsewhere.
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