Mildura 2023 near miss final report out
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Mildura 2023 near miss final report out
Apologies, I couldn't remember if there was already a separate thread for this one, and a quick search didn't bring anything up.
https://www.atsb.gov.au/publications...rt/ao-2023-025
Near collision involving Piper PA-28-161, VH-ENL, and Bombardier DHC-8-315, VH-TQH, at Mildura Aerodrome, Victoria, on 6 June 2023.
https://www.atsb.gov.au/publications...rt/ao-2023-025
Near collision involving Piper PA-28-161, VH-ENL, and Bombardier DHC-8-315, VH-TQH, at Mildura Aerodrome, Victoria, on 6 June 2023.
The occurrence
In the early afternoon of 6 June 2023, a Piper PA-28-161 (PA‑28), registered VH-ENL taxied for runway 36[1] at Mildura, New South Wales, for a private flight to Broken HillCC
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What sort of airborne assistance were the Qlink crew hoping to offer to the Piper pilot?
According to the report they say the pilot saying RWY35 instead of 36 meant they didn’t think it was at Mildura.
On the transcript they don’t seem to have said Mildura in their IFR taxi call which the Piper may have overheard and been helped by.
According to the report they say the pilot saying RWY35 instead of 36 meant they didn’t think it was at Mildura.
On the transcript they don’t seem to have said Mildura in their IFR taxi call which the Piper may have overheard and been helped by.
“QantasLink has updated its operations manual to reflect the updated minimum company requirements of a rolling call to be made at all CTAF aerodromes”
Which QantasLink entity has updated its manual? Nearly half of domestic aircraft operated by the Qantas Group are branded QantasLink.
Which QantasLink entity has updated its manual? Nearly half of domestic aircraft operated by the Qantas Group are branded QantasLink.
Oh come on Aussieflyboy, we've known for a long time there is THE Qantaslink and then there's all the other Qantaslinks! 
Radio shielding is now a known probably at Mildura, which wasn't discussed much in the report.
However, there was a second near miss at Mildura and the ATSB are finally investigating these radio issues.
Just more of the he who cannot be named's mindset of not "talking". Sure, they made all the broadcasts like the book says (some plain wrong) but gee, wouldn't you at least ask the Dash 8 if they heard you?
As for RWY 35 at Wentworth, it might be... Then again it could be a lighty that has royally screwed up.
I see the Mildura "taxis" are still in business. No uber yet?
As for RWY 35 at Wentworth, it might be... Then again it could be a lighty that has royally screwed up.
I see the Mildura "taxis" are still in business. No uber yet?
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I don't think this is a case of not enough talking. I think it's a case of not enough listening and thinking about the implications of what was said and actually known, exacerbated by comms and visibility limitations due to the physical layout of the runways and buildings.
There have always been strange comms issues in the vicinity of Mildura. Last time I went there - quite a while ago because Mildura has become very GA 'unfriendly' - I gave taxiing, entering, backtracking and rolling calls for 18 after hearing an inbound call from a SAAB (I think it was a SAAB) to the east for a straight in 27, with an ETA minutes after I was due to start - and did start - rolling on 18 for a departure to the east.
I took off and stayed well south of the track straight in 27. I'm guessing my transponder then showed up in the SAAB's cockpit because the aircraft called the aircraft in my location, I said g'day and I was aware of their location, track and ETA and was clear. They asked whether I'd made a taxiing call and I said yep, I called "taxiing", "backtracking" and then "rolling" on 18 when each of those events occurred. They'd evidently heard none of those calls. I was evidently on the correct frequency and my transmitter was working, because I heard everything the SAAB said on CTAF (and to Centre on Area), and the SAAB heard me when I responded to their call in the air.
Strange thing is that there is no obvious physical/topographical issue as would cause comms problems between an aircraft on the ground on the eastern side of Mildura aerodrome (me) and an aircraft in the air to the east of Mildura (the SAAB). Perhaps my calls on the ground were all 'over-transmitted', but I wasn't hearing too much traffic other than the SAAB at the time. The only other alternatives I can envisage are distractions or finger trouble in the SAAB cockpit, but the SAAB did make its inbound call on the correct CTAF.
And to anticipate the Cap'n having conniptions about me not 'double checking' whether the SAAB had heard and comprehended my three CTAF calls, I'm not in the habit of seeking those confirmations after I've decided that another aircraft's location, ETA and intentions compared with my location, ETD and intentions will not result in any risk of collision with that aircraft. That, ultimately, is what the calls are for. I'm then concentrating on another risk: unknown traffic. If something changes for me or other known traffic, that's when more thinking and talking may be necessary.
I've commented before on the irony of these incidents coming to attention because of comms systems/transponders eventually doing their job, when bigger risks arise from aircraft with no transponder and a comms system suffering 'finger trouble'.
Call me crazy, but maybe aerodromes with an RPT service should be CTR during RPT operations, and a control service provided as a 'public good' rather than on a 'user pays' basis by a monopoly government ANSP pretending to be a business?
There have always been strange comms issues in the vicinity of Mildura. Last time I went there - quite a while ago because Mildura has become very GA 'unfriendly' - I gave taxiing, entering, backtracking and rolling calls for 18 after hearing an inbound call from a SAAB (I think it was a SAAB) to the east for a straight in 27, with an ETA minutes after I was due to start - and did start - rolling on 18 for a departure to the east.
I took off and stayed well south of the track straight in 27. I'm guessing my transponder then showed up in the SAAB's cockpit because the aircraft called the aircraft in my location, I said g'day and I was aware of their location, track and ETA and was clear. They asked whether I'd made a taxiing call and I said yep, I called "taxiing", "backtracking" and then "rolling" on 18 when each of those events occurred. They'd evidently heard none of those calls. I was evidently on the correct frequency and my transmitter was working, because I heard everything the SAAB said on CTAF (and to Centre on Area), and the SAAB heard me when I responded to their call in the air.
Strange thing is that there is no obvious physical/topographical issue as would cause comms problems between an aircraft on the ground on the eastern side of Mildura aerodrome (me) and an aircraft in the air to the east of Mildura (the SAAB). Perhaps my calls on the ground were all 'over-transmitted', but I wasn't hearing too much traffic other than the SAAB at the time. The only other alternatives I can envisage are distractions or finger trouble in the SAAB cockpit, but the SAAB did make its inbound call on the correct CTAF.
And to anticipate the Cap'n having conniptions about me not 'double checking' whether the SAAB had heard and comprehended my three CTAF calls, I'm not in the habit of seeking those confirmations after I've decided that another aircraft's location, ETA and intentions compared with my location, ETD and intentions will not result in any risk of collision with that aircraft. That, ultimately, is what the calls are for. I'm then concentrating on another risk: unknown traffic. If something changes for me or other known traffic, that's when more thinking and talking may be necessary.
I've commented before on the irony of these incidents coming to attention because of comms systems/transponders eventually doing their job, when bigger risks arise from aircraft with no transponder and a comms system suffering 'finger trouble'.
Call me crazy, but maybe aerodromes with an RPT service should be CTR during RPT operations, and a control service provided as a 'public good' rather than on a 'user pays' basis by a monopoly government ANSP pretending to be a business?
Last edited by Lead Balloon; 15th May 2024 at 06:48. Reason: Correct a typo
Personally I think making a 'lining up' or 'rolling call' before doing so is a very good idea. The back track on some of the longer runways out there could be a few minutes with silence over the radio. Although I still see aircraft making 'entering' calls as they enter, which defeats the purpose of giving another aircraft time to let you know they are there. The issue Qantaslink had, is that there is a camp out there that think they just have to make the minimum mandatory calls, and don't understand the need to be more assertive in these scenarios to ensure they are heard, and that other traffic understand what is going on. They talk about 10nm as a minimum distance to make initial calls, however the approaches start at 15nm out, where an IFR aircraft is going to be quite busy in the last 10nm before that. So really aircraft need to be on CTAF listening and even broadcasting from 25nm out (if feasible) in these places.
I'll still harp back to the nearest we had to a real mid air collision disaster was at Albury while the tower was open and only TCAS saved the day.
Call me crazy, but maybe aerodromes with an RPT service should be CTR during RPT operations, and a control service provided as a 'public good' rather than on a 'user pays' basis by a monopoly government ANSP pretending to be a business?
Call me crazy, but maybe aerodromes with an RPT service should be CTR during RPT operations, and a control service provided as a 'public good' rather than on a 'user pays' basis by a monopoly government ANSP pretending to be a business?
after I've decided that another aircraft's location, ETA and intentions compared with my location, ETD and intentions will not result in any risk of collision with that aircraft.
but maybe aerodromes with an RPT service should be CTR during RPT operations
They talk about 10nm as a minimum distance to make initial calls
however the approaches start at 15nm out, where an IFR aircraft is going to be quite busy in the last 10nm before that. So really aircraft need to be on CTAF listening and even broadcasting from 25nm out (if feasible) in these places.
2400-odd total hours for the Captain. Not a lot in a high pressure OCTA environment in a high-cap RPT TP.
Our SOP was to monitor the CTAF from TOD, call at 30nm (jet). No company nonsense below Transition (or preferably none on Descent), just sit and listen.
I agree with listening to CTAF well in advance though, at least double the distance you would normally make a call. The problem is the smaller aircraft may only be listening and broadcasting from 10nm or less. So you might commence an RNP and find a Cessna half way between you and the field all of a sudden make an inbound call. Also, I can't understand why ADSB coverage does not extend to ground in the Mildura area. I remember a few years back there was a problem with some sort of interference near the circuit, sounded like electrical or machinery emission breaking through, haven't been there recently so not sure if they've fixed it in the last few years or not.
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The RPT network will only get away with a near miss 9 times out of 10 and wont the various CEO's and Boards of Government Business Enterprises scurry for cover. when a near miss becomes a collision.
I think all RPT ports should have discrete, independent frequencies. Whoever designed the frequency segregation was only thinking of the local area at low altitude, not high performance aircraft dropping in from the flight levels.
That would create a paradox, typified by Mildura and Wentworth. If they had different CTAFs, which one would be used by an aircraft e.g. 6.5nms SE Wentworth / 6.5nms NW Mildura, tracking NE or SW?
Remember: A CTAF is just a frequency, not a zone of defined dimensions.
I think we’ll find that the choice to have the same CTAF for Mildura and Wentworth (and Narrandera and Leeton, and…) was deliberate and steeped in the history of AFIZs (and MBZs and CTAFRs…). Heavy metal traffic in and out of Mildura apparently ‘wants to know’ about operations in the vicinity of Wentworth, 13nms away. (There’s no doubt the Sunraysia gliding field only a couple of NMs away from Mildura should have the same CTAF.)
Short of the implementation of CTR at Mildura during RPT ops, I don’t envisage a change in the frequency allocations for Mildura and Wentworth. Assuming I’m wrong and they were changed to have different CTAFs, could someone walk me through what calls would be made on what CTAF, and what CTAF would be monitored, by my example aircraft: 6.5nms SE Wentworth / 6.5nms NW Mildura, tracking NE at 5,500’ or SW at 4,500’?
In any event, while ever Mildura and Wentworth are both just in G, sharing the same CTAF, I make the following, inexpert suggestions:
- If you’re in an aircraft on the ground at Mildura and you think you’re hearing an aircraft on the ground at Wentworth: Think again. There’s around 13nms of trees, buildings, cars, trucks, power lines and other crap in between the antennas of those line of sight radios. Remember: Aircraft on the ground at Mildura have occasional difficulty in VHF comms with each other, with less than 1nm separation, due to big metal-clad buildings in between them.
- If you’re in an aircraft on the ground at Mildura and you think you’re hearing an aircraft on the ground at or in the vicinity of Wentworth, but none of that aircraft’s transmissions include the word “Wentworth”: Think again, harder.
- If you’re in an aircraft on the ground at Mildura and you think you’re hearing an aircraft on the ground at or in the vicinity of Wentworth, but all of that aircraft’s transmissions include the word “Mildura”: Think again, much harder.
- And, as always in G, always assume there are aircraft near you that you haven’t heard from, because of someone’s finger trouble or equipment malfunction.
Call me crazy, but wouldn’t it be great if one of the four webcams at Mildura could be set up to give continuous vision of the threshold of RWY 36 through to TWY B, so that aircraft taxiing for and taking off from RWY 09 could check to see if there were any unknown aircraft rolling or potentially about to roll on 36?
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ATSB should talk to ACMA.
[
Re 'Call me crazy, but wouldn’t it be great if one of the four webcams at Mildura could be set up to give continuous vision of the threshold of RWY 36 through to TWY B, so that aircraft taxiing for and taking off from RWY 09 could check to see if there were any unknown aircraft rolling or potentially about to roll on 36?'[/QUOTE]
G'Day Mr Crazy,
You sorta mean like the proposed new system at 'Badgerys'.......cameras lookin' 'everywhere' and not an ATCer in sight?
That vision could be relayed to ML CEN who could then say....'Hold' or 'Looks clear for T/O.....Really'.... But it wouldn't be on the CTAF, would it?
Any of the Mildura ex FSO's on this channel? What were your ground VHF 'blackspots' in those former 'good ole days'..??
I used to pass thru a few times and don't remember any probs.
Cheeerrrsss....
Re 'Call me crazy, but wouldn’t it be great if one of the four webcams at Mildura could be set up to give continuous vision of the threshold of RWY 36 through to TWY B, so that aircraft taxiing for and taking off from RWY 09 could check to see if there were any unknown aircraft rolling or potentially about to roll on 36?'[/QUOTE]
G'Day Mr Crazy,
You sorta mean like the proposed new system at 'Badgerys'.......cameras lookin' 'everywhere' and not an ATCer in sight?
That vision could be relayed to ML CEN who could then say....'Hold' or 'Looks clear for T/O.....Really'.... But it wouldn't be on the CTAF, would it?
Any of the Mildura ex FSO's on this channel? What were your ground VHF 'blackspots' in those former 'good ole days'..??
I used to pass thru a few times and don't remember any probs.
Cheeerrrsss....
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Yes, but…
That would create a paradox, typified by Mildura and Wentworth. If they had different CTAFs, which one would be used by an aircraft e.g. 6.5nms SE Wentworth / 6.5nms NW Mildura, tracking NE or SW?
Remember: A CTAF is just a frequency, not a zone of defined dimensions.
I think we’ll find that the choice to have the same CTAF for Mildura and Wentworth (and Narrandera and Leeton, and…) was deliberate and steeped in the history of AFIZs (and MBZs and CTAFRs…). Heavy metal traffic in and out of Mildura apparently ‘wants to know’ about operations in the vicinity of Wentworth, 13nms away. (There’s no doubt the Sunraysia gliding field only a couple of NMs away from Mildura should have the same CTAF.)
Short of the implementation of CTR at Mildura during RPT ops, I don’t envisage a change in the frequency allocations for Mildura and Wentworth. Assuming I’m wrong and they were changed to have different CTAFs, could someone walk me through what calls would be made on what CTAF, and what CTAF would be monitored, by my example aircraft: 6.5nms SE Wentworth / 6.5nms NW Mildura, tracking NE at 5,500’ or SW at 4,500’?
In any event, while ever Mildura and Wentworth are both just in G, sharing the same CTAF, I make the following, inexpert suggestions:
- If you’re in an aircraft on the ground at Mildura and you think you’re hearing an aircraft on the ground at Wentworth: Think again. There’s around 13nms of trees, buildings, cars, trucks, power lines and other crap in between the antennas of those line of sight radios. Remember: Aircraft on the ground at Mildura have occasional difficulty in VHF comms with each other, with less than 1nm separation, due to big metal-clad buildings in between them.
- If you’re in an aircraft on the ground at Mildura and you think you’re hearing an aircraft on the ground at or in the vicinity of Wentworth, but none of that aircraft’s transmissions include the word “Wentworth”: Think again, harder.
- If you’re in an aircraft on the ground at Mildura and you think you’re hearing an aircraft on the ground at or in the vicinity of Wentworth, but all of that aircraft’s transmissions include the word “Mildura”: Think again, much harder.
- And, as always in G, always assume there are aircraft near you that you haven’t heard from, because of someone’s finger trouble or equipment malfunction.
Call me crazy, but wouldn’t it be great if one of the four webcams at Mildura could be set up to give continuous vision of the threshold of RWY 36 through to TWY B, so that aircraft taxiing for and taking off from RWY 09 could check to see if there were any unknown aircraft rolling or potentially about to roll on 36?
That would create a paradox, typified by Mildura and Wentworth. If they had different CTAFs, which one would be used by an aircraft e.g. 6.5nms SE Wentworth / 6.5nms NW Mildura, tracking NE or SW?
Remember: A CTAF is just a frequency, not a zone of defined dimensions.
I think we’ll find that the choice to have the same CTAF for Mildura and Wentworth (and Narrandera and Leeton, and…) was deliberate and steeped in the history of AFIZs (and MBZs and CTAFRs…). Heavy metal traffic in and out of Mildura apparently ‘wants to know’ about operations in the vicinity of Wentworth, 13nms away. (There’s no doubt the Sunraysia gliding field only a couple of NMs away from Mildura should have the same CTAF.)
Short of the implementation of CTR at Mildura during RPT ops, I don’t envisage a change in the frequency allocations for Mildura and Wentworth. Assuming I’m wrong and they were changed to have different CTAFs, could someone walk me through what calls would be made on what CTAF, and what CTAF would be monitored, by my example aircraft: 6.5nms SE Wentworth / 6.5nms NW Mildura, tracking NE at 5,500’ or SW at 4,500’?
In any event, while ever Mildura and Wentworth are both just in G, sharing the same CTAF, I make the following, inexpert suggestions:
- If you’re in an aircraft on the ground at Mildura and you think you’re hearing an aircraft on the ground at Wentworth: Think again. There’s around 13nms of trees, buildings, cars, trucks, power lines and other crap in between the antennas of those line of sight radios. Remember: Aircraft on the ground at Mildura have occasional difficulty in VHF comms with each other, with less than 1nm separation, due to big metal-clad buildings in between them.
- If you’re in an aircraft on the ground at Mildura and you think you’re hearing an aircraft on the ground at or in the vicinity of Wentworth, but none of that aircraft’s transmissions include the word “Wentworth”: Think again, harder.
- If you’re in an aircraft on the ground at Mildura and you think you’re hearing an aircraft on the ground at or in the vicinity of Wentworth, but all of that aircraft’s transmissions include the word “Mildura”: Think again, much harder.
- And, as always in G, always assume there are aircraft near you that you haven’t heard from, because of someone’s finger trouble or equipment malfunction.
Call me crazy, but wouldn’t it be great if one of the four webcams at Mildura could be set up to give continuous vision of the threshold of RWY 36 through to TWY B, so that aircraft taxiing for and taking off from RWY 09 could check to see if there were any unknown aircraft rolling or potentially about to roll on 36?
Although it’s actually “Class Q” airspace by the way some of that operators crew boss people around CTAFs these days.
They key problem here though was their assumption the Piper was at a different airport and no assertiveness to check.
I recall descending into Kadina (126.7) and hearing a call that we weren’t sure was “Kadina” or “Ceduna”. Call me crazy but we just asked them to clarify.
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