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Serious occurrences into Tullarmarine, Mt. Hotham and Newcastle

Serious occurrences into Tullarmarine and Mt. Hotham

The series of incidents into Melbourne’s Tullamarine airport, which largely revolve around a difficult to fly STAR route are detailed below and should be combined with the report by The Australian into another Mt. Hotham incident.

Also below is the Sandilands – Newcastle coal loader incident.

ADSB anyone??

Old 16th Sep 2015, 21:20   #18 (permalink)
Join Date: Dec 2008
Location: SA
Age: 54
Posts: 225
I thought that Thorn Bird was probably referring to a multitude of occurrences involving aircraft flying too low into Melbourne Tullamarine.

As an example:
PPRuNe thread – QF Captain was feeling low…
Media report (at the time the ATSB Report was released).
Qantas captain was feeling tired, sick and hardly ate on day his plane flew too low

  1. ATSB Report:
    Qantas captain was feeling tired, sick and hardly ate on day his plane flew too lowInvestigation: AO-2013-047 – Flight path management and ground proximity warning involving Airbus A330-202, VH-EBV, 15 km NNE of Melbourne Airport, Victoria on 8 March 2013Others:
  2. Investigation: AO-2012-120 – Descent below minimum permitted altitude involving Boeing 747, N409MC, 11 km E of Melbourne Airport, Vic. on 9 September 2012
  3. Investigation: AO-2013-130 – Descent below approach path involving Boeing 777, VH-VPF, Melbourne Airport, Victoria on 15 August 2013
  4. Investigation: AO-2015-048 – Descent below minimum permitted altitude involving an A319, VH-VCJ, near Melbourne Airport, Vic. on 15 May 2015
  5. Investigation: AO-2014-128 – Flight below minimum altitude involving a Boeing 777, A6-ECO, near Melbourne Airport, Vic on 18 July 2014As I said at the time of the release of the ATSB EBV report
Air traffic control procedures:
Air traffic controllers are able to issue clearances for visual approaches when flight crew have established and can continue flight to the airport with continuous visual reference to the ground or water and with visibility at least 5 km. Once an air traffic controller clears a crew to conduct a visual approach, the crew has responsibility to maintain separation from terrain and, in the case of the occurrence flight, remain at least 500 ft above the lower limit of controlled airspace.After the occurrence, the air traffic service provider (Airservices Australia) advised that the minimum safe altitude warning system (MSAW) had been inhibited in certain areas to the north-east of Melbourne to reduce the number of false alarms in those areas. In addition, Airservices Australia advised that when a flight is cleared for a visual approach its corresponding cleared flight level is set to 000 (ft) on the controller’s air situation display. As a result, the system automatically inhibits the MSAW aural alarm and display for that flight.

Really, is this good enough?


Minimum safe altitude warning system (MSAW) had been inhibited in certain areas to the north-east of Melbourne to reduce the number of false alarms in those areas.
  • Why not fix the software to reduce the number of false alarms?
  • Why not develop SOP to reduce the likelihood of false alarms?
  • Was a safety alert issued by the controller?

Swiss cheese anyone?

I wasn’t challenged at the time I wrote this.

Surely an advanced Air Traffic Control system should generate airspace protection and low altitude warnings for all flights subject to an air traffic control clearance.

Is it really world’s best practice to automatically inhibits the MSAW aural alarm and display for flights assigned a visual approach?

sunnySA is offline Report Post Reply

Inquiry vowed on near air collision at Mount Hotham

Inquiry vowed on near air collision

Former air safety chief Dick Smith fears the inquiry will be too narrow. Picture: Renee Nowytarger Source: News Corp Australia

Australia’s transport safety watchdog has promised a broad-ranging investigation into claims 18 lives were endangered in the skies above Mount Hotham, in the Victorian Alps, but is being urged to also seek overseas expert advice.

The Australian Transport Safety Bureau vowed yesterday to examine all the events of September 3, when a pilot claims there was a “breakdown of separation” between his plane and another­ that could have caused a disaster.

“The scope of this investi­gation will cover air traffic aspects such as communications and radar coverage,” ATSB media manager Marc Kelaart told The Australian. “We are now gathering information to assess how significant these aspects were in relation to the occurrence.

“The proximity of aircraft to each other will be examined as a part of establishing the facts surrounding this incident.”

However, former air safety chief Dick Smith expressed concern that the ATSB investigation was likely to be too narrow and wrote to its chief commissioner, Martin Dolan, urging it to seek input from American aviation authorities to ensure the Mount Hotham airspace was safe.

As revealed in The Australian yesterday, the pilot of a charter from Bankstown, in Sydney’s west, to the Victorian alpine resort­ on September 3 made an incid­ent report to the ATSB claiming the safety of passengers on both planes had been ­“compromised”.

The pilot’s report says the second plane, part of the same overall charter but from a different company based in Essendon, in Melbourne’s northwest, reported its position as 10 nautical miles to the west of Mount Hotham but later changed this to 10 nautical miles to the east.

In between, based on the initial position given by the second plane, the first pilot had started his final approach to the airstrip.

His report says he was “alarmed at the close proximity” of the other plane implicit in the changed advice and believed the situation could have caused a mid-aid collision in cloud and poor weather.

It is understood the second pilot, who had report­ed trouble with his GPS in the lead-up to the incident, will tell investigators there was no danger of collision.

It is understood he will say he contacted Airservices Australia to ask it to use its Melbourne-based radar to help keep him separated from the four other aircraft involved in the overall charter.

While the area has radar coverage, radar is not used to provide a separation service to aircraft once they descend below 18,000 feet. Below this altitude, pilots must “self-separate” by telling each other their location via radio.

Pilots can ask Airservices to use the radar to help keep them separated from other aircraft in the event of an equipment failure, as the second pilot suggests he did on this occasion.

However, the first pilot suggested in his report that a collision could easily have occurred in the meantime, and that the incident highlighted the need to “identify the root causes, thereby preventing a similar occurrence that may cause an accident”.

Airservices acting chief executive Jason Harfield last night said its assistance to the pilot reporting GPS problems was in-line with Civil Aviation Safety Authority requirements.

Near miss for planes carrying 18 people

Too close for comfort.

Too close for comfort. Source: TheAustralian

An “unsafe” close encounter ­between two planes near Mount Hotham Airport in Victoria allegedly placed up to 18 lives at risk, fuelling demands for better use of radar at Australia’s regional airports.

According to an incident ­report obtained by The Australian, two Beechcraft B200 King Air planes on private charters from different companies — one from Essendon in Melbourne and one from Bankstown in Sydney — were vertically within 300ft (90m) of each other on September 3.

It appeared the Essendon-based pilot, struggling with a faulty GPS in heavy morning cloud and poor weather, did not know where he was and reported being in vastly different locations, varying by up to 20 nautical miles, within a short period of time.

Radar traces of this plane, chartered from small Essendon-based operator Seidler Properties, show an apparently erratic path at times, and that the scheduled 38- minute flight took an hour and 27 minutes.

The Essendon plane came within one nautical mile (1.8km) of the other aircraft and eventually landed at Mount Hotham, in the Victorian Alps northeast of Melbourne, but only after what the report by the other pilot ­described as an “unsafe” approach from the “wrong direction”. There were three other aircraft also en route to the airport at the time.

The report, titled “breakdown of separation”, says passengers on the Essendon-based plane were so shaken they refused to return with the same pilot later that day, ­requiring another to be flown to Mount Hotham to pick them up.

In a report being investigated by the Australian Transport ­Safety Bureau, the pilot of the Bankstown-originating aircraft — a senior pilot at a major charter firm — describes the situation as “not safe”.

He suggests he is making the report not to attack the Essendon-based pilot, but rather to highlight an ongoing risk of tragedy in the absence of a safety back-up in cases of pilot error at uncontrolled regional airports.

“If this event did result in a midair collision, two aircraft would have been destroyed and 18 people would have been killed,” says the Bankstown-originating pilot in the report, sent to the ATSB two days ago.

“As a chief pilot, I am significantly concerned with the breakdown of (aircraft) separation caused by this incident. This is not a standard of operation that I would tolerate from my pilots and I do not accept that his event goes without investigation.

“Two high-performance aircraft with 300ft separation (vertic­ally), within one nautical mile of each other (horizontally), in IMC (instrument meteorological conditions), is not safe.”

The incident has further highlighted the lack of radar control of aircraft to low altitudes at ­regional airports in Australia, which The Australian has documented in the series of articles over the past two months.

In uncontrolled airspace, ­pilots must communicate with each other by radio to ensure they remain safely separated, with no support from an air traffic controller monitoring them on radar or providing co-ordination.

At Mount Hotham, radar-based separation of aircraft ends at 18,000ft, below which pilots must self-separate, despite radar being available to a far lower altit­ude.

Veteran aviator Dick Smith told The Australian the latest Mount Hotham incident highlighted the need to make full use of radar coverage at regional airports to improve safety.

“If they were using the existing radar for control at Mount Hotham, neither of these things (the ­alleged mid-air near collision and subsequent alleged dangerous ­approach) would have happened, because the controller would have told the pilot what was happening,” Mr Smith said.

He said it was particularly frustrating the existing radar was not being used to control aircraft to low altitude at Mount Hotham, given the deaths of three people in a crash there in 2005 and of six people in an accident at Benalla, about 150km from Mount Hotham, in 2004. He believed both crashes could have been averted had radar control close to ground level been provided.

“How many more frightening incidents like this before there are more unnecessary deaths?” Mr Smith said.

He said all that was needed to make use of existing radar for separation control to low altitudes at regional airports was for Airservic­es Australia to provide more training to controllers at its Melbourne and Brisbane radar centres.

Airservices insist the air traffic system is safe and that levels of control around the country are appropriate for local traffic volumes and types.

An ATSB spokesman said the latest Mount Hotham incidents were being investigated.

However, an official statement on the bureau’s website refers only to the “unstable approach” to the runway; not the earlier alleged close encounter. Seidler Properties suggested it was unaware of any investigation and declined to comment.

Know more? denholmm@theaustralian.com.au

REX turbo-prop confused coal loader for airport in Newcastle stuff up

The ATSB has dissected the confused performance of two REX pilots who set up their SAAB 340 turbo-prop to land on a coal loader they had mistaken for Newcastle Airport  in an incident in November 2012.

The small airliner eventually landed safely at the airport after being spotted by an air traffic controller about 11 kilometres from the airport in failing daylight made worse by a cloud bank obscuring the western horizon below which the sun had just set.

This wasn’t a simple visual mistake either.  The ATSB report details the concerns of the first officer over the capacity of the captain to identify the airport, and records in what must be almost painful detail for other pilots and the airline the intricate sequence of errors made on the flight deck as well as providing helpful comparison photos of the coal loader and airport.

Data from the aircraft’s flight data recorder showed that the aircraft commenced a shallow descent from 1,500 ft on a westerly heading and then turned right. During the turn, the crew commenced configuring the aircraft for landing.

After turning right onto a base leg, the FO was unable to resolve his confusion about the aircraft’s position and handed control to the captain. The captain reported that after taking control, they could not see the runway, but had formed a strong belief that they were in the airport environment. Being unable to discern the runway, the captain thought that they may have overshot the runway centre-line. The FO reported that after handing over control to the captain, he became aware that the aircraft was not positioned as intended, having observed the lighting and width of the coal loading and storage facility and noted their distance from the airport was greater than expected.

At about 1932, the tower controller offered to increase the intensity of the runway approach lighting.[1] The controllers reported realising that the crew had probably lost situation awareness and, at the approach controller’s suggestion, the tower controller advised the crew that they were 6 NM (11 km) south-west of the airport tracking to the east. Recorded radar surveillance data also showed the aircraft tracking in a south-easterly direction toward the coal facility. When told they were not at the airport, the captain immediately requested radar vectors to resolve the uncertainty. As the tower controller was not qualified to provide radar vectors, a heading of left 020° was suggested. At about the same time, the crew turned onto a southerly heading and descended to 680 ft.

While the aircraft was tracking south, heading toward the boundary of controlled airspace, the approach controller advised the tower controller to instruct the crew of TRX to initiate a climb and pass traffic advice to the crew about another aircraft 5 NM (9 km) ahead and outside controlled airspace. The tower controller advised the crew to climb, but did not issue a safety alert or a clearance as that would have necessitated a coordinated handover to the approach controller and a radio frequency change. Instead, the controllers elected to keep TRX on the tower frequency and under tower control as visual meteorological conditions existed and both controllers could see the aircraft.

Information from the flight data recorder showed that the aircraft climbed to about 900 ft. The captain reported that engine power was increased but they did not commence a go-around or reconfigure the aircraft.

The approach controller reported suggesting that the tower controller advise the crew to turn north in order to locate the airport. The captain complied and adopted a northerly heading before requesting further guidance as they could still not see the runway. The tower controller turned the runway lighting to stage 6 (full brightness) and continued to provide position information until satisfied that the crew had sighted runway 12.

At about 1935, after further guidance, the captain identified the runway and approach lights and positioned the aircraft for a landing on runway 12. The aircraft landed at about 1937, 14 minutes before last light. After landing, the crew advised the aerodrome controller that they were unfamiliar with locating the airport ‘at night’.

The ATSB report also recounts other incidents in which airports have not been correctly visually identified by approaching airliners, including the 1989 incident in which an Australian Airlines Boeing 737 pulled up only 170 feet above the ground when it thought it was landing at Mackay Airport but had descended on an adjacent highway instead.

The report outlines the steps REX has taken to prevent such a stuff up in the future.  This incident might seem amusing on a quick reading of the ATSB summary. The full report, linked to the summary page, makes it clear that this was a serious incident, and responded to as such by the airline.

A loss of situational awareness in failing light approaching an airport is never funny, nor trivial.




  • Posted March 13, 2015 at 2:17 pm | Permalink

    “they could not see the runway, but had formed a strong belief that they were in the airport environment.”

    It is unfathomable that with the technology available today, that pilots can lose situational awareness like this.

    A passenger sitting in the back with an iPad would have a better idea of the location of the aircraft than the pilots.

  • 2
    Posted March 13, 2015 at 2:31 pm | Permalink

    comet…you’re not wrong….it’s VERY basic stuff. You’d expect that even if they did believe the coal loader was the runway, the distance readout to the airport should have given it away. However internal REX factors also influenced the crew to fail; it’s not all their fault, and disappointing to see that both REX and the ATSB didn’t identify them as safety factors in the report.

    Regardless of the actions of the crew, it’s an example of poor safety culture to see REX calling the Captain multiple times on an RDO, which followed sick leave, applying commercial pressure to operate on an RDO which subsequently led to them operating while not fit. Swiss cheese hole #1
    Along with a 400 hour pilot (approximately flying for only 1.5 years) receiving deficient CRM training. A safety concern in itself…

  • 3
    Posted March 13, 2015 at 2:36 pm | Permalink

    Indeed. An $80 automotive GPS from Harvey Norballs would do it. Why is aviation so backward? I get why it’s so conservative, but backward is something else.

  • 4
    Posted March 13, 2015 at 2:50 pm | Permalink

    I well recall a flight I took in mustering helicopter on a remote northern cattle property a decade or so ago. The pilot had flown out from town for the job (mine, not the mustering). Primary navigation instrument? A simple hand held GPS duct taped to the screen pillar. Why? Well … he actually had to find me! I wonder if it may still be so.

  • 5
    Sam Jackson
    Posted March 14, 2015 at 6:17 am | Permalink

    Your local SP bookie must, if survival is envisioned, be very able in the art of setting the odds and laying the field. It’s a numbers game and the SP odds for ‘Major Hull Loss’ are shortening every day, soon to go odds on. Look at the recent form: one seriously bent ATR, two domestic jets which flew past viable alternates only to land in a Mildura fog, one ATR doing silly things and a Saab which had trouble defining it was about to land 6 miles from the airport. Add some 60 odd recommendations for serious systematic changes which are being ignored, an ATSB which is happily providing top cover and a Minister riding shotgun on the status quo and suddenly Major Hull Loss is an odds on favourite. It’s high time the Australian travelling public paid a little more attention to matters aeronautical and demanded the powers that be get it sorted. Starting from the Senate inquiry into pilot training and working forward, the mess has been clearly defined. Why nothing apart from a little window dressing has been done is a very good question which needs to be asked. A coal loader through the windscreen is not a question which can be taken on notice, delayed, differed or obfuscated.

  • 6
    Posted March 14, 2015 at 10:58 am | Permalink

    Ben is right, it is no laughable matter.

    What has been demonstrated over and over again is that anyone, once they are bent on a course of action stop assessing facts and simply throw out those that do not fit in what actions they have focused.

    I did some of that as a pilot (wrong airport though in line with my destination) and have done it as a technician trying to find the cause of a problem.

    The issue is endemic to people. What is needed is research to get inside that decision cycle and break out of it.

    Not as easy as it sounds.

  • 7
    Posted March 14, 2015 at 4:46 pm | Permalink

    Hmmm. The aircraft that was lining up to land on a coal loader was Rex, and Rex is also the parent company for Pel Air.

  • 8
    Posted March 15, 2015 at 3:30 am | Permalink

    No disagreement bad ops are more prone, but

    Parent company for AF447 was Air France

    Parent company for Asiana 214 was well Asiana

    American Airlines stuffed a 757 into mountains in SA

    Good pedigree does not guaranteed good results. I don’t pretend I have a full answer, but I do know it lies in a good understanding of the human mind and how to break into a bad decision cycle (or sorting out pilots who can’t do that)

  • 9
    Sam Jackson
    Posted March 15, 2015 at 8:27 am | Permalink

    This latest episode in the chain, another Rex in flight duck up is simply an alternate aspect of the large, ugly, dangerous ice berg, revealed through the Pel-Air inquiry heading towards Australia’s Titanic. These two pilots are victims of that same culture and system. The McComic legacy and the Pel-Air curse are conspiring, plotting a major incident. No one will be to blame of course. The system will live long and live large; spoon fed by the great Australian apathy. Yes, Aunty Pru is vexed. The villain is the system – the victims? – someone you know perhaps. Tick tock…http://auntypru.com/forum/showthread.php?tid=41&pid=179#pid179

  • 10
    Posted March 15, 2015 at 9:28 am | Permalink

    This seems strange to me, The ATC in the tower could see the aircraft some distance away but even after the pilots had been advised they were in the wrong place, they couldnt see the airport ?
    Is there an issue with pilots eyesight in the transition from day into night?

  • 11
    Posted March 15, 2015 at 7:10 pm | Permalink

    not excusing the poor navigation here, but surely if you have a runway-length thing in a similar compass direction as a runway near a runway, sooner or later someone’s going to try to land on it? (not sure which was there first or if some sort of lighting on the coal facility could make it more obvious it’s not a runway?)

  • 12
    Posted March 16, 2015 at 12:34 am | Permalink

    Let’s close all nearby roads, freeways, farms with dark coloured crops, and anything else that may look like a runway.

    A schoolkid in his bedroom running FlightRadar24 on his PC would have been able to see the aircraft was in the wrong place.

    But the two pilots were bamboozled, as the pointed their aircraft towards a coal loader. They were actually headed in the complete opposite direction but had no idea.

  • 13
    Sam Jackson
    Posted March 16, 2015 at 8:18 am | Permalink

    @ NiallOC – Rather than waste Ben’s bandwidth and bore SLF to death, I’ll presume on his inherent good nature and post a link which, IMO touches on some of the deeper, operational issues which are, or should be of great concern to ‘aviation’ folk. With sincere apologies to the purists. Thanks Ben – I’ll pipe down now….http://auntypru.com/forum/showthread.php?tid=41&pid=183#pid183

  • 14
    Posted March 16, 2015 at 10:25 am | Permalink

    So why is there not a large moving map GPS display, front-and-centre, in every aircraft? Dumb events like this would immediately become rare, restricted to cases of major equipment failure. The technology is not new, not expensive, very reliable and very hard to misinterpret. Perhaps some sort of remnant “great pilot” hubris?

    I mean that in all seriousness. When, a quarter of a century ago (25 years!), GPS began penetrating marine navigation, there were the inevitable complaints from the old hands. What will you do when the device breaks / the batteries go flat / you drop it overboard / the satellites fall from the sky. Best study how to use that sextant and tables. The answer was obvious, and rapidly became general — just take two, or three, or four … and a huge pack of batteries. Find me someone today who can still take a star sight from a heaving deck.

    So you still call up the tower to ask where you are, FFS. Guys … 21st century.

  • 15
    Posted March 16, 2015 at 8:56 pm | Permalink

    Wow .. sobering stuff. Was the airport punched into the GPS? Moving map aside, it’s simple to glance across at the distance to WPT value. If it’s not ~0 nm … then that’s not the airport! Oh, and the ADF needle – where was that pointed? Towards the coal loader? I don’t think so.

    I don’t want to be an armchair critic (because it’s unhelpful, and because anyone can make _a_ mistake) … but this would seem like basic stuff covered routinely during PPL training … right? How it cannot be happening 100% of the time on the flight deck of any RPT is beyond comprehension.

  • 16
    Jackson Harding
    Posted March 18, 2015 at 5:34 pm | Permalink

    The psychological reasons behind this are well known and are studied by commercial pilots as part of their human factors training. It is called “task focussing”. You become so fixated on the task (landing the plane) that you stop taking in external cues that would otherwise tell you you are wrong. You just don’t see the GPS, the ADF needle, or the fact the coal loader is next to a river in the centre of town.

    Incidentally landing on highways is not an uncommon problem. Runway 34 at Melbourne has lead in strobes because three aircraft from an airline in a country to our immediate nnw tried to land either at Essendon or on the Tullamarine Freeway, both of which are more or less aligned the same as 16/34 at Melbourne.

  • 17
    777 Steve
    Posted March 19, 2015 at 1:49 am | Permalink

    Simply unforgivable, the reality relating to the mindset on display here is simple..”we will fly a visual approach” when the conditions were not appropriate to carry out that approach. It’s symptomatic of a mindset where the benefit of not completing an instrument approach and replacing it with a visual is viewed as desirable given the extra track miles and fuel burn. I would have reasoned that a 12000hr or so ATPL would have viewed flying with. 200 and something an hour CPL as a big enough threat to try and keep things as simple as possible. Lots of us who fly for a living have operated into aerodromes where visual approaches are the norm, but there is a time and a place, low light conditions even if you are familiar with the area can be a receipe for disaster, there are dozens of accident and incident reports that reflect this.



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