Mildura 2023 near miss final report out
The risks to aircraft taking off on 09 posed by potential traffic using 36, and vice versa, at Mildura are as plain as canine testicles, FTS, and have been for a long time. No hindsight involved.
More than one person posting in this thread has suggested a number of steps that could easily have been taken, but weren't, to mitigate the evident risks, Cap'n. Whether they would have negated the risks? We'll never know.
What I do know is that the reasonable foreseeability of a collision rather than a near miss in the very circumstances in which the Dash and ENL found themselves in this case is a foregone conclusion. The subsequent analysis, in various fora, of a collision in the same or similar circumstances at Mildura will just be of what everybody could and should have reasonably done to prevent the collision and, given the disastrous consequences of this (easily) foreseeable event in similar circumstances, there'll be a very high bar set for the standard of care owed by both pilots involved. I wish the best of British to anyone who reckons they'll get away with: "There's nothing more I could easily have done to mitigate the risks and anyone who reckons there was is just being wise in hindsight."
I assume you (FTS and the Cap'n) aren't answering 'yes' to my question: If there had been a collision between the Dash and ENL, who thinks it would be reasonable to attribute the cause to ENL’s mistaken broadcast of “35” rather than “36”, alone? Please let me know if my assumption is wrong. If my assumption isn't wrong, it follows that you concede that there were - as usual - more holes in the Swiss cheese than one in this case.
I get the impression that any suggestions as to what more the Dash could have done so as to potentially mitigate the risks is being construed as blaming the pilot of that aircraft alone for what happened. That's not intended, at least by me. FWIW: CASA, the ATSB, the ANSP, the airlines and the aerodrome operator are much higher on my 'blame list' than the pilots involved.
More than one person posting in this thread has suggested a number of steps that could easily have been taken, but weren't, to mitigate the evident risks, Cap'n. Whether they would have negated the risks? We'll never know.
What I do know is that the reasonable foreseeability of a collision rather than a near miss in the very circumstances in which the Dash and ENL found themselves in this case is a foregone conclusion. The subsequent analysis, in various fora, of a collision in the same or similar circumstances at Mildura will just be of what everybody could and should have reasonably done to prevent the collision and, given the disastrous consequences of this (easily) foreseeable event in similar circumstances, there'll be a very high bar set for the standard of care owed by both pilots involved. I wish the best of British to anyone who reckons they'll get away with: "There's nothing more I could easily have done to mitigate the risks and anyone who reckons there was is just being wise in hindsight."
I assume you (FTS and the Cap'n) aren't answering 'yes' to my question: If there had been a collision between the Dash and ENL, who thinks it would be reasonable to attribute the cause to ENL’s mistaken broadcast of “35” rather than “36”, alone? Please let me know if my assumption is wrong. If my assumption isn't wrong, it follows that you concede that there were - as usual - more holes in the Swiss cheese than one in this case.
I get the impression that any suggestions as to what more the Dash could have done so as to potentially mitigate the risks is being construed as blaming the pilot of that aircraft alone for what happened. That's not intended, at least by me. FWIW: CASA, the ATSB, the ANSP, the airlines and the aerodrome operator are much higher on my 'blame list' than the pilots involved.
43Inches, until a Rolling call is made mandatory, your argument doesn't hold up, and in fact it could be argued it lead to this incident because ENL (if what you say is correct) assumed that the Dash would make a rolling call (probably because most others do), didn't hear one so therefore assumed it (the Dash) couldn't have been rolling and took off themselves. I don't think it's good airmanship, even if/when such a call is mandated, to blast off, as ENL did, without saying to themselves "now hang on, I know they taxied out, I wonder where they are? Have a missed a call?" I would hope I certainly wouldn't.
I'm not suggesting we don't mandate a rolling call. But be aware that CDF still applies and until a third-party CAGRO or similar is set up, it will probably be the final hole in the cheese if not employed.
I'm not suggesting we don't mandate a rolling call. But be aware that CDF still applies and until a third-party CAGRO or similar is set up, it will probably be the final hole in the cheese if not employed.
LB, I don't answer stupid questions.
43Inches, until a Rolling call is made mandatory, your argument doesn't hold up, and in fact it could be argued it lead to this incident because ENL (if what you say is correct) assumed that the Dash would make a rolling call (probably because most others do), didn't hear one so therefore assumed it (the Dash) couldn't have been rolling and took off themselves. I don't think it's good airmanship, even if/when such a call is mandated, to blast off, as ENL did, without saying to themselves "now hang on, I know they taxied out, I wonder where they are? Have a missed a call?" I would hope I certainly wouldn't.
I'm not suggesting we don't mandate a rolling call. But be aware that CDF still applies and until a third-party CAGRO or similar is set up, it will probably be the final hole in the cheese if not employed.
I'm not suggesting we don't mandate a rolling call. But be aware that CDF still applies and until a third-party CAGRO or similar is set up, it will probably be the final hole in the cheese if not employed.
Again the rolling call should not be mandatory by rule, as it's situational, it SHOULD be made in any instance there is a delay between entering a runway and departure regardless of sighting arrangements. The same as I would make a line-up and holding call if I had a delay for some reason departing said runway, or any other call that gives my position if it was such that a conflict could arise. All of this is common sense defensive aviating to make traffic aware of your presence and communication can then resolve any future conflict. Your argument is like saying we should not practice defensive driving because it's not mandated in the rules.
Both ENL and the Dash crew made mistakes based on assumptions that should have been clarified, it was however identified and corrected by QLink that they had a deficiency in procedure.
Seriously anyone who is in command of a regional turboprop should know this stuff backwards.
I wonder if the Captain was fined 100 Penalty units for failing to avoid collision risk and failing to safely operate in regard to traffic.
satisfied that traffic conditions at the aerodrome enable such a landing or take‑off to be carried out safely.
Something happened. Let's learn from it.
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If you don't understand the basics of airlaw you have no place in command of an airliner where your job is 90% about compliance with the law.
What it shows is that some here will defend a badge no matter what the consequence, even when the badge owner has admitted they had a problem and fixed it.
The comment about whether the captain was fined was more a joke that i'm sure LB will understand regarding 'strict liability' and the like.
BTW the comment about learning must be for the slow, as learning how to avoid catastrophes on take-off by using the radio appropriately was something studied over 50 years ago, or are we reminding ourselves each time we repeat something by not following best practice? Have to have an accident or two every now and then to remind the slow of us that accidents are bad....
Oh such a voice of reason becomes suddenly unhinged.
The last point there effectively states that you have to fit in with traffic operating into wind, not that the traffic fits in with you, ie give way. Seriously anyone who is in command of a regional turboprop should know this stuff backwards.
If your aircraft is incapable of using the most into wind runway then you have to give way to those that are, sorry but that's how it works.
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No references in your reply align with the following comment or apply to cross strip ops (both runways had headwind):
91.380 Operating on manoeuvring area, or in the vicinity, of non‑controlled aerodrome—landing and taking off into the wind
(1) The pilot in command of an aircraft for a flight contravenes this subregulation if:
(a) the aircraft is operated on the manoeuvring area of, or in the vicinity of, a non‑controlled aerodrome; and
(b) the pilot does not, to the extent practicable, land and take off into the wind.
(2) Subregulation (1) does not apply if:
(a) the aircraft flight manual instructions for the aircraft allow the aircraft to land or take off downwind or crosswind; and
(b) the pilot is satisfied that traffic conditions at the aerodrome enable such a landing or take‑off to be carried out safely.
(3) A person commits an offence if the person contravenes subregulation (1).
Penalty: 50 penalty units.
Note: A defendant bears an evidential burden in relation to the matters in subregulation (2): see subsection 13.3(3) of the Criminal Code.
(1) The pilot in command of an aircraft for a flight contravenes this subregulation if:
(a) the aircraft is operated on the manoeuvring area of, or in the vicinity of, a non‑controlled aerodrome; and
(b) the pilot does not, to the extent practicable, land and take off into the wind.
(2) Subregulation (1) does not apply if:
(a) the aircraft flight manual instructions for the aircraft allow the aircraft to land or take off downwind or crosswind; and
(b) the pilot is satisfied that traffic conditions at the aerodrome enable such a landing or take‑off to be carried out safely.
(3) A person commits an offence if the person contravenes subregulation (1).
Penalty: 50 penalty units.
Note: A defendant bears an evidential burden in relation to the matters in subregulation (2): see subsection 13.3(3) of the Criminal Code.
2 (a), Allows you to take off with a crosswind component or tailwind if your aircraft flight manual allows such operation. So it's not just about headwind, its about being the most directly into wind unless you have a flight manual that allows crosswind or tailwind operations.
2 (b) Then states if you can accept a crosswind or tailwind, you then must assess the traffic situation and be able to operate safely with regard to that traffic, it does not matter what runway, if they are even using a runway. This means there is an additional onus on the least-headwind departure or arrival to fit in with traffic in the area, regardless of the runway in use. This is the aviation legalese of a give way sign, that is the least-headwind departure must make way to fit in with any traffic that is operating in a normal fashion, most in compliance with rule 1. Its clear what it is referring to as it says "traffic conditions at the aerodrome enable such a landing or take‑off to be carried out safely", which means if the normal circuit into wind is being used then the crosswind or downwind operation must fit in with that traffic, or any other traffic conflicting with the departure, so not just traffic on the runway, but traffic in the circuit, arriving and departing etc etc.
There is no such rule as you alluded to earlier about operating with tailwind, the rule is you must take-off into wind as much as practicable unless you comply with conditions under heading 2, which also allows tailwind operations.
If you wish to challenge point 2 (b) with CASA, I suggest you do before you push in front of an aircraft complying more with section 1, you might find yourself in trouble. And in breach of CASR 91.340.
You also bang on about mandatory rolling calls, but it probably wouldn't haven made a difference if they can't hear each other from respective thresholds. So there goes that layer of defence you want to defend so vigorously.
I will add that communication with the thresholds between 09 and 36 is clearly possible, there is very little radio shielding. I've had an exchange with a Warrior in the exact same scenario, where they elected to hold while we departed after we lined up and asked their intentions. There are always possible scenarios where the angle of the aircraft relative to each other can make radio reception worse, but you can definitely communicate between thresholds given two aircraft facing down each respective runway. And anywhere else on field for that matter.
PS having right of way does not mean you can push in front of others, there are many scenarios that can not be written into exact 'give way' regulations, that's why the rules are not finite on the situation. However if you do take-off on the least headwind runway and end up in conflict with traffic complying with the rules more so, then you will be in breach as the onus was on you to safely operate with regard to traffic.
Last edited by 43Inches; 19th May 2024 at 22:40.
Let’s assume that everything you say is rock-solid true, FTS. It follows, therefore, that aircraft which can neither see nor hear each other effectively, including RPT aircraft full of fare paying passengers, continue to play Russian roulette on 09/36 at Mildura today.
In the 21st century, it’s not practicable to come up with a technical solution to the comms screening and interference problems quickly, such that aircraft within a nautical mile of each other can communicate reliably. It’s beyond our collective wit and wisdom. It’s not practicable to do anything to work around the visibility issues by installing webcams quickly, such that aircraft can get access to real time, reliable images of what can’t be seen directly. That’s beyond our collective wit and wisdom, too. It’s not practicable to have a CAGRO or some other third party monitoring and advising or even controlling the traffic. Apparently, it’s all ‘too expensive’.
When an RPT aircraft full of fare paying passengers is lost in a collision in these or similar circumstances, presumably the explanation will be that the costs of mitigating the obvious risks were not justified because of the rarity of the event. I reckon that explanation will go down like a lead balloon.
(On the specific issue of rolling calls, the ATSB itself said: “The lack of a requirement for mandatory rolling calls increased the risk of aircraft not being aware of each other immediately prior to take-off.” Setting aside the tautology and the ATSB’s and many others’ mistaken belief that the only “mandatory” calls are the ones specified on a list of standard broadcasts at particular places and times, it’s not just 43” suggesting that the absence of a rolling call increased the risk in this case.)
In the 21st century, it’s not practicable to come up with a technical solution to the comms screening and interference problems quickly, such that aircraft within a nautical mile of each other can communicate reliably. It’s beyond our collective wit and wisdom. It’s not practicable to do anything to work around the visibility issues by installing webcams quickly, such that aircraft can get access to real time, reliable images of what can’t be seen directly. That’s beyond our collective wit and wisdom, too. It’s not practicable to have a CAGRO or some other third party monitoring and advising or even controlling the traffic. Apparently, it’s all ‘too expensive’.
When an RPT aircraft full of fare paying passengers is lost in a collision in these or similar circumstances, presumably the explanation will be that the costs of mitigating the obvious risks were not justified because of the rarity of the event. I reckon that explanation will go down like a lead balloon.
(On the specific issue of rolling calls, the ATSB itself said: “The lack of a requirement for mandatory rolling calls increased the risk of aircraft not being aware of each other immediately prior to take-off.” Setting aside the tautology and the ATSB’s and many others’ mistaken belief that the only “mandatory” calls are the ones specified on a list of standard broadcasts at particular places and times, it’s not just 43” suggesting that the absence of a rolling call increased the risk in this case.)
against rolling calls, as they were not mandatory.
the ATSB itself said: “The lack of a requirement for mandatory rolling calls
From CASA guide:
MUST
in the vicinity of a non-controlled aerodrome – the pilot in command considers it necessary to broadcast to avoid the risk of a collision with another aircraft (91 MOS 21.04(1)),
SHOULD
The other recommended (but not mandatory) that help everyone out. Rolling is not one of them.
There's countless threads on here bemoaning the congestion on frequencies because of all the calls others make to 'help" .
I think it's a bit different for IFR aircraft. Don't they have some mandated - specifically prescribed - calls listed for specific events/times, even in G? And aren't radios mandatory for everyone in the vicinity of Certified aerodromes, even in G?
And for my part, I don't think a rolling call by an aircraft that's broadcast backtracking/taxiing on a runway constitutes unnecessary congestion, especially if it's an RPT aircraft. (My pet peeve is when 10 words are used but 5 would have sufficed - that's unnecessary congestion.)
If I had to bet folding money on what a coroner would decide about the lack of a rolling call if there'd been a collision in this case ...
And for my part, I don't think a rolling call by an aircraft that's broadcast backtracking/taxiing on a runway constitutes unnecessary congestion, especially if it's an RPT aircraft. (My pet peeve is when 10 words are used but 5 would have sufficed - that's unnecessary congestion.)
If I had to bet folding money on what a coroner would decide about the lack of a rolling call if there'd been a collision in this case ...
It's not about whether rolling calls were mandatory or not, it's the fact everyone else except QLink used it in these circumstances to avoid this exact situation. This is why QLink has changed it's procedure, for many years now QLink was operating contrary to what many would call best practice, and in a short space of time it all came to a head where a number of incidents occurred including this one where their lack of radio assertiveness resulted in a close call. So if there was an accident the coroner/investigators would be asking why this operator did not make these calls, if the rest of the industry was for many years. In this case they get away with a few close calls and re-write their ops manual, done.
The point is all along is that QLink almost went out of their way to NOT make rolling/advisory calls, which led to this situation and others. This was completely avoidable if their 217 had instructed pilots earlier of the need to make this call when not immediately departing a runway from entry so as to alert traffic. This was discussed before this incident occurred and it took the involvement of the ATSB/CASA to shake their 217 enough to make the change.
The point is all along is that QLink almost went out of their way to NOT make rolling/advisory calls, which led to this situation and others. This was completely avoidable if their 217 had instructed pilots earlier of the need to make this call when not immediately departing a runway from entry so as to alert traffic. This was discussed before this incident occurred and it took the involvement of the ATSB/CASA to shake their 217 enough to make the change.
And aren't radios mandatory for everyone in the vicinity of Certified aerodromes, even in G
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operating contrary to what many would call best practice
There seems to me to be some confusion around what calls are “mandatory”. But it may be that I’m the only one who’s confused.
Set aside the list of specific reports, in MOS Part 91 table 21.06(1), that IFR aircraft in G must make to ATS. And set aside any specific reports or broadcasts included in an operator’s ops manual. There remains the generally applicable rule that a broadcast must be made when the PIC considers it reasonably necessary to avoid the risk of a collision with another aircraft.
Take the simplest of topical examples. What PIC of an aircraft would consider it to be unnecessary to broadcast, on the CTAF, that the aircraft is entering and backtracking or taxiing on a runway at an aerodrome in G with crossing runways and ERSA entries saying “multiple RWY may be in use with significant TFC within circuit at any time” and “ACFT on RWY may not be visible to one another”?
If it’s the case that the general rule won’t be breached if the PIC simply doesn’t comprehend any potential risk of collision at all in those circumstances and therefore doesn’t even think about whether a broadcast is necessary, or comprehends the risk but doesn’t think a broadcast would avoid the risk, the general rule would seem to me to be meaningless.
I continue to consider it be an objective test, rather than just a question as to the subjective state of mind of the pilot. It would certainly be an objective test in ascertaining the pilot’s standard of care as an element of negligence. Either way, I’d call that broadcast “mandatory” – and I'll say it: as well as a “rolling” broadcast - in the hypothetical circumstances. It might be different at a single runway aerodrome at 3am local in gin-clear 360 visibility.
Set aside the list of specific reports, in MOS Part 91 table 21.06(1), that IFR aircraft in G must make to ATS. And set aside any specific reports or broadcasts included in an operator’s ops manual. There remains the generally applicable rule that a broadcast must be made when the PIC considers it reasonably necessary to avoid the risk of a collision with another aircraft.
Take the simplest of topical examples. What PIC of an aircraft would consider it to be unnecessary to broadcast, on the CTAF, that the aircraft is entering and backtracking or taxiing on a runway at an aerodrome in G with crossing runways and ERSA entries saying “multiple RWY may be in use with significant TFC within circuit at any time” and “ACFT on RWY may not be visible to one another”?
If it’s the case that the general rule won’t be breached if the PIC simply doesn’t comprehend any potential risk of collision at all in those circumstances and therefore doesn’t even think about whether a broadcast is necessary, or comprehends the risk but doesn’t think a broadcast would avoid the risk, the general rule would seem to me to be meaningless.
I continue to consider it be an objective test, rather than just a question as to the subjective state of mind of the pilot. It would certainly be an objective test in ascertaining the pilot’s standard of care as an element of negligence. Either way, I’d call that broadcast “mandatory” – and I'll say it: as well as a “rolling” broadcast - in the hypothetical circumstances. It might be different at a single runway aerodrome at 3am local in gin-clear 360 visibility.
Moderator
A wise man once observed to me that "the only valid rule is 'don't crash'. All else is mere titivation".
The 'all else', I would opine, is anything else which might reasonably be invoked/applied to maximise the probability of compliance with the rule ?
Is such mandated ? If not, one reverts to the observation that the rules represent a minimum standard and that one is not precluded from rising above that minimum standard ?
The 'all else', I would opine, is anything else which might reasonably be invoked/applied to maximise the probability of compliance with the rule ?
Is such mandated ? If not, one reverts to the observation that the rules represent a minimum standard and that one is not precluded from rising above that minimum standard ?
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1 (b), States that you are committing an offence if you don't take off into wind, this means as directly as possible towards the wind direction.
It's not about whether rolling calls were mandatory or not, it's the fact everyone else except QLink used it in these circumstances to avoid this exact situation. This is why QLink has changed it's procedure, for many years now QLink was operating contrary to what many would call best practice, and in a short space of time it all came to a head where a number of incidents occurred including this one where their lack of radio assertiveness resulted in a close call.
It's posts like yours that remind me why I took time away from pprune. And your tone and views are the exact reason the two most recent generations of pilots now avoid pprune like the plague. Don't worry, I'll see myself out while you continue to rant about the good old days and why errors would have never happened when you were flying.
Either way, I’d call that broadcast “mandatory”
when the PIC considers it
You appear to have overlooked the bit about the pilot's duty of care and standard of care at common law. That was the other "way" referred to in the words "either way". There are many (many) cases in which people have been found negligent, notwithstanding that they haven't breached any legislation.
You may well be right about the interpretation of the general rule in the Part 91 MOS. But, as I said, that would render the rule practically meaningless.
You may well be right about the interpretation of the general rule in the Part 91 MOS. But, as I said, that would render the rule practically meaningless.