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air safety

Mar 9, 2017

ATSB slams AirServices for endangering two jets, helicopter over Melbourne

Nick Xenophon's allegations that air traffic management at Melbourne's two airports have put public safety at serious risk are supported by this scathing ATSB report

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An overview of the scene of this madness

The ATSB has reported on a truly third world performance by AirServices Australia in failing to properly separate two 737s using Melbourne’s main airport at Tullamarine and a helicopter above the adjacent general aviation airport at Essendon on January 26, 2016.

The safety investigator doesn’t mince words on this occasion,

On the morning of 26 January 2016, the air traffic controllers at Melbourne Airport, Victoria conducted a runway change from runway 16 for arrivals and runway 27 for departures to runway 16 for arrivals and departures. The Melbourne Tower Coordinator and the Melbourne Approach East Controller were required to coordinate the runway change with the Essendon Aerodrome Controller. However, both Melbourne controllers forgot to conduct the coordination.

At Essendon Airport, the pilot of a Robinson R44 helicopter, registered VH-WYR (WYR), had been cleared to operate overhead the airport, not above 1,500 ft, as there were overcast conditions above that level.

At 0705 Eastern Daylight-saving Time, a Boeing 737 was cleared for take-off on Melbourne runway 16. About 1 minute later, another Boeing 737 was cleared for take-off on the same runway. The Essendon Aerodrome Controller observed the first Boeing 737 departing runway 16 on their Tower Situation Awareness Display. As the controller was unaware of the change of runway at Melbourne, they believed the Boeing 737 was an uncoordinated missed approach.

Shortly after, the second Boeing 737 departure appeared on the display. The Essendon Aerodrome Controller queried the active runway with the Melbourne Planner Controller, and found out that the active runway had been changed at Melbourne Airport without the required coordination with Essendon. At 0708, the Essendon Aerodrome Controller instructed the pilot of WYR to operate over or to the east of the Essendon runway 26 threshold, ensuring a 3 NM (5.6 km) separation with the runway 16 departures from Melbourne Airport.

A review of the surveillance data confirmed losses of separation between WYR and the two Boeing 737 aircraft. At their closest, the first was 2.4 NM (4.4 km) west of and 800 ft above WYR, the second 2.5 NM (4.6 km) west of and 800 ft above. Either a 3 NM (5.6 km) surveillance separation standard or a 1,000 ft vertical separation standard was required.

What the ATSB found

The ATSB found that, while there were requirements for coordination between Melbourne and Essendon Airports, there were no documented procedures, checklists, tools or memory prompts to assist controllers to coordinate runway and airspace changes. In this case, the Melbourne Tower Coordinator and Melbourne Approach East Controller each forgot to conduct the required coordination with the Essendon Aerodrome Controller. Neither controller could explain this lapse.

The ATSB report justifies claims  repeatedly made by Senator Nick Xenophon that air navigation arrangements involving the two closely located Melbourne airports are unacceptably dangerous.

Readers can draw their own conclusions as to whether the safety findings at the end of the full report here will have outcomes which are worth the paper on which any hard copies are printed.

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11 comments

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11 thoughts on “ATSB slams AirServices for endangering two jets, helicopter over Melbourne

  1. Mick Gilbert

    Ben, I think that it is absolutely astounding, bordering on criminally negligent, that Air Services did not have a written local work instruction for what might be a routine but also a relatively high risk procedure. They are meant to be certified to AS/NZS ISO 9001:2008 (they have just completed their recertification audit) which is a quality management system that, inter alia, places reasonable emphasis on the process approach (ie managing activities and related resources as a process).

    1. Dan Dair

      At very least, you would imagine that there would be a box to tick somewhere on a checklist, either hard copy or computer screen, to confirm that the requisite procedures had been appropriately followed.?

      But it appears that there wasn’t any written procedure for it.???

      I was only recently reading about the anniversary of the loss of the car ferry in the English Channel thirty years ago.
      I’m sure I recall at the time one of the crewmembers telling the inquiry that the ‘official’ signal for whether it was his job to close the bow-doors, was whether the other bloke who might do it had left his boots outside his cabin door.!
      (which meant he was off-duty & wouldn’t be closing them)
      Still, at least they had a system, poor as it was.?

    2. Chris Randal

      ISO9001 is purely about having the paper work right for the audit.

      It has nothing to do with practicalities

      1. Mick Gilbert

        A quality systems is no different to any other business system, its relationship with practical outcomes is driven by management. ISO 9000 systems are a bit like toasters, you need to put bread in to get toast out, fail to do that and you simply get hot air and wasted energy.

  2. George Glass

    Why are you surprised? Australias aviation infrastructure is hopelessly inadequate.Everyone in the industry knows it.

  3. 777 Steve

    Ben, whenever I operate in Australian airspace and in particular to Australian Airports, the one thing that is included is a pertinent briefing on the threats for the day. Regrettably, air traffic control in places like Greece and Hungary is more predictable and reliable than most if not all Australian airports. For a supposed first world country, the level of service offered and competency shown is abysmal.

    1. Dan Dair

      Do you think AirServices could tempt-away a CEO or similar from one of the European ATC’s to take control of Australian ATC & bring it up to ‘Western’ standards.?
      Or would they be likely to throw their hands up in despair on their first day & catch the first plane back home.?

      1. 40years

        Dan,
        What ‘Western Standards’ do you mean?
        Do you mean European surveillance and traffic management systems in use in Australia over the last 50 years? Tick!
        Do you mean adherence to ICAO SARPS with minimum differences? Tick! ( The USA nominates the most differences from ICAO of any country)
        Do you mean appointing a CEO from overseas such as the USA or, god help us, New Zealand? Tick!
        What ‘Western’ standards do you mean?
        Steve 777: Give examples. We’re sick of Sky-God pronouncements from above.
        Put some meat on the bones, or perhaps visit a Centre or two. It may surprise you to find that Pilots do not have all the answers, any more than a driver on the Monash Carpark can provide useful traffic resolution proposals.

        1. 777 Steve

          40 years, what a classic case of shooting the messenger! How about we flip your comments on their head? How about some of the controllers or better yet the organisations management and policy makers visit a few centres in other countries to see how much better it can be done? I remember watching a documentary a few years ago where Australia was leading the way in removing flightcrew from the decision making process with respect to air traffic control, I remember thinking at the time that the level of arrogance shown by the designers and advocates of the system was astounding, your response to my observations would suggest that you don’t consider “skygods” anything other than a nuisance or worse.
          As for meat on the bones, where I start??? poor co-ordination leading to pointless and poorly planned speed control, lack of adaptability for different types with differing performance levels, inconsistent clearances with an unrealistic expectation of adherence….but that’s just a few off the top of my head from my last visits to YMML, YBBN and YSSY.
          As the well known joke in aviation circles around the world goes, Australia..the worlds second best ATC, and when pressed as to who’s the best?
          “Everywhere else” is the answer.

          1. Yes No Maybe

            …inconsistent clearances with an unrealistic expectation of adherence… “unrealistic expectation of adherence” – do tell, compliance with a clearance is crucial with any ATC system otherwise what do we have? I expect aircrew to comply with their clearance and if unable then say so and I will adjust as required. I will monitor your compliance and adjust if required.

  4. ghostwhowalksnz

    Only a year to issue a report ?
    Musn’t have been one of the major airlines fault, as they would drag it out for years

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