Aviation safety investigations & reports

Breakdown of separation - Boeing B737-7Q8, VH-VBF and a Boeing B767-338, VH-OGU, near Melbourne Airport, Victoria, 5 December 2010

Investigation number:
AO-2010-104
Status: Completed
Investigation completed

Summary

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On 5 December 2010, at 1422 Eastern Daylight-saving Time, a breakdown of separation occurred between a Boeing Company B737-7Q8 (737), registered VH-VBF, and a Boeing Company B767-338 (767), registered VH-OGU, on departure from Melbourne Airport, Victoria. The flight crew of the 737 had reduced their aircraft's speed in order to meet a height requirement of the Standard Instrument Departure. The following 767 aircraft climbed at a faster speed.

When the aircraft were transferred from the aerodrome controller to a departures controller, there was 3.4 NM (about 6.3 km) separation between them. The departures controller expected them to climb at a similar speed, and did not recognise the loss of separation assurance. The controller's actions to manage the compromised separation were not fully effective. At one point, radar separation had reduced to 1.9 NM (3.5 km) and vertical separation to 500 ft.

On 12 October 2011, a similar breakdown of separation occurred at Melbourne between an Airbus A320-232 and a Boeing Company 737-8BK. This incident involved different controllers to those involved in the 5 December 2010 incident.

The ATSB identified a safety issue in that the procedures for takeoffs at Melbourne Airport allowed for aircraft to depart relatively close to each other, with no documented requirements to ensure jet aircraft would maintain a set climb speed or to require flight crews to advise air traffic control if that speed could not be achieved. Although the Melbourne procedures were based on those used in Sydney, the Sydney procedures specified a minimum climb speed. The safety assessment report for the Melbourne procedures did not include a detailed comparison of the procedures used in the two locations. In response to the identified safety issue, Airservices Australia has commenced action to establish a standard speed profile for use at radar terminal area aerodromes in Australia, and to ensure that pilots of jet aircraft notify air traffic control when operating at a significantly lower speed than stipulated in that profile.

Download Final Report
[Download  PDF: 627KB]
 
 
Alternate: [Download  DOC: 1.77MB]
 

Safety Issue

Go to AO-2010-104-SI-01 -

Melbourne speed restrictions

The Auto Release procedures at Melbourne Airport allowed for aircraft to be departed at or close to the separation minima, with no controls in place to ensure aircraft would maintain a minimum speed and flight crews would advise air traffic control if the speed could not be achieved.

Safety issue details
Issue number: AO-2010-104-SI-01
Who it affects: All flight operations in Class C airspace
Status: Adequately addressed
General details
Date: 05 December 2010   Investigation status: Completed  
Time: 1422 ESuT   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): near Melbourne Airport    
State: Victoria   Occurrence type: Loss of separation  
Release date: 02 May 2012   Occurrence class: Airspace  
Report status: Final   Occurrence category: Serious Incident  
  Highest injury level: None  

Aircraft 1 details

Aircraft 1 details
Aircraft manufacturer The Boeing Company  
Aircraft model 767  
Aircraft registration VH-OGU  
Serial number 29118  
Type of operation Air Transport High Capacity  
Damage to aircraft Nil  
Departure point Melbourne, Vic.  
Destination Sydney, NSW  

Aircraft 2 details

Aircraft 2 details
Aircraft manufacturer The Boeing Company  
Aircraft model 737  
Aircraft registration VH-VBF  
Serial number 30630  
Type of operation Air Transport High Capacity  
Damage to aircraft Nil  
Departure point Melbourne, Vic.  
Last update 14 November 2018