Safety investigator silent on how Virgin Australia responded to pilot confusing flaps zero with flaps 30 in botched landing approach
On April 2 this year a Virgin Australia ATR turboprop was flown at the wrong speed and flap setting toward an intended landing at Brisbane Airport with 38 passengers as well as two cabin crew and two pilots on board before the captain broke off the approach after an audible warning from its enhanced ground proximity warning system.
The high wing regional airliner was less than 172 feet off the ground when the synthetic voice called TOO LOW FLAP and the captain, who was flying the approach, initiated a go-around, climbing away from the airport and bringing the flights which had started at Moranbah back for a properly configured landing.
According to the ATSB investigation into this serious incident, published today, the captain was so concerned at the events of that initial landing attempt that he then decided to stand himself and the rest of the crew down and not operate the next two intended regional flight sectors.
As the ATSB reports, it turned out that when the captain had called for the first officer to set the aircraft’s flaps to 30 degrees the junior pilot set them to the other end of the scale, at zero degrees.
The ATSB points out that had this setting been retained, the aircraft would have been moving at just under stalling speed, that is, no longer technically flying, when it made contact with the ground.
The ATSB doesn’t elaborate on the perils of such a situation, but they should be self evident. A stalled airliner discharging its kinetic energy without control on a runway at night. What could possibly go wrong?
There is no detailed explanation as to why the captain cancelled his and his crews participation in the intended next two flight sectors for this duty period. Yet the ATSB reveals that the captain didn’t learn that the first officer had set the flaps to zero at the wrong moment, until the airline showed him a post flight animation, some time after the serious incident occurred.
This report is very thorough on the technical side as required by such an investigation. But it is silent on what actions Virgin Australia may have taken subsequently to prevent such incidents exposing their employees and their customers to the dangers or risks they pose.
In compiling this report on the ATSB investigation no media response has been sought from the airline. All that counts in these investigations is what the ATSB says it found, not statements from carriers that unfailingly state that safety is their Number One priority.
It might be this or any carrier’s number one priority, and it can be argued that it is in fact an absolute requirement of their holding an air operator certificate for the aircraft concerned and the procedures the company undertakes to enact. These responsibilities are mandatory for Australian airlines and the personal responsibility of each and every one of their board members. They aren’t optional, and they don’t involve the exercise of choice to make them ‘the priority’. They are compulsory.
In this case, if its accepted that safety is the number one priority of the carrier, then that priority wasn’t successfully applied.
Aug 17, 2017
Will the need for a resumed MH370 search get a 'look in' from an Australian government in crisis, even with long awaited new information on satellite imagery and drift analyses?
Pressure is being applied on two fronts to the Turnbull Government to re-open the search for missing flight MH370 just as it seems all but paralysed by the political and constitutional crisis caused by Australian parliamentarians holding dual nationalities.
Whether these campaigns to resume looking for the Malaysia Airlines 777-200 ER that disappeared while on its way from Kuala Lumpur to Beijing on March 8, 2014 with 239 people onboard are successful may well be determined by their perceived value as ‘circuit breakers’ from the risks to the survival of this Coalition government posed by this unrelated but over arching crisis.
The Australian Transport Safety Board (ATSB) provides the time poor with this succinct notification of the progress made by Geoscience Australia in interpreting images of debris in the south Indian Ocean taken by a French military satellite on March 23, 2014, and a separate report by the CSIRO refining drift analysis it has carried out on debris from the jet recovered from westerly locations in that ocean.
In this latest notification ATSB Chief Commissioner Greg Hood tactfully hoses down the blunter claims made in some media reports that the CSIRO has identified a precise location for the wreckage, yet one which his Minister for Infrastructure, Darren Chester has declined to endorse because it doesn’t guarantee that it identifies the location of the sunk wreckage of the jet with sufficient precision.
In fact the CSIRO analysis that first identified a new search prospect was published with implicit and unambiguous ATSB encouragement just before Christmas last year.
It was also rapidly rejected as a new search imperative by Minister Chester the same day, and this led to extensive discussion on Plane Talking in the following months and those detailed reports and discussions can be accessed using the MH370 search button on this site.
Coming over the top of these latest refinements, and the long sought release of more information from the French military satellite, is the offer by an American oceanographic exploration firm, Ocean Infinity, to launch a radically faster seabed search for an undisclosed fee paid only if it succeeds in finding the wreckage.
There has been no coherent nor official Yes/No response to this offer a ‘free’ resumption of searching from either the Australian or Malaysian authorities.
Ocean Infinity has put both countries on the spot, something which may not elicit the co-operation of the administrative branches which advise governments in both countries, and it is the Malaysians who actually make the calls when it comes to what the ATSB managed (suspended) search for MH370 actually does.
Public service culture is strongly media pressure resistant, and as the principal sources of information and advice to governments, they tend to double down on errors of judgment, in the interests of face saving, and sometimes with very undesirable policy outcomes.
While it is true that none of the French identified potential objects were identified or examined by the original AMSA search, or the later aerial and sea surface activities of the ATSB managed searches, it has long been argued that the ATSB was with hindsight too hasty in shifting its efforts to the north-east of the zone near where the satellite images were made.
That has been a controversial talking point since late March 2014, and reported as such on some news sites, including this one.
Aug 3, 2017
An apparently well resourced privately funded offer to keep looking for MH370 puts the Australian, Malaysian and Chinese authorities on the spot
An American oceanographic exploration firm, Ocean Infinity, has offered to launch a radically faster seabed search for the sunk wreckage of missing flight MH370 for an undisclosed fee paid only if it succeeds in finding the Malaysia Airlines Boeing 777 that vanished with 239 people on board on March 8, 2014.
The offer, publicised by independent MH370 researcher Victor Iannello puts authorities in Malaysia, Australia and China on the spot in terms of support, given the controversial suspension of the official tripartite search in January contrary to a recommendation by Australian scientists to make a final examination of a comparatively small section of the southern Indian Ocean seabed to the southwest of Perth, Western Australia.
The Australian transport safety investigator, the ATSB, managed the now suspended oceanic search on behalf of its Malaysia and China partners in the quest to find the wreckage, and locate and recover, if possible, the flight data and cockpit voice recorders.
There is nothing to prevent any entity from searching for the main wreckage from MH370, although there are long standing internationally agreed rules that seek to avoid disturbing any aircraft wreckage pending a examination by an accident inquiry that conforms to the protocols of the International Civil Aviation Organisation which was founded in 1947.
MH370 was over the Gulf of Thailand early on March 8, 2014, on its way from Kuala Lumpur to Beijing, when it abruptly ceased to be visible to air traffic control systems as a transponder identified flight.
Automatically generated signals from MH370 picked up by an Inmarsat communications satellite indicated that the jet eventually flew into southern Indian Ocean airspace before running out of fuel.
Jul 27, 2017
How not to land a 777-200 at Canberra Airport
There is more terrain to think about on approaches to Canberra Airport than at most of the nation’s airline gateways, and as the newest to take wide-body international flights, the arrival of a Singapore Airlines 777-200 with 248 people on board on February 22 this year did so while twice at an unsafe altitude for parts of its descent in visual conditions toward Australia’s capital city.
Using its new fondness for gentle but precise language, the ATSB has nailed a series of mistakes made by the crew of the jet as the passed by some very big hills to the south and southwest of the airport before the pilots could see the runway.
In plain English, the crew at first flew 500 feet below a section of the approach with a safe minimum altitude of 7500 feet, and after correcting that error by climbing back to 7500 feet on the advice of tower control, they then descended the jet to 4600 feet above sea level at a closer in part of the approach profile where they should have maintained 5300 feet.
Canberra Airport is 1886 feet or 575 metres above mean sea level. The aircraft was cleared to continue to a safe landing from that lower than required level.
The ATSB report deals with the state of Canberra Airport at the time, with one navigational aid unavailable, and with the changes underway in near airport navigational procedures at Australian airports which are best left to technical forums.
The report also summaries the responses of Singapore Airlines, starting with its briefing the crew to expect an approach procedure which turned out not be be available when its flight was drawing close to the very high hills near Canberra.
This is the sort of report that might best be read by interested lay air travelers over a nice rich pudding accompanied by a desert wine.
Jul 11, 2017
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
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.
Jul 5, 2017
No doubt to the frustration of conspiracy theorists the missing signals from MH370 endorse the ATSB's most likely scenario for the jet's final moments
Independent MH370 investigations says that previously ‘secret’ communications satellite data supports Australian claims that the Malaysian Airlines jet, missing for more than three years, crashed at high speed into the south Indian Ocean.
In his forensic review of that data, Victor Iannello says Considering that the newly available data generally supports the conclusions of the official investigators, it remains a mystery as to why Malaysia withheld the data for so long, and why it chose to release the data at this time.
That data was released last month to one of the next of kin of the 239 people who died when MH370, a Boeing 777-200ER, vanished on a flight from Kuala Lumpur to Beijing on March 8, 2014.
A critical feature of the missing data was that it also contained all of the information transmitted via an Inmarsat satellite link on the previous flight by the jet, from Beijing to Kuala Lumpur, picking up features within it that were common to both flights and not anomalies unique to MH370.
As a result of revised drift analysis, the CSIRO and the ATSB now say there is more certainty as to the likely resting place of sunk wreckage from the flight on the floor of the ocean, but the search for that debris was called off in the New Year by the search partners, Australia, Malaysia and China.
Jul 2, 2017
After all the controversy over Air France AF447 a short ATSB report about a Jetstar incident shows how good safety cultures can avoid tragedy
There are sobering similarities between a Jetstar 787 control incident which is the subject of an ATSB investigation published last month and the loss of an Air France A330 which crashed into the mid Atlantic on its way to Paris from Rio de Janeiro in June 2009.
Fortunately the Jetstar incident in December, 2015, involving the similar temporary blocking of air speed measuring devices called pitots, did not end in a tragedy like that which killed all 228 people on board Air France flight AF447.
The Jetstar pilots did what apparently all other pilots have been done (other than those of AF447) when confronted by a sudden loss of vital data and a consequent disconnection of the autopilot system.
They held their throttle and attitude settings until the pitots self cleared, and then dealt with deciding whether to proceed with the flight or land for the technical reasons outlined by the ATSB.
The AF447 pilot flying did something inexplicably different to the unreliable airspeed procedures used by airlines, by pulling back on the side stick controller and sending the Airbus on a climb which ended with the airliner stalling and soon after, belly flopping with a force of 32G on impact, on the surface of the ocean
His colleagues proved incapable of identifying or rectifying the problem.
An astonishing litany of smokescreens and fierce arguments ensued for months over the conduct of the last moments of AF447.
The ATSB report doesn’t refer to AF447, nor cross reference other well documented cases of scheduled flights suffering from similar transient failures causing unreliable airspeed indications in the cockpits of various types of jets..
Given the bitterness that persists over the loss of AF447, this is understandable. This isn’t a case of safety lessons according to some pilots, but a reminder that degraded safety cultures which forget such lessons can destroy lives.
For all its tactful brevity, the ATSB report is an important contribution to air safety and an endorsement of the professionalism of the Jetstar pilots.
Jun 26, 2017
There are some deeply troubling questions to ask about this latest AirAsia X incident in Australian skies
No-one asked the critical question yesterday about the AirAsia X flight that returned to Perth after about 90 minutes of flight with a severely disabled engine that vibrated like a malfunctioning washing machine.
Why didn’t this jet land immediately at Learmonth (near Exmouth) in compliance with the internationally accepted safety rule that requires a twin engine airliner to land at the first available suitably equipped airport if one engine fails or is shut down?
The AirAsia X flight to Kuala Lumpur, an A330-300 with 359 people on board, was about 370 kms from the fully equipped alternative airfield when one of its engines ingested a fractured fan blade according to the Aviation Herald.
Yet instead of heading directly to Learmonth, the big wide body twin airliner was turned around and flown for around 720 kilometres back to Perth, during which time maritime rescue services were put on alert for a possible ditching in the sea north of the city.
AirAsia X, the Australian safety regulator CASA, and the Australian air safety investigator the ATSB, all have some very serious matters to consider. And the joke media that passes for news reporting in this country needs to hire reporters smart enough to take a look at the maps and look up the rules that apply to airliners that suffer in flight engine failures.
Jun 5, 2017
A key assumption about how MH370 behaved in its last moments isn't necessarily supported by the fine print in a Boeing manual
A previously overlooked line in a Boeing 777 training manual suggest that the Malaysia Airlines flight MH370 could have experienced an additional roll to the left as it plunged at very high speed to its impact in the south Indian Ocean after the jet ran out of fuel before crashing on March 8, 2014.
In his latest paper, MH 370 investigator Victor Iannello analyses an end-of flight scenario with banked descent and no pilot input.
He draws attention to this note found by fellow independent MH370 investigator Don Thompson in the Aircraft Maintenance Manual (AMM) for the B777, in the section on the Ram Air Turbine System:
Training Information Point
When the RAT is extended and hydraulics off, the airplane rolls left. Two to three units of right control wheel rotation are necessary to hold the wings level.
As explained in the analysis, the Ram Air Turbine or RAT is a very small tethered windmill type electrical generator hard wired to pop out into the slipstream of an airliner and provide some critical instrumentation and systems functioning in a jet that is no longer drawing power from engine driven generators.
Victor Iannello’s paper reads as an important refinement of the general scenario and conclusions drawn by Boeing’s end-of-flight simulations for MH370 with the assumption that there was no pilot input. Those simulation results were released in November 2016 by the ATSB as part of a report entitled MH370 – Search and Debris Examination Update.
This isn’t about suddenly identifying the final resting place of large, or maybe, not so large, chunks of the heavy wreckage of MH370, a Boeing 777-200ER, which was carrying 239 people on a red eye flight from Kuala Lumpur to Beijing when it vanished on March 8, 2014.
It’s about collecting and analysising data and working through the possible implications that arise in such studies. As such its the antithesis of the rush-to-judgment, mind-made-up coverage that has dogged the MH370 story since shortly after the jet disappeared.
The analysis includes a video showing the view from the cockpit during the simulated descent. The aircraft rolls past 180° and impacts the water at a pitch angle that is almost vertical. During the descent, the speed reaches about Mach 1.1, breaking the sound barrier, and the descent rate approaches 60,000 feet per minute.
(Although not discussed in this paper, the recovered debris from MH370 supports the high likelihood of airframe disintegration during a descent that would have exceeded some design limitations and a high energy impact with the sea surface by the denser and stronger parts of the jet.)
The sea floor search for MH370 was called off by Australia and Malaysia with the apparent agreement of China in January. The Australian Prime Minister, Malcolm Turnbull, has in the last week dropped hints that a physical search might resume.
May 5, 2017
More safety issues with the infamous Virgin Australia ATR 72 incidents of 2014 have emerged
Updated: CASA has applied addition oversights and a condition on ATR operators.
The ATSB has issued an alarming interim report into a set of incidents involving a Virgin Australia ATR 72 turbo-prop in 2014 saying a fault in the design had not been taken into account when it was certified as safe to fly.
The report also makes it clear that the inability of Virgin Australia to properly identify the unsafe condition of the airliner which continued to fly 13 sectors over five days after the incident remains under investigation.
The first incident happened on February 20, 2014, as the Virgin flight sustained a pitch disconnect crisis while on descent into Sydney. The pitch disconnect occurred while the crew were attempting to prevent the airspeed from exceeding the maximum permitted airspeed (VMO). The aircraft was significantly damaged during the occurrence.
In its first interim report issued last year the ATSB found to put it in blunter language that the two pilots broke the structure of the T-tail by forcing the controls in opposite direction.
In this report it finds that:
During the continued investigation of the occurrence, the ATSB has obtained an increased understanding of the factors behind this previously identified safety issue. This increased understanding has identified that there are transient elevator deflections during a pitch disconnect event that could lead to aerodynamic loads that could exceed the strength of the aircraft structure.
The ATSB also found that these transient elevator deflections were not identified, and therefore not considered in the engineering justification documents completed during the aircraft type’s original certification process. The ATSB considers that the potential consequences are sufficiently important to release a further interim report prior to completion of the final investigation report.
ATR isn’t represented in Australia, but Plane Talking understands that the maker, based in Toulouse, and partly owned by Airbus, is well aware of the contents of the second interim report and will respond in due course.
The separate issue of the disclosure standards from Virgin Australia, the quality of its oversight of the regional turbo-prop division, and prima facie evidence of an unsatisfactory culture outcome in the cockpit of the flight on descent into Sydney remains extremely important.
It was dealt with in Plane Talking at that time but largely ignored by the PR obedient general media in this post.
The core elements of the ATSB report show that Virgin Australia’s engineering contractor and the airline failed to identify and understand serious damage done to this aircraft in the turbulence event.
The aircraft was then allowed to carry passengers for thirteen sectors in that state before an in-flight crisis five days later approaching Albury from Sydney where it was grounded after landing, and remains to this day, pending repairs if indeed it can be repaired.
These are scandalous disclosures. No one in the general flying public in this country expects that a contract maintenance organisation could be so bad at its job that it failed to understand and identify the grave safety of flight issues apparent on the Virgin turbo-prop on 20 February.
It is after all, what the maintenance provider is paid by Virgin to do, rather than scratch their heads and release the aircraft back into service.
It’s Virgin’s inescapable legal obligation to ensure that all aircraft are safe before flying. It didn’t ensure the safety of these 13 flights. It’s CASA’s role to enforce and maintain a safe level of oversight on airline operations and ensure that those who carry out aircraft maintenance are competent and effective.
This is a 68 passenger airliner. The situation with the turbo-prop which remained grounded at Albury for months, was one that could have ended, at any time during the five days Virgin Australia had no obvious idea what was going on, in a pile of wreckage and bodies.
Learning, as the industry does today, there was also a blind spot in the certification of the turbo-prop as safe doesn’t build confidence in either the airliner nor the operator in this situation.
The public communication of the seriousness of the ongoing situation in February 2014 was non-existent, and for those media that did make inquiries, totally unsatisfactory.
More recently Virgin Australia has further rolled back its involvement with regional turbo prop services to keep a token force of six of the aircraft operating across parts of it network, once its Queensland ATR base is closed down. Canberra will remain a focus of ATR operations, contradicting the emphasis on E-190 jet flights that prevailed in recent years.
The airline has often said that safety is its first priority and that the ATR operations are safe. Well, they weren’t safe for five days in 2014, the airline was clueless as to what was going on, and the issues with this aircraft appear to be of sufficient concern for the ATSB to issue a global notification to other ATR operators.
Virgin Australia said:
Safety is Virgin Australia’s number one priority, and we continue to liaise closely with the relevant regulatory bodies and the aircraft manufacturer in relation to the Australian Transport Safety Bureau’s ongoing investigation into the ATR’s pitch disconnect mechanism. Virgin Australia has taken a number of risk mitigation measures and is confident the aircraft remains suitable for operations.
CASA continues to audit ATR aircraft operators to ensure appropriate actions have been taken to reduce the likelihood of the aircraft being mishandled in a manner similar to the incident flight. Flight procedures and pilot refresher training for the ATR aircraft operated in Australia have been amended since the event occurred.
CASA concurs with the European Aviation Safety Agency (EASA), the State of Design, that the aircraft is safe when operated in accordance with documented operating procedures.
CASA will look carefully at the findings of the aircraft manufacturer’s engineering analysis of the issues associated with a pitch disconnect when this work is completed.
If this analysis raises any ongoing safety issues CASA will take appropriate action. CASA will take into account any measures taken by EASA.
CASA is requiring monthly reports from the air operators of ATR aircraft to make sure the actions that have been implemented continue to be effective.
Apr 27, 2017
That much reported tail strike incident involving a SingaporeAir jet at MEL turns out to have been a case of exemplary piloting when things didn't go as planned
The actions of Singapore Airlines pilots in continuing to fly to Singapore in a Boeing 777 after a confirmed tail strike on takeoff from Melbourne Airport last October have been exonerated and praised by an ATSB inquiry.
The ATSB found that the pilots had correctly determined that the aircraft’s pressurisation system had not been affected, and that they had continued the flight safely and in accordance with Boeing’s recommended action for dealing with such incidents.
The report is an interesting sequel to various tabloid media reports at the time insinuating that the pilot actions were unsafe or risky, and that they should have turned back immediately once Melbourne Airport confirmed that a tail strike protection device had left evidence of it being scraped along part of the runway.
The incident, on October 9 last year, occurred during wild weather with high gusty winds at Melbourne Airport. During the pre-flight external inspection of the 777-300 one of the pilots noted that “it was difficult to walk straight due to the wind.”
While taxying to their holding point for takeoff from runway 34 they saw two aircraft go around after abandoning approaches to the same runway.
The ATSB found that winds had been gusting to a maximum of 45 kt, and turbulence had been reported in the control zone.
During the take-off run, as rotation was initiated, the headwind component decreased resulting in the aircraft’s airspeed reducing below rotation speed. This airspeed reduction prolonged the time to lift-off, allowing the pitch attitude to exceed the tail skid contact attitude.
After take-off, air traffic control contacted the flight crew alerting them of a ‘possible tail strike’. With no TAIL STRIKE caution message displayed on the engine indication and crew alerting system the flight crew carried out the unannunciated tail strike non-normal checklist and determined the aircraft structural integrity was intact.
An inspection of the runway identified contact marks, consistent with a tail skid contact. Air traffic control advised the flight crew that ‘only superficial concrete debris were found’ during the runway inspection.
The flight crew discussed all the available information and considered their options. With the aircraft pressurisation system indicating no abnormalities the captain made the decision to continue to the destination. The remainder of the flight was uneventful. On arrival in Singapore engineers conducted a post-incident inspection of the aircraft. Damage was evident to the tail skid system indicating that a moderate energy skid contact had occurred during take-off.
The pilots used a reduced thrust engine setting for takeoff, as most jet airliners do when using suitably long runways. This saves fuel and engine wear.
The ATSB notes that had the pilots on this occasion used a higher thrust setting it would most likely have minimised the exposure of the 777 to the gusty wind conditions during rotation and liftoff.
The tail skid protection system contact with the runway was caused by airspeed stagnation at the critical moment. The pitch attitude of the 777 when it lifted off was 10.7 degrees nose up, exceeding the 8.9 degrees where a 777-300 will have a tail strike.
The report says that Singapore Airlines has since drawn pilot attention to Boeing’s recommendation to use a higher thrust and rotation speed during gusty and strong crosswind conditions.
However it concludes by saying that the Singaporean crew provided an excellent example of how to manage a non-normal situation and through good communication and decision making processes, were able to complete the flight without compromising safety.
Apr 26, 2017
At this moment efforts to revive the MH370 search have been choked by good intentions
Attempts by the ATSB to encourage a resumption of the search for the wreckage of missing Malaysia Airlines flight MH370 have instead drawn attention to claimed weak points in a revised CSIRO drift analysis that favors searching a comparatively smaller section of south Indian Ocean seafloor off Western Australia.
As a consequence, the abandonment of the search by Australia and Malaysia, with little commentary from China, in January, seems even less likely than before to be reversed, even though some observers had hoped for a provision for this in the Australian federal budget next month.
Things went off the rails for the ATSB after the Australian researcher Mick Gilbert, pointed out some of the untidy aspects of the revised CSIRO study (which can be downloaded at source here) in a comment to this post on Plane Talking.
This was followed by a very detailed post by Independent Group member Victor Iannello that built on more work by his peer in MH370 analysis Richard Godfrey.
What might we make of these developments? The ATSB seems to have taken the politically more realistic view that it should make efforts to resume the search for MH370 (which vanished on a flight from Kuala Lumpur to Beijing on March 8, 2014) as small a target for naysayers as possible, while doubling down on its support for earlier conclusions as to the likely resting place of the sunk wreckage.
Independent analysts like Victor Iannello, Richard Godfrey and Mick Gilbert have however no alternative to taking a far broader view of the variables and factuals that complicate any attempt to confine the wreckage to high probability zones, even if the latest is in fact one quarter the size of the previous and now terminated search zone.
Politicians value ‘confidence’ over mathematically defined ‘probability’. However the ATSB’s ‘confidence’ comes with criticisms that undermine its credibility. This isn’t good for the case for resuming the search, even though its discontinuation was undoubtedly premature, and the focus should always have been not on a new confined area, but addressing all of the concerns about MH370’s final path that have come to light since the jet went missing.
Finding MH370 may well involve as much cost and effort as has already gone into the search up until it was discontinued. That appears to be politically impossible at this time.
Apr 21, 2017
The ATSB has just published a CSIRO report that makes the political decision to suspend the MH370 search highly questionable
The CSIRO has revised earlier drift analysis of a wing flaperon from missing Malaysia Airlines flight MH370 that washed up on La Réunion island in 2015 and says it increases confidence that the wreckage of the Boeing 777 lies within a proposed new search area in the southern Indian Ocean that the Australian and Malaysian governments controversially decided not to search in January this year.
The publication of the CSIRO report by the ATSB is a reminder that the Australian air safety investigator which was managing the sea floor search for the jet, which vanished with 239 people onboard on its way from Kuala Lumpur to Beijing on March 8, 2014 (local time), doesn’t agree with that decision.
The optics of Australia’s abrupt abandonment of the search was arguably as bad as the sanctimonious words spoken by the Minister responsible for aviation, Darren Chester, when he overrode the documented expectation of the ATSB that this very last proposed search area, identified and recommended in the MH370 First Principles Review, would be examined by deep water sonar scanning devices.
That review, and other supporting or related documentation can be found at this same link on the ATSB website. It makes a nonsense of the ATSB ‘conspiracy of silence’ reports that are regularly appearing in The Australian and other News titles.
The executive summary of the new CSIRO report prepared for the ATSB says:
This report explores the possibility that an improved ability to simulate the path taken by the flaperon across the Indian Ocean might yield an improved estimate of the location of the remains of the aircraft on the sea floor.
Our earlier field testing of replicas of the flaperon was unable to confirm numerical predictions by the Direction Generale de L’Armement (DGA) that the flaperon drifted left of the wind. Field testing of a genuine Boeing 777 flaperon cut down to match photographs of 9M-MRO’s flaperon has now largely confirmed the DGA predictions, at least with respect to drift angle. The impact of this information on simulated trajectories across the Indian Ocean is that the July 2015 arrival time at La Reunion is now very easy to explain.
This new information does not change our earlier estimate of the most probable location of the aircraft. It does, however, increase our confidence in that estimate, so we are now even more confident that the aircraft is within the new search area identified and recommended in the MH370 First Principles Review (ATSB 2016).
The proposed new search area has been determined by combining many lines of evidence, the strongest being that the descent began close to the SatCom 7th arc. The following evidence from drift modelling helps indicate where along the 7th arc the aircraft impacted the sea surface:
- The July 2015 arrival date of the flaperon at La Reunion island is consistent with impact occurring between latitudes 40°S and 30.5°S.
- Arrival off Africa of other debris exclusively after December 2015 favours impact latitudes south of 32°S, as does the failure of the 40-day aerial search off Western Australia to find any floating debris.
- Absence of debris findings on Australian shores is only consistent with a few impact latitudes – the region near 35°S is the only one that is also consistent with other factors.
The new search area, near 35°S, comprises thin strips either side of the previously-searched strip close to the 7th arc. If the aircraft is not found there, then the rest of the search area is still likely to contain the plane. The available evidence suggests that all other regions are unlikely.
The reference to ‘the rest of the search area’ still being likely to contain the wreckage if it isn’t found in this last proposed search zone is significant.
There are reasonable if debatable concerns that the sunk wreckage of MH370 may be been so shattered and dispersed in a high speed mid-air breakup as it plunged toward the ocean, or on impact, that it had not been detected in the previously searched but often very deep and complex 120,000 square kilometres priority zone.
There is abundant evidence in other pieces of identified or probable fragments of MH370 that have been recovered on African and Indian Ocean island shores that the Malaysia Airlines flight experienced destructive forces on or before impact.
ATSB finds hitherto unknown dangerous part failure in REX flight that suddenly lost a prop
Regional airline REX appears was blindsided by a previously unknown flaw in an engine gearbox when a propeller came off one of its SAAB 340 turbo-prop aircraft while it was approaching Sydney Airport with 19 people on board on March 17.
None of the maintenance requirements REX was following in servicing a particular sub-set of its SAAB 340 fleet even required it to look at the component that failed, according to a preliminary report just released by the ATSB.
But that is about to change, with the ATSB warning similarly at-risk-airlines world wide of the fault.
The propeller that came off the aircraft when it was over the Macarthur area not only missed hitting vital control surfaces on the wing or tail of the small commuter aircraft, but then crashed to earth near houses when it came down in a bushland reserve in the Revesby area.
The ATSB says that the cracks and corrosion that were apparent in photos of the aircraft after it landed safely at Sydney Airport started within the so-called mounting flange of the propeller’s gear box, before spreading to a shaft section.
The propeller shaft had then fractured, leading to the separation of the propeller.
It found corrosion and pitting in a dowel pin bore in the engine, and describes the process in considerable detail by which this then led to the ultimate breaking free of the propeller.
The ATSB report says this is the first known critical failure of this type initiating within the propeller hub flange of a GE Aviation CT7-9B engine. It points out that the same propeller gear box is fitted to the widely used CASA CN-235 utility turbo-prop. It warns that any corrosion or cracking within the bore may go undetected until it progresses to the surface of the flange.
The safety investigator has outlined extensive additional work that it will have to conduct before it can issue a final report.
Approaches and landings at Hong Kong airport are often bumpy, but this one crossed a red line
The Australian air safety investigator the ATSB is sparing in its use of the term ‘serious incident’ which it has applied to the apparent control and turbulence issues that coincided with minor injuries to 15 Qantas passengers in a 747-400 approaching Hong Kong airport last Friday, April 7.
The ATSB has in the past said a ‘serious incident’ was one which had the potential to cause a crash.
That makes this inquiry of the highest importance, but it doesn’t permit premature conclusions to be drawn from the small amount of publicly available information, as carried by various media reports like this.
The fact that the stick shaker warning was activated is an indication that the 747-400 was in a situation where a further decline in its airspeed would put it at risk of a stall.
On the other hand stick shaker warnings are designed to alert pilots to the impending risk of such an event. They do not go off at the very final moment, but at a moment when prompt action will remedy the situation.
There is no suggestion that the Qantas pilots didn’t promptly and professionally respond to the warning and deal with it as effectively as possible. The paucity of information available doesn’t give an insight into whether all of the related systems on the jet were functioning properly, or that the warning was ‘real’, or that the turbulence experienced in the jet was in fact directly related to the onset of low speed buffeting in the airframe.
In short, there is no reason at this stage to jump to conclusions about the answers to what are important questions.
What can be highlighted is that air traffic vectoring on approach to Hong Kong airport is notably complex and naturally prone to turbulence because of a combination of the constraints of surrounding PRC air space management, and disturbances that can be caused by the uneven terrain that is flown over.
A fact based insight into the conditions that prevailed when this incident occurred can be found in this Aviation Herald report.
As this extract makes clear, this was a very bumpy ride.
Data off the ADS-B capable transponder of the aircraft suggest the aircraft was descending to enter the hold at about 340 knots over ground on a track of 315 degrees, when descending through FL229 at 17:47L (09:47Z) the speed decayed to 290 knots over ground still on a track of 315 degrees before increasing to above 400 knots over ground in altitude fluctuations between FL214 and FL230 before levelling off at FL220 at 390 knots over ground subsequently reducing to 340 knots over ground.
Mar 29, 2017
The causes of the Essendon disaster remain unresolved and the investigation has no cockpit voice or sound recordings to work on
The pilot of the Beechcraft King Air B200 that crashed at Essendon Airport last month was unable to explain the cause of his Mayday call before it struck the roof of the adjacent DFO retail centre killing all five people on board.
The aircraft was airborne for about 14 seconds before being destroyed on impact after taking off as a charter flight to King Island according to the preliminary accident report released by the ATSB this morning.
No evidence of engine or equipment malfunction (other than a problem with the cockpit voice recorder) has been as yet identified in the wreckage of the small high performance twin engined turbo-prop.
However the ATSB report cautions that its investigations into the clues that may be provided by the wreckage are incomplete. It provides the first detailed and unambiguous map of the flight path from takeoff to impact, as shown below.
While the ATSB has been able to read the flight data recorder, the cockpit voice recorder only contained voice and sounds from the aircraft’s previous flight. The crash investigator said it was trying to determine the reason why no sounds were recorded during the short interval between takeoff and impact.
In its brief preliminary report that ATSB says:
Witnesses familiar with the aircraft type reported that the take-off roll along runway 17 was longer than normal. After becoming airborne, the aircraft was observed to yaw left. The aircraft performed a shallow climbing left turn while maintaining a relatively level pitch and roll attitude. Airservices Australia Automatic Dependent Surveillance Broadcast (ADS-B) data indicated the aircraft reached a maximum height of approximately 160 ft above ground level while tracking in an arc to the left of the runway centreline (Figure 1). The aircraft subsequently collided with a building in the Essendon Airport retail precinct.
The report said that he aircraft collided with the roof of the building and associated concrete parapet before coming to rest in the building’s rear car park. Examination of the significantly fire- and impact‑damaged wreckage determined that, at impact the:
- aircraft was configured with 10° of flap
- landing gear was in the extended and locked position.
Examination of the building roof showed evidence of propeller slash marks and nose and main gear tyre marks. Those marks were consistent with the aircraft having significant left yaw and a slight left roll at initial impact.
The ATSB said that on-site examination of the wreckage did not identify any pre-existing faults with the aircraft that could have contributed to the accident.
The left and right engines separated from their mounts during the impact sequence. Both engines had varying degrees of fire and impact damage. The engines were removed from the accident site to a secure facility where they were disassembled and inspected by the ATSB with assistance from the engine manufacturer. That examination found that the cores of both engines were rotating and that there was no evidence of pre-impact failure of either engine’s internal components. However, a number of engine components were retained for further examination and testing.
The pilot Max Quartermain called Mayday seven times before the aircraft struck the DFO centre, but did not say anything else as recorded by tower audio.
The ATSB has outlined further aspects of the crash for full and intensive investigation, and would in the normal course of events, issue a final report by February next year.
Summary The causes of the disaster haven’t been determined, and may take considerable time and effort to resolve.
Mar 20, 2017
A SAAB 340 similar to the REX plane did lose a propeller in similar circumstances 26 years ago
The possibility that the REX incident involving a lost propeller from a SAAB 340 turboprop approaching Sydney last Friday was caused by a rare manufacturing fault has firmed following the finding of a US investigative report concerning a similarly non-fatal incident in America in 1991.
The parallels between the US findings and the known details concerning the shedding of a propeller from the REX flight are striking, although it is far from confirmed that they do in fact explain that incident.
The NTSB summary is all in upper case.
An earlier post on this topic (for which the comments have been preserved) contained some incorrect information published in good faith.
To be blunt, this reporter is unhappy with this situation, particularly given some of the sources.
It has now been established that the flight last Friday from Albury to Sydney was well past Canberra Airport when the pilots shut down the right hand engine and feathered its propeller, shortly before it separated and fell away, fortunately missing any control critical surface of the SAAB 340, which could have caused an crash likely to kill all 16 people on board.
That propeller hasn’t been found. My apologies to REX and their pilots for doubting the judgments that led to a continuation of the flight when it was incorrectly described as having first encountered engine problems near Canberra.
The ATSB inquiry is in its early days. The close up photos of the break point between the missing propeller and the engine appear to indicate some sort of structural failure induced by stresses that may or may not have been affecting the assemblage even prior to the vibrations that caused it to be shut down while near Canberra. Whether the causes include structural as well as maintenance related factors remains to be determined.
Mar 9, 2017
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
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.