ATSB enquiry for fog at Launceston Airport

[Russell D]

Was on the ABC's website when I the headline caught my eye. Story was pretty interesting, although I don't remember much about the incident ever surfacing in the news (a good think I might add). Here's the link and story below:

http://www.abc.net.au/unleashed/stories/s2941179.htm

Cost cutting provokes foggy stuff-up

30 June 2010

By Ben Sandilands

An Australian Transport Safety Bureau (ATSB) inquiry into a close call between a Virgin Blue 737 and a Jetstar A320 above a fog-bound Launceston Airport shows how the cost cutting focus of Australian airlines can put lives at risk.

Both airlines had scheduled their jets, equipped with a combined tally of 357 seats, to arrive at the airport from Melbourne on May 1 within minutes of each other after 10:00pm, not long after its air traffic control service had clocked off at 9.45pm.

In the dark and fog, both did missed approaches when they couldn't see the runway at 200 feet on their first attempts to land, first the Virgin Blue 737 (with 121 on board) closely followed by the Jetstar A320 (with 101 on board).

But because the landings saved cents per passenger by not having to pay for full air traffic control, the pilots were supposed to arrange their safe separation by talking to each other on a common traffic advisory frequency (CTAF) procedure.

And as the ATSB finds; "The 737 [Virgin Blue] pilots did not adequately communicate their intentions regarding separation in the event that the A320 [Jetstar] pilots also conducted a missed approach."

The result was that as the Jetstar flight climbed away from the invisible airport and emerged above the fog at 2,700 feet, its pilots saw the lights of the Virgin Blue 737 turning to the left and toward them at the 11 o'clock position at an altitude of 3,100 feet.

In the pas des deux that followed, rapidly, the Jetstar crew flew through the 3,100 feet level of the approaching Virgin Blue flight because they had entered air space where the safe minimum altitude for a holding pattern was also 3,100 feet and prohibited diving lower and the separation between the jets diminished to what the ATSB calls a "close proximity of about 5 kilometres".

Both jets would have been flying at a speed of around 5 kilometres per minute, and for a moment, toward each other. The anodyne language of the ATSB report describes that as a "surprise" to the Jetstar pilots. After which Jetstar continued to 4,000 feet, and Virgin Blue landed, the fog having lifted sufficiently to see the runway from what pilots call "decision height".

The ATSB is not charged with laying blame and is seldom given to using strong or alarming words in its reports.

But it begs the question, what sort of management culture deliberately schedules an arrival at a fog-prone airport just after its ATC is turned off?

It is true that CTAF procedures are commonly used at smaller Australian airports, but the option of choosing to deliberately schedule outside the availability of controlled separation is perverse.

The ATSB report, which is quite short and has an absorbing little diagram showing the relative positions of the two jets, can be found at atsb.gov.au by going to the aviation reports section. It's not terribly user friendly so the document number for the PDF is AO 2008-030.

Like its recent final report into a seriously incompetent approach to Sydney Airport by a Qantaslink turboprop on December 26, 2008, the ATSB refers to submissions from the airlines responsible for the flights involved and from the safety regulator, the Civil Aviation Safety Authority, which it has taken into account.

But in the Australian tradition of secrecy in aviation safety, those submissions are not released to the public, unlike the transparency and accountability provided by the US Federal Aviation Administration in its documentation of airline safety issues.

The Qantaslink incident saw a first officer disobey a command by a captain on final approach the Sydney Airport and cause that aircraft, with 55 passenger seats, come close to stalling twice within 10 seconds. It was a very serious situation.

In the US, incidents like that and the Launceston stuff-up, come under intense media scrutiny. In Australia, it's all hush, hush, everything is fine, move along now.

[Owen H]

In the US, incidents like that and the Launceston stuff-up, come under intense media scrutiny. In Australia, it's all hush, hush, everything is fine, move along now.

I'd suggest much of that has to do with the actions of reporters like Sandilands himself. Media scruitiny should be reserved and aimed at those incidents which have serious safety potential, and not on simply overreporting and sensasionalising stories to sell newspapers by reporting marginal incidents with the major carrier(s).

Sure, the ATSB does not release the submissions of the relevant parties. And for good reason. The key to a safety culture is allowing open and free communication and reporting. If the ATSB start releasing airline submissions, the submissions would be heavily vetted, and contain no substance. We want our airlines to be able to tell the ATSB the ugly truth, not the media-relations edited version.

Sandilands seems to miss the point that the ATSB's prime responsibility is aviation safety investigation, not placating (or even feeding) the media.

He does make one very good point, however:

...what sort of management culture deliberately schedules an arrival at a[n] ...airport just after its ATC is turned off?

[Edward Terry]

Out of interest, why don't these reports identify airlines?

[Paul McFarlane]

Edward:

The ATSB is not charged with laying blame

The ATSB investigates the incident itself and does not identify the airlines to prevent others from playing the blame game.

..and is seldom given to using strong or alarming words in its reports.

Unlike Ben Sandilands!