air safety

Jul 11, 2017

ATSB writes massive report avoiding key issue in 2013 Mildura fog crisis

Somehow the ATSB has done a research report on the Mildura fog crisis of 2013 that doesn't mention the 737s didn't have to carry enough fuel to prevent it happening

Ben Sandilands — Editor of Plane Talking

Ben Sandilands

Editor of Plane Talking

[caption id="attachment_62708" align="aligncenter" width="610"] ATSB Mildura Fog follow up report cover[/caption] The ATSB has just covered the Mildura fog crisis that involved Virgin Australia and Qantas 737s landing blind at the rural airport four years ago because they didn't have enough fuel to go anywhere else, under a blanket of first class but irrelevant research. The new research report doesn't deal with the fact that it is permissible for domestic airliners in this country to set off on flights between cities without sufficient fuel to reach a planned alternative airport if the weather prevents them landing at their intended destination within the regulated safe minimums in terms of visibility and other conditions. On June 18, 2013, the Qantas and Virgin flights found that they couldn't meet those requirements because of an unforecast fog at Adelaide airport and elected to land at Mildura instead, which was within reach of their remaining fuel. However unforecast fog at Mildura saw both jets land at the country town without enough fuel to do anything else. The upshot of various missed approaches by the jets was that the Virgin 737 eventually had to land despite considerable uncertainty as to whether it would find the runway, with the cabin prepped for a crash landing, passengers in the brace position, and calls of ‘brace, brace,brace’ from the flight attendants. In its final report into those incidents, published last year, the ATSB said both flight crews uploaded sufficient fuel for the originally-forecast conditions in accordance with their operators’ fuel policy and the Civil Aviation Safety Authority requirements. However the ATSB failed to inquire, in breach of its obvious responsibility to do so, into the adequacy of the Australian fuel requirements for such flights. It was severely criticised by some pilots and safety analysts at the time for its gutlessness. That administrative cowardice extends to today's release of a study entitled The effect of  Australian aviation weather forecasts on aircraft operations: Adelaide and Mildura airports. Today's research release is of course first class in its compilation and execution, but structured no doubt by total coincidence,  to avoid the blindingly obvious need to examine the adequacy of the fuel rules followed by Qantas and Virgin Australia on the morning of the Mildura crisis. The 177 page research report published today says that in relation to Adelaide and Mildura (and we dare to suggest every other jet capable airport in Australia) it is relatively more important that forecasts are retrieved at the latest possible time (before the point where a diversion is no longer possible) prior to arrival. Will this research publication fool anyone? No. It could have been subtitled How to avoid going too far up sh*t creek when the unforecast weather threatens to close airfields you never thought you'd need to land on because you really don't have the fuel to do anything else. Two Australian passenger jets were put in harms way by inadequate fuel rules. Had developed world standards for these been in force, both jets would have diverted to more distant airports, such as at Melbourne, or Sydney, or perhaps a more distant jet runway equipped country town than Mildura that was fog free.

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43 thoughts on “ATSB writes massive report avoiding key issue in 2013 Mildura fog crisis

  1. James Nixon

    I call it “the cleanest third world country in the world”.

    After 31 years in the industry I am still amazed that an Australian A380 can fly from Dubai to Sydney and not have to carry an Alternate because of a CASA “Grandfather Clause”.

    This saves them carrying 20 tonnes of fuel every day compared to international airlines, and has resulted at least one declaration of emergency so they could land below minima. That flight didn’t even have enough fuel to divert to Canberra.

    Twice inbound Australian international flights have had to declare emergencies when arriving at Perth after unforecast weather materialised. One flight, from Singapore, Pilots even discussed ditching until a paxing Captain convinced them otherwise.

    Despite being called (behind their backs) “AUSTR-ONAUTS” for their pedantic ways, Australian pilots routinely set off to destinations in Australia without carrying enough fuel to reach an alternate airport, carrying only enough to cover and INTER or TEMPO for bad weather.

    But they don’t get it. It’s not only weather that can cause troubles. The better the weather, the more light planes out and about.

    One day, before flying from Alice Springs to Darwin, a Flight Engineer and I had to work really hard to convince a new Captain to carry enough fuel to get to Katherine if anything went wrong. He was terrified he would “be called in the office” for carrying extra fuel.

    We arrived in Darwin, on short final for 11, to see a Cessna 210 brake off a wheel and spin on the runway in front of us. Going around from fifty feet, we had only seven minutes of fuel before we were committed to fly to Katherine.

    Thankfully, the Cessna pilot dragged his wreck off onto the cross runway, the men in the little yellow car removed the wheel; and our passengers reached their destination.

    Had my Captain taken his planned fuel, and had the Cessna suffered a more debilitating arrival; we would have had to land over the wreckage on whatever runway remained.

    Fog is the enemy in Australia, a country that talks big about air safety, but only has two Cat 3B runways. When you fly into third world countries that have better facilities you wonder: “So does that make my country, Australia, the 4th, or 5th, world?”

    Pilots: if they don’t give you a Lo Vis licence and Cat 3B runways, cover your backside with fuel to go somewhere else. Not 200 kgs on every flight “for Mum” (200 kgs gets you no-where and is not going to help your Mum); but enough for a realistic alternate.

    And if they want to call you in the office for it, great. Get them to put it in writing. Take pics of every document, then contact Ben Sandilands or me.

    We’ll make you famous for sticking-up for your passengers.

    As Don Kendell once told me: “I haven’t spent 20 years building my company so you can turn a Metro into a rotary hoe, 20 miles west of Hamilton. Take The Fuel”.

    He was a very wise man.

    James Nixon

    1. Dan Dair

      Australia is flying 21st century, state-of-the-art aircraft,
      with fuel-alternative rules that were ‘cutting-edge’ in the late 1950’s.!!!

      (& with an unfeasably large number of airfields served by passenger jets, with no control tower, ILS, fire-service or effective weather monitoring….. but hey, she’ll be right.?)

  2. JW (aka James Wilson)

    Jesus wept! A 177-page report to state something that’s blindingly bloody obvious. What a waste of taxpayer dollars.

  3. comet

    So now we have to follow the money trail to discover the reasons the ATSB refuses to perform its duty.

    Royal Commission needed.

    1. Dan Dair

      ….or proper, old-school investigative journalism in the Australian mass-media.?

      1. Zarathrusta

        Four Corners is the one that could force a change.

  4. Dan Dair

    I wonder from where the ATSB could acquire such a devious plan……….

    Sir Humphrey Appleby to Jim Hacker:
    “Put the problem in the title of the report, thus avoiding any further need to refer to it in the text”
    The ‘Yes Minister’ school of action-avoidance.

  5. Resolute

    “doesn’t mention the 737s didn’t have to carry enough fuel to prevent it happening”
    Exactly Ben !
    CASA is always very good at arse covering.

  6. Chris Randal

    Whilst you could be correct it is more that fact that Australia seems to believe that the appropriate NAVAIDS/Approaches are available/developed.

    The fault is NOT with the carriers – it is with CASA and their masters, and the fact that the motive for those running airports is profit NOT safety.

    Even WLG and CHC have ILS approaches and ZQN has an RNP approach. What does BNE/ADL/any other airport in Australia have?

    1. Chris Randal

      Sorry – I’ll rephrase the first paragraph:

      “Whilst you could be correct it is more that fact that Australia seems to believe that the appropriate NAVAIDS/Approaches are not required”

    2. JW (aka James Wilson)

      Your comparison with New Zealand airports is not valid. BNE, ADL and other ‘large’ city airports in Australia have ILS approaches, but only MEL (and soon PER) has a full CAT IIIB ILS approach that allows landing in very low visibility conditions. The others only allow landings where the visibility is at least 550m, or in some cases higher. New Zealand is no better off than Australia – the only CAT IIIB approach is in Auckland. The approaches at WLG, CHC and ZQN do not allow landings in low visibility conditions (ie less than 550m).

      1. Dan Dair

        Are there any figures available on just how much the new ILS system at Perth will cost.?

        1. JW (aka James Wilson)

          I believe the total cost of the upgrade is about $36 million. Most of that cost isn’t actually the ILS upgrade; it’s the lighting infrastructure and transmissometers that are required to support low visibility operations.

    3. Dan Dair

      “The fault is NOT with the carriers”
      Whilst agreeing that it is CASA who should be providing the lead on this matter, by requiring proper fuelling for an alternate airfield, in line with normal world standards,
      I’ll take issue with it being ONLY about CASA & not the airlines.

      Independently, any airline COULD choose to fly with enough fuel for a proper alternate, but they actively choose not to.
      That choice is made every day by virtually all of Australias carriers for the good of their profits
      & in direct conflict with claims of the so-called emphasis upon a passenger-safety culture.

      I would be extremely surprised if most/any Australian passengers realised that their home airlines don’t carry alternate fuel on a day-to-day basis,
      or that this practise is completely within the laws & regulations of Australia.?
      I anticipate that most passengers just assume that what they see in TV & films, about diverting to an alternate airport is what happens at home as a matter of course,
      and this is what their plane will do if the destination becomes unavailable.?

      Should the worst ever happen (as it nearly did at Mildura), the airlines will be quick to blame CASA, but this simply won’t wash.
      It is the airlines who are putting pressure upon CASA not to tighten the regulations, because they know it will affect short-term profits.
      Any airline could take this step & then market it as a safety feature (which it is.!), to attract concerned passengers & shame other airlines into following suit.?

  7. Dan Dair

    “unforecast fog at Mildura”
    IMO that’s a significant part of the problem.

    Mildura isn’t the centre of the universe, but equally it’s not a one horse town.
    They have regular jet services as well as a bunch of daily turbo-props.
    But what they don’t have, is anyone actually on the ground who could let anyone in the AirServices main control office know that it was a bit foggy there.

    So AirServices allowed the two B737’s to divert to Mildura because they thought the weather was OK.?
    Actually, they must have KNOWN the weather was OK, otherwise they wouldn’t have let them divert.?
    Which is a bit of a shame considering they were completely wrong.!

    1. JW (aka James Wilson)

      The BoM does have an observer on the ground at Mildura, who reports to the BoM. The BoM then issues the observations and forecasts that are passed to aircraft by AirServices. In this case, AirServices personnel on the ground in Mildura (if they existed) would not have made much difference. If I remember correctly, the BoM observer stated that the fog formed very quickly, by which time the two aircraft were almost overhead Mildura with no fuel to go anywhere else.

      1. Dan Dair

        I wasn’t there & don’t purport to be definitive on this,
        but in my experience Mist forms very quickly.
        Fog tends to develop over a period. Indeed Mist may form & then lead to fog later.?

        My only experience of ‘instant’ fog is that which happens when you are travelling & move into a ‘fog bank’.

        If you’re stationary & the fog exists as a bank, you can see it slowly moving towards you.
        If it forms around you. it tends to do it over a period of an hour or hours.

        However, whilst I freely admit that I have no idea what is normal & usual for the area around Mildura airport,
        I would venture to suggest that the observer may have had his feet-up until ‘the two aircraft were almost overhead’, at which point he started rapidly thinking-up a good excuse.?.

        1. JW (aka James Wilson)

          I wasn’t there either, but the ATSB investigation report into the incident states the following:
          “Between 0925 and 0931, the visibility at Mildura abruptly decreased from about 28 km to 1,000 m. In addition to the recorded indications, the BoM forecaster received a phone call from ATC asking about the conditions. In response the forecaster contacted the BoM observer located at Mildura Airport. The observer advised the forecasting office that the mist and subsequent fog arrived rapidly from the south.”

          1. Dan Dair

            “Between 0925 and 0931, the visibility at Mildura abruptly decreased from about 28 km to 1,000 m”
            So, according to the observer the weather changed from essentially completely clear to totally boxed-in, over a period of just six minutes.?

            I refer you back to my previous ‘feet-up’comment.!

          2. Tango

            Dan: You are being your usual obscured self.

            I have seen fog banks move over 2 miles in very short periods of time.

            In minutes you can go from totally clear to zero zero.

            There is a lot lacking in the system, but with what they had it was what looked like an easy choice.

            What I can say is that if you have the instruments, you can both predict and forecast the POSSIBLIY of a sudden fog development or movement.

            That certainly was lacking.

            My take was I would have taken Adelaide, but then I have a great deal of confidence in my ability to fly instruments, Adelaide had much better setup than Mildura and a diversion with no reserves if iffy at best.

          3. Dan Dair

            I’m not being ‘obscured’.?
            JW tells us that the official report says;
            “Between 0925 and 0931, the visibility at Mildura abruptly decreased from about 28 km to 1,000 m”

            28 kilometers is around 17.5 miles. That’s a darned sight more than two miles……
            If the observer was actually observing, it’s not unreasonable to imagine that they’d have noticed the weather begin to close-in when they first saw the fog-bank or adverse conditions, around the time that visibility was no-longer at 28km.?

            With the benefit of hindsight, Adelaide is a far better option, especially as it ended-up having much better weather than was forecasted.!
            But importantly, the two aircrafts’ crews were told by AirServices that Adelaide was fogbound & Mildura was clear, when actually, the reverse turned-out to be true.!

        2. JW (aka James Wilson)

          I should add, the aircraft arrived overhead Mildura shortly after 0930.

          1. Dan Dair

            & I should add that according to the figures you tell us were in the report,
            this weather-front closed-in on Mildura at an approximate speed of approaching 300kph or around 180mph.
            That’s pyroclastic flow or hurricane pace, not that of a random bit of weather.?

          2. JW (aka James Wilson)


            If you are interested in finding out what happened then I suggest you read the report. It’s available on the ATSB website.

            The paragraph preceding the one I previously quoted provides further detail about the abrupt decrease in visibility: “At 0918, a special weather report (SPECI) observation was issued for Mildura, listing the cloud as broken at 200 ft, and visibility in excess of 10 km. Subsequent SPECIs at 0928, 0930 and 0932 showed the visibility decreasing from 5,000 m to 2,100 m in mist, with broken cloud at 200 ft. The first SPECI indicating the presence of fog was issued at 0948, showing visibility as 900 m in fog and cloud overcast at 100 ft.”

            You previously said that mist forms very quickly, which is exactly what happened. It’s defined as fog once the visibility drops below 1,000m.

        3. BugSmasher

          Dan, your experience is not realistic. I hope you are not a pilot if you believe that fog is part of a ‘frontal’ or advective system. Fog is not associated with a frontal system – it can be advective but not in the same way as differing air masses are in frontal terms. Please revisit your Met knowledge. I can help if you like as I have 100% record and had a question permanently removed from CASA Met exams for inaccuracy.

          As you use the term ‘feet up’, I have to assume you are a pilot. In that case it is extremely serious that you dont understand how you are being professionly undermined by the destaffing of BoM stations, including Mildura which has already been destaffed.
          Destroy yourselves by ignorance, or lobby your ‘management’ for decent forecasts and observations. Or pay the ultimate price.
          It will happen. Again.
          Norfolk Island. Mildura. Who is next?

  8. George Glass

    It is difficult to convey to the general public how crap the infrastructure in Australia is.Politicians are terrified of infrastructure. It cost money. It’s in unpopular. Fat better spend money on child care centres. So infrastructure is ignored. Perhaps you could justify Cat 1 20 years ago. Today is delusional.Its exhausting even thinking about how you to explain to the travelling public how exasperating it is for professional aircrew to have to explain delays/ diversions etc. etc. And it all boils down to this; crap infrastructure, weak bureaucracy,know nothing politicians and no forward planning. It’s dangerous, it’s incredibly frustrating for all professionally involved and won’t change until there is a black smoking hole in the ground. The subsequent Royal Commission will be a ripper.

    1. Dan Dair

      I entirely concur.
      The strange thing IMO though, is that the pollies don’t allocate a fund to deal with the ILS issue (or the thing that’s supposedly just about to replace it), & then charge it back to the industry over a period of ten years (including interest), in the same way that would happen in a PFI infrastructure project.?
      AirServices & CASA already exist to maintain & monitor hardware, so it’s not as it any new departments would need to be created, just the funding for the overseeing of any additional kit.? (which you then charge-back to the industry through the existing taxation system.?)

      Having a ‘no alternate’ fuel policy could at least be justified to a greater extent, if AirServices & CASA were able to say that ‘there are no foreseeable circumstances where weather would prevent an aircraft from landing at it’s intended destination’.
      ………. it wouldn’t help a jot with James Nixon’s tale, though.!

  9. Resolute

    Just for the record Virgin Australia Boeing 737-800 was
    – Registed VH-YIR.
    – Called Cactus Beach.
    Cactus was close to being Cactus. Not Good !
    CASA need to account and be held responsible for this but they will not.
    More here –

  10. Tango

    An aside, has there been any more on the B200 Crash?

    We just had a C-130 come apart mid air in the S.E. US which is bizzare as well.

    1. Ben Sandilands

      Horrified by the C-130 crash, and keen to know more, since this is so out of character by any test for such a mishap. However I would never consider trying to report on it from Australia. I don’t set out to be a comprehensive aviation news site, but to chose topics where my own contacts, including those abroad, can provide reliable guidance or information. On the RFDS B200 crash, I don’t think I could add anything extra to the ATSB and general media reports. And in the flow of things, I am spending too much of today in cardiac care, after a chemo session yesterday was terminated by the need to understand a sudden heart problem. Older people are like older aircraft, we do require maintenance sometimes at inconvenient moments.

      1. [email protected]

        All the best Ben. Here’s hoping for good results.

      2. comet

        Thoughts with you, Ben.

      3. Dan Dair

        I hope they can sort it out properly at your next D-check Ben.?

    2. Dan Dair

      Aprops the C130 crash;
      If it were in a combat zone, you’d speculate it was shot-down
      or if it was a civilian airliner you’d be thinking bomb on board.

      Since neither of those is the case,
      an apparent mid-air breakup must be somewhat concerning for almost everyone, since pretty-much every nation in the Western world operates these things.?

      1. Jaeger

        I wouldn’t rule out either option.
        Reports says that the KC-130 (tanker/transport variant of the C-130) was “loaded with ammunition”, and that this hindered the fire fighting operation on the ground.

  11. Slingshot

    Any chance of a question to Brisbane airport authorities about the debacle last week when fog rolled in around 7 pm and resulted in a massive number of diversions and flight cancellations?
    It appears journalists(?) in this country seem incapable of asking the question to Brisbane Airports corporation CEO as to why the management are incapable of providing infrastructure to support low vis ops. Instead she comes out in an interview and agrees, yes the fog was thick.!! ! Sweet mother of god…..

    1. Dan Dair

      “she comes out in an interview and agrees, yes the fog was thick.!! !”

      I didn’t see that report
      & I agree with your comment upon it.

      I’d despair of the standards of modern journalism, except that I’ve already worn that one out,
      you’ve got to respect the CEO for convincing the ‘journo’ that fog closing the airport, was nothing the airport could possibly have done anything about.?

  12. Ben Sandilands

    None. Cancer has changed my life, in that I have less time, and I have to chose what I do on what is an unpaid gig more carefully than before. There is no way I’d revisit a week later a story I didn’t cover in the first place. But this isn’t about me but reporting in general. The media can’t afford specialist reporters anymore, and those that are in my opinion most important are covering politics and finance, and perhaps within a year, they might all be gone.

  13. comet

    Slingshot said:
    “It appears journalists(?) in this country seem incapable of asking the question…”

    Dan Dair said:
    “….or proper, old-school investigative journalism in the Australian mass-media.?”

    Slingshot and Dan: You are both disgruntled with the Australian media. Which news organisations do you have a subscription to?

  14. Dan Dair

    I don’t subscribe (in terms of fee-paying) to any news agency.
    I do read & watch a lot of news (because I’m actually interested) from a lot of sources. Even ones known to be somewhat ‘disreputable’, such as Al-Jazeera, Huffington Post & Fox News.
    Sometimes you get to see a very different angle by understanding the way other people, with a very different agenda, are interpreting / re-interpreting a story.?

    1. comet

      If you want ‘old school investigative journalism’ someone has to pay for that.

      Everyone wants it, but nobody thinks it’s worth it. There aren’t many products like that.

  15. Dan Dair

    I stopped buying a daily newspaper when I realised that the most important thing in it for me was the TV listings.
    Later, when I was playing footie I’d buy a ‘quality’ paper to read on the bus, but it then took me all week to actually read everything in the paper. (I’d be getting to the sports section on Thursday or Friday in last Saturdays paper.??? a bit weird.!!!)

    I’ve hardly bought a newspaper at all since I stopped playing.
    I often think I’d like to take a ‘quality’ paper again when I retire.?

    As to your “Everyone wants it, but nobody thinks it’s worth it” comment,
    you might well be right.?

    On the other hand, it might be that people no-longer have a grasp of world events & prefer their ‘newspaper’ to carry stories about TV, TV stars, soap stars, celebrities, etc, etc, etc because it’s easier to understand.?
    These are the same people who complain about ‘the government’ whilst having little or no idea about how difficult it is to govern fairly or to deal with problems presented by other nations.
    It’s probably also the reason that successive governments seem so corrupt….. They know most ordinary people won’t find out about it, or if they do, they can probably be persuaded that it was all just a big mistake.?

    Perhaps if the standards of journalism were better, the dailies would attract a new generation of readers (& purchasers)?

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