1.1 History of the flight
On 26 October 2003, at about 1346 Eastern Standard Time, a Boeing 767-238 aircraft, registered VH-EAL, with two pilots, seven cabin crew and 207 passengers, took off from Coolangatta Airport, Queensland, on a scheduled regular public transport service to Sydney, NSW. The aircraft had arrived at Coolangatta earlier that day, having flown the first sector from Sydney to Coolangatta. Shortly after takeoff, passing through an altitude of about 800 ft, the aircraft encountered heavy rain, hail and windshear. The crew reported that they increased thrust in accordance with the operator's published windshear escape manoeuvre. During the windshear encounter, the aircraft descended about 130 ft and a ground proximity warning system (GPWS) Mode 3 aural alert 'DON'T SINK' sounded.
During the subsequent climb, the cabin crew reported to the flight crew that there was damage, in the form of dents, to the leading edges of the wings. After diverting out to sea around the weather, the flight continued to Sydney. The crew configured the aircraft early in the approach to Sydney, in the event of flap and leading edge device extension difficulties due to the damage, however an uneventful landing was conducted.
1.1.2 Sequence of events
|0145||The Bureau of Meteorology (BoM) issued a terminal aerodrome
forecast (TAF) for Coolangatta, valid for the period 0400 to 2200
on 26 October. The TAF was a statement of meteorological conditions
expected for a specified period in the airspace within a radius of
5 NM of the reference point for Coolangatta Airport. It indicated
temporary periods of less than one hour of rain and thunderstorms
with associated wind gusts to 35 kts during the period 1400 to 1800
on 26 October, with a requirement for either 60 minutes holding
during that period, or diversion to an alternate aerodrome.
|0823||The BoM issued an amended TAF for Coolangatta aerodrome, valid
for the period 1000 26 October to 0400 27 October. The indications
for rain, thunderstorms and holding were unchanged.
|0945||The BoM forecasting team met to discuss the developing
situation and TAF requirements for thunderstorm activity for
Brisbane Airport were brought forward to 1400.
|1250||The BoM issued an Airport Warning for Coolangatta Airport
indicating that thunderstorms were expected to affect the aerodrome
|1310||Coolangatta Automatic Terminal Information Service (ATIS) Echo
was issued by Air Traffic Services (ATS). It included information
on current wind direction and speed, cloud and visibility. The
content of ATIS Echo is discussed at paragraph 1.9. It indicated no
adverse weather conditions at Coolangatta.
|1322||The BoM issued a report warning of significant meteorological
activity (SIGMET) for the Brisbane Flight Information Region, valid
from 1300 to 1900, which warned of a line of active thunderstorms
from Dalby to Stanthorpe moving east at 30 kts.
|1328||A Boeing 767 aircraft landed on runway 32 at Coolangatta.
|1330||The BoM radar imagery indicated a thunderstorm developing very
rapidly, ahead of the main line of thunderstorms, to the north-west
of Coolangatta and starting to move south-east in a direction at
least 30 degrees to the right of the average direction of the storm
|1330:03||A Boeing 737 aircraft was cleared for takeoff from runway 32 at
|1330:24||EAL was issued an airways clearance.
|1332:11||An Airtrainer CT4 aircraft was cleared to land on runway 35 at
|1336||The BoM reported that forecasters first became aware of the
severity of the thunderstorm involved in the occurrence at about
1336. The storm continued to intensify and quickly moved to the
|1338:22||Coolangatta ATIS 'Foxtrot' was issued. It included information
on current wind direction and speed, cloud and visibility, and
advice of rain and thunderstorms. The content of ATIS Foxtrot is
discussed at paragraph 1.9.
|1338:27||A Raytheon Beech 200 Super King Air aircraft was cleared to
land on runway 35 at Coolangatta.
|1339:07||The crew of EAL requested taxi clearance and reported in
receipt of ATIS Echo.
|1340||The BoM subsequently advised that the thunderstorm passed over
Coolangatta aerodrome between about 1340 and 1349.
|1343||The Coolangatta Tower controller advised the approach
controller that visibility at Coolangatta was 2000 m in heavy
|1345:00||EAL was cleared for takeoff from runway 32 and assigned a
departure heading of 060 degrees at 2 DME.
|1346:49||The crew of EAL advised the Coolangatta Tower controller that
they had stopped the turn and were heading 030 degrees due to
|1347:51||The crew of EAL requested that Approach advise Coolangatta
Tower that they encountered heavy rain and hail on departure from
1.2 Injuries to persons
No injuries to persons were reported.
1.3 Damage to aircraft
A post-flight technical examination revealed substantial damage to the leading edge slats, leading edge wedge panels, horizontal stabiliser, vertical stabiliser, radome, fuselage area above the pilots' windows, nose-cowls of both engines and fan blades on both engines (see Figures 1 and 2).
1.4 Other damage
1.5 Personnel information
1.5.1 Pilot in command
Type of licence: Air Transport Pilot (Aeroplane) Licence
Medical certificate: Class 1
Flying experience (total hours): 11,126
Hours on the type: 5,156
Hours in the preceding 30 days: 47
Type of licence: Air Transport Pilot (Aeroplane) Licence
Medical certificate: Class 1
Flying experience (total hours): 3,614
Hours on the type: 924
Hours in the preceding 30 days: 52
Both pilots last completed windshear training as part of the operator's recurrent training matrix during the period December 2002 to January 2003.
1.6 Aircraft information
Manufacturer: Boeing Commercial Airplane Group
Serial number: 23306
1.6.1 Aircraft weather radar information
The aircraft was fitted with a Collins WXR-700X weather radar system, which did not include a windshear warning or a predictive windshear warning function. The weather radar display was superimposed on the aircraft navigation displays and indicated rainfall intensity in different colours, with green depicting light precipitation, yellow medium precipitation and red or magenta heavy precipitation. The radar manufacturer's documentation stated that red was equivalent to a rainfall rate of 12.7 to 50.8 mm per hour, indicating a storm category of 'strong to very strong'.
Specific guidance on the use of the weather radar was provided to crews in the operator's Flying Manual and a training CD-ROM. A document was also provided to crews on the operator's intranet site. Use of the weather radar was covered as part of the operator's recurrent training matrix.
The crew reported that the weather radar was set according to the operator's requirements for takeoff. During taxi, and the time taken to negotiate a departure heading with ATS, the crew scanned the weather ahead of the aircraft flight path. They reported areas of red on the display, with no hooks, fingers, contours, scalloped edges or U-shaped returns that could have indicated the presence of hail. They reported that they consequently assessed the areas of red on the weather radar display as heavy rain only.
1.7 Meteorological information
1.7.1 Prevailing weather conditions during the afternoon of the occurrence
An intense surface trough was moving across the south-east inland of Queensland, towards the south-east corner and was forecast to move off the south coast by about 1800 to 1900. The atmosphere was very unstable ahead of the trough and scattered to widespread showers and thunderstorms were forecast from about 1400. Computer model output and morning temperature and moisture profiles, obtained from weather balloon flights, indicated very favourable conditions for the development of thunderstorms, and the possibility of associated severe weather phenomena.
During the afternoon, the BoM issued a number of amended forecasts and warnings including area forecasts (ARFORs), TAFs and Airport Warnings for Coolangatta. Those forecasts included reference to thunderstorm activity expected to affect Coolangatta aerodrome after 1400. The Airport Warning for Coolangatta, issued at 1250, indicated that the thunderstorms may produce strong wind gusts and large hail. A SIGMET for the Brisbane Flight Information Region, valid from 1300 to 1900, was issued to warn of a line of active thunderstorms from Dalby to Stanthorpe moving east at 30 kts.
The aircraft operator provided the crew with a meteorological briefing package prior to departure from Sydney. In addition, the crew reported discussing the meteorological situation with the BoM meteorologist, positioned in the operator's flight dispatch organisation, prior to departure from Sydney. Further, they were aware of the line of storms to the west and south-west of Coolangatta, having negotiated past them during the first sector from Sydney to Coolangatta. During the turn-around at Coolangatta, the crew updated the Sydney TAF using the aircraft communications addressing and reporting system (ACARS) and obtained Coolangatta ATIS Echo.
The operator reported that the meteorologist was aware of the development of the thunderstorm in the vicinity of Coolangatta Airport, from the weather radar monitor located in the operator's flight dispatch area. That information was passed to the operator's port staff at Coolangatta, however, it was not passed to the crew of EAL, as the operator did not have a procedure for disseminating such information to crews once they had commenced taxiing.
1.7.2 Bureau of Meteorology - weather radar
The BoM received three-dimensional radar data for the Brisbane to Coolangatta area from weather radars located at Brisbane Airport and Marburg. The Marburg radar was situated on the Little Liverpool Range between Marburg and Rosewood about 50 km west of Brisbane.
The BoM reported that forecasters first became aware of the severe nature of the thunderstorm involved in the occurrence at about 1336. It continued to intensify and quickly moved to the Coolangatta area, passing over Coolangatta Airport between about 1340 and 1349. EAL was issued a takeoff clearance at about 1345. Images of the thunderstorm passing over Coolangatta at 1340 and 1350, including the aircraft flight path from takeoff to 10,000 ft, are depicted at Figures 3 and 4 respectively.
Two-dimensional images from BoM's weather radars were displayed at various air traffic control working positions by means of a PC-based system known within Airservices Australia as METRAD (Meteorological RADar) and within the military as RAPIC (RAdar PICture). The use of METRAD/RAPIC by Air Traffic Services (ATS) controllers is described at paragraph 1.17.1.
1.8 Aids to navigation
Not a factor in this occurrence.
All communications between ATS and the crew were recorded by ground based automatic voice recording equipment for the duration of the occurrence. The quality of the aircraft's recorded transmissions was good.
An ATIS broadcast provided advice of conditions pertaining to the operation of aircraft within 5 NM of the respective aerodrome reference point. Coolangatta ATIS Echo was current until 1337:41. ATIS Echo included runway 32 (active runway), wind from 350 degrees at 22 kts, crosswind maximum 15 kts, visibility greater than 10 km and three to four eighths of cloud at 2,500 ft.
At 1338:22 ATIS Foxtrot was issued. It included information to expect a VOR/DME approach, runway 32 wet, wind at 350 degrees at 20 kts, crosswind maximum 15 kts, visibility reducing to 5,000 m in rain and thunderstorms, five to seven eighths of cloud at 2,500 ft and one to two eighths of cloud at 1,500 ft.
At 1339:07, 45 seconds after ATIS Foxtrot was issued, the crew requested taxi clearance and advised having received ATIS Echo. The SMC controller did not advise the crew of the changed ATIS or provide them with the changed conditions.
1.10 Aerodrome information
Runway 32 at Coolangatta was sealed and level. It was 2,042 m long, 45 m wide and aligned on a magnetic heading of 319 degrees.
1.11 Flight recorders
The aircraft was equipped with a Honeywell solid state flight data recorder (FDR). The FDR data indicated that EAL encountered windshear at about 800 ft above ground level. The encounter lasted about 30 seconds and included an 11-second period where the aircraft descended, resulting in a total altitude loss of about 130 ft. The pitch attitude changed from about 20 degrees nose up to 6 degrees nose up during this period. A GPWS Mode 3 aural alert 'DON'T SINK' was recorded for 4 seconds. Take-off thrust was de-rated giving an engine pressure ratio (EPR) of 1.39 and the power setting did not vary during the event. The de-rate is equivalent to a thrust reduction of 9 per cent.
The recorded FDR data indicated that, throughout the windshear encounter, both EPR and thrust lever angle (TLA) remained in the take-off position until climb thrust was set when clear of the encounter.
Recorded FDR data, indicating aircraft pitch attitude and GPWS Mode 3 alert, is depicted at Appendix 1.
1.12 Wreckage information
Not a factor in this occurrence.
1.13 Medical information
The crew reported no physiological or medical condition that could have impaired their performance.
1.15 Survival aspects
Not a factor in this occurrence.
1.16 Tests and research
1.17 Organisational information
1.17.1 Air Traffic Services information
The manual of air traffic services (MATS) was a joint document of Airservices Australia and the Department of Defence. The manual was based on rules published by both those organisations and the Civil Aviation Safety Authority (CASA). Section 5.1.7 of MATS permitted ATS controllers to use the BoM PC-based METRAD/RAPIC two-dimensional weather radar displays, in conjunction with information obtained from other sources, to provide as much information that was available to crews on hazardous weather avoidance. Those displays, which were also available to the general public, were updated every 10 minutes and therefore, could have been up to 10 minutes behind the actual time. Coolangatta ATS reported that they had access to METRAD/RAPIC. ATS did not offer, nor did the crew request, weather information accessed from the METRAD/RAPIC display.
1.18 Additional information
1.18.1 Aircraft flight path information
After encountering the adverse weather, the crew reported that they stopped the cleared turn and attempted to divert around the conditions being experienced. ATS radar data indicated that the aircraft continued on easterly headings to about 70 NM east of the coast, before turning south towards Sydney. The crew was unable to regain the cleared flight-planned route.
1.18.2 Other aircraft movements
There were a number of other aircraft movements into and out of Coolangatta aerodrome preceding the occurrence flight. A Boeing 767 landed on runway 32 at 1328, a Boeing 737 took off from runway 32 at about 1330, a CT4 landed on runway 35 at about 1335 and a B200 Super King Air landed on runway 35 at about 1340. The landing aircraft had approached Coolangatta from the south. No reports of thunderstorm activity, heavy rain, hail or windshear were received from any of those aircraft, except to say that the line of storms was approaching from the west and south-west.
1.18.3 Previous similar occurrence
The occurrence involving EAL displayed a number of similarities to a Boeing 737 microburst encounter that occurred at Brisbane aerodrome on 18 January 2001 (see ATSB investigation report BO/200100213). As a result of that occurrence, the ATSB issued a number of safety recommendations to Airservices Australia, BoM and CASA. Those recommendations included, but were not limited to:
- a review of air traffic controller initial and recurrent training programs to ensure they adequately addressed the effect of convective weather on aircraft performance and the limitations of airborne weather radar
- expediting the introduction of an integrated weather radar/air traffic control radar video display system capable of providing multiple weather echo intensity discrimination without degradation of air traffic control radar information
- an increased emphasis in air traffic controller training programs to ensure that all appropriate sources of information, such as meteorological forecasts, controller observations, radar information, and pilot reports are provided to flight crews
- development of a standard scale of thunderstorm intensity for use within the aviation industry
- BoM meteorologists to act as focal points for liaison with air traffic control units.
- As a result of the occurrence and safety recommendations, the following safety actions were implemented:
- Airservices Australia produced a hazardous weather training program for its air traffic controllers
- with the assistance of BoM and the radar manufacturer, the operator produced a CD-ROM based weather radar training program for issue to its crews
- the operator included information regarding operation of the weather radar and flight in heavy rain in its Flying Manual
- BoM integrated a qualified meteorologist into the operator's flight dispatch organisation.
1.19 New investigation techniques
Not relevant in this occurrence.
The occurrence involving EAL involved a number of issues including the limitations of airborne weather radar, the mutual exchange of information between BoM and air traffic control, and provision of information to the B767 crew. Further, the occurrence involving EAL displayed a number of similarities with a Boeing 737 microburst encounter at Brisbane Airport on 18 January 2001.
2.2 The aircraft
2.2.1 Aircraft weather radar
The aircraft weather radar did not have the capability to provide predictive forward-looking windshear detection and avoidance information to the crew, nor was there a requirement for it to do so. That capability would have provided an early alert to the crew about the hazardous conditions that existed ahead of the aircraft and may have assisted them to avoid or minimise those hazards.
The presence of red or magenta on the aircraft weather radar display is a measure of rainfall intensity. The crew reported areas of red on the display, with no hooks, fingers, contours, scalloped edges or U-shaped returns that could have indicated the presence of hail or other adverse weather conditions. In addition, they reported that they assessed the areas of red on the weather radar display as heavy rain only. The crew could see heavy rain approaching the aerodrome, but were not aware of any associated adverse weather conditions, such as thunderstorm activity and hail. In the absence of any indications of adverse weather from either the aircraft weather radar or ATS, they would have been unaware of the presence of adverse weather conditions in the takeoff flight path.
2.2.2 Aircraft flight path
The crew reported that they increased thrust in accordance with the operator's published windshear escape manoeuvre. However, recorded FDR data indicated that, throughout the windshear encounter, both EPR and thrust lever angle (TLA) remained in the take-off position until climb thrust was set when clear of the encounter. The investigation was unable to resolve the discrepancy.
2.2.3 Other aircraft movements
A number of other aircraft movements into and out of Coolangatta Airport occurred in the short time before EAL took off. None of those aircraft reported encountering adverse weather, including the Boeing 737 that took off from runway 32 about 15 minutes before EAL was issued clearance to takeoff from the same runway. The absence of any reports of adverse weather encounters likely contributed to the crew of EAL assessing that the weather conditions that they could see visually, and which were displayed on the aircraft weather radar, consisted of heavy rain only.
2.3 Organisational issues
2.3.1 Bureau of Meteorology
The BoM reported that the thunderstorm encountered by EAL developed in a short time-frame ahead of the main line of thunderstorms. Forecasters became aware of the severity of the thunderstorm 9 minutes before EAL was cleared to take-off. Despite observing the storm cell move towards and pass over Coolangatta aerodrome, forecasters did not contact Coolangatta ATS to advise of the approaching hazardous weather.
2.3.2 Air Traffic Services
ATIS Echo was current until 1337:41. ATIS Foxtrot was issued at 1338:22. The crew requested taxi clearance, notifying receipt of ATIS Echo, 45 seconds after ATIS Foxtrot was issued. Accordingly, the crew had not been advised that thunderstorms were present within 5 NM of Coolangatta Airport.
The SMC controller did not inform the crew that the ATIS had changed and did not advise the crew of the change in weather conditions. Accordingly, an opportunity was missed to provide the crew with updated information of the prevailing meteorological conditions at the time that the aircraft was intending to take-off.
Coolangatta ATS controllers could see that the thunderstorm was approaching and that weather conditions were deteriorating, however, they did not contact BoM staff to ascertain the severity of the approaching weather. Consequently, neither BoM nor Coolangatta controllers had a complete picture of the deteriorating meteorological situation. In turn, the crew of EAL was not provided with a complete picture of the meteorological situation in the vicinity of Coolangatta Airport and their intended departure flight path.
Coolangatta ATS reported that they had access to the BoM PC-based METRAD/RAPIC display. Controllers were aware that information depicted on those displays could be up to 10 minutes behind actual time. Due to the rapid development of the thunderstorm cell encountered by EAL, the investigation was unable to confirm if the METRAD/RAPIC display would have been able to provide Coolangatta controllers with sufficient information to advise the crew of EAL of approaching hazardous weather.
2.4 Previous occurrence
The occurrence involving EAL displayed a number of similarities to a Boeing 737 microburst encounter that occurred at Brisbane Airport on 18 January 2001. The circumstances of the occurrence involving EAL indicate that the ATSB recommendations published in ATSB investigation report BO/200100213 remain valid.
- An intense thunderstorm developed in a short time-frame ahead of the main line of thunderstorms, producing heavy rain, hail and windshear, which the aircraft encountered shortly after take-off.
- Air traffic control and Bureau of Meteorology staff did not mutually exchange information regarding the thunderstorm as it developed and approached Coolangatta aerodrome.
- Coolangatta Air Traffic Services staff did not ensure that the crew were aware of the changed weather conditions and the new Automatic Terminal Information Service broadcast advising that thunderstorms were in the area.
- The crew did not have a complete and timely picture of a hazardous and rapidly deteriorating meteorological situation from which to make an accurate assessment of that situation.
As a result of this occurrence, the operator has advised the ATSB that:
- amended procedures for the dissemination of weather information to crews have been trialled since the occurrence, and documented procedures are being amended
- an audio-visual presentation on the occurrence has been produced and provided to Airservices Australia
- the audio-visual package was presented at an Airservices Australia/Airline Industry Forum
- an awareness article was produced for dissemination to crews
- a program to add a predictive windshear capability to the operators fleet is continuing.
indicated have been referenced from a number of sources, which used
different time bases. Times obtained from the aircraft flight data
recorder are EST+3 seconds and those obtained from Brisbane air
traffic control are EST+7 seconds.
2 The average direction is based on mid-level wind direction.
3 The BoM reported that thunderstorms that move to the left or right of the average direction of the storm line, typically display severe characteristics.
4 Distance Measuring Equipment.
5 Windshear warning and predictive windshear warning functions were not required to be incorporated in the aircraft weather radar system.
6 BoM staff a meteorologist position in the operator's flight dispatch organisation.
7 Times are EST+3 seconds.
|Date:||26 October 2003||Investigation status:||Completed|
|Time:||1339 hours EST|
|Release date:||17 March 2005||Occurrence class:||Environment|
|Report status:||Final||Occurrence category:||Serious Incident|
|Highest injury level:||None|
|Aircraft manufacturer||The Boeing Company|
|Type of operation||Air Transport High Capacity|
|Damage to aircraft||Minor|
|Departure point||Coolangatta, QLD|
|Departure time||1335 hours EST|
|Role||Class of licence||Hours on type||Hours total|