On 26 November 2013, a SOCATA TB-10 aircraft registered VH-YTT, departed Parafield Airport, South Australia, for solo night circuits in visual meteorological conditions. After one hour of flying circuits the student pilot conducted a touch and go landing prior to a final full stop circuit. At about 200 feet above the ground (AGL) after take-off the student noticed a vibration with a loss of power from the engine. The student initiated a gradual turn to the right until the large dark area of Parafield airport could be seen. At about 2120, just passing over the airport fence the student broadcast on the CTAF that the engine had failed. The student could see the white lights of the duty runway 21R/03L and the green lights of Bravo taxiway. The aircraft was at about 50 feet AGL and with partial engine power navigated toward the duty runway. There were no other aircraft on final or landing on runway 21R. The engine power was cutting in and out as the aircraft touched down on runway 03L at about a 30 degree angle, the aircraft remained on the runway, rolled through and turned off onto taxiway B5 where the engine lost all power and the aircraft stopped on the taxiway. The student broadcast on the CTAF that the aircraft was clear of the runway. The student pilot was uninjured and the aircraft was not damaged.
pre-flight decision making and planning for emergencies and abnormal situations for the particular aerodrome
conducting a thorough pre-flight and engine ground run to reduce the risk of a partial power loss occurring
taking positive action and maintaining aircraft control either when turning back to the aerodrome or conducting a forced landing until on the ground, while being aware of flare energy and aircraft stall speeds.
On 7 March 2014, a Fokker 100 aircraft, registered VH-FZO, departed Perth on a scheduled passenger flight to Argyle, Western Australia. On board was a captain designated as the pilot flying (PF), and a training captain, seated in the right seat, designated as the pilot monitoring (PM).
During the cruise, the aircraft pitched down and both thrust levers came back towards idle to maintain the selected speed during the descent. The rate of descent reached about 1,700 feet per minute and the aircraft descended about 300 ft. The PF then disconnected autopilot 1 and connected autopilot 2.
The aircraft continued to Argyle and the crew commenced descent to the aerodrome. When at about 1,000 ft above ground level (AGL) and about 3 NM from the runway threshold, the PF stated that the thrust levers were stuck. The PM then tried to move the thrust levers and confirmed they were stuck. The PM applied force with both hands on the thrust levers and they jerked forwards, resulting in about a quarter of the normal available thrust. The PM directed the PF to get the aircraft back onto the normal profile and the PF extended full flap. Just prior to touchdown, the PM extended the speed brake and when at about 10 ft AGL, he applied sufficient force to move the thrust levers to the idle position. Engineers found that an elevator servo and a thrust lever servo had failed.
This incident provides an excellent example of how an experienced crew faced with a novel and unanticipated threat, were able to modify their roles and work together to safely complete the flight.
At approximately 0800 hours Eastern Standard Time on the morning of 22 March 1968 the Bell 204B helicopter, VH-UTW, owned and operated by Helicopter Utilities Pty. Ltd., commenced transporting a party of twenty-six journalists, photographers and public relations personnel from West Sale Aerodrome in Victoria to Barracouta Platform. Three separate flights were required to transport the party which had assembled principally from Sydney, Melbourne and the Gippsland area of Victoria and was visiting the platform for inspection and photographic purposes. The last group arrived at the platform shortly after midday.
Barracouta Platform stands in approximately 150 feet of water and is positioned over a natural gas recovery drilling point at latitude 38 degrees 18 minutes south, longitude 147 degrees 11 minutes east. The platform is 36 miles east south-east of the West Sale Aerodrome and 13 miles off-shore. Barracouta Platform is jointly owned and controlled by Esso Exploration and Production Australia Inc., and Haematite Petroleum Pty. Ltd.
At approximately 1215 hours VH-UTW took off with a party of television cameramen aboard for a short local flight around the platform for photographic purposes. Approximately five minutes later an approach from the east to the Barracouta helipad was made for the purpose of landing. The helicopter made a normal approach which terminated in the hover position with the heels of the undercarriage pontoons approximately four feet above the helipad surface. From this position directional control was lost and, after making contact with the helipad on the pontoons, it slewed through an arc of approximately 160 degrees in a clockwise direction as viewed from above. The helicopter came to rest on the helipad with its tail fin slightly over-hanging the western edge of the pad (Refer to Appendix A). The undercarriage had distorted in such away as to allow the main rotor blades to make contact with the helipad surf ace during the rundown period and this induced a fragmentation of the extremities of these blades.
During the period between the initial loss of directional control and the final stopping of the main rotor blades, serious injuries were caused to seven of the eleven members of the press party who were observing the landing of the helicopter from positions on the helipad and on it's access stairway. In respect of three persons the injuries proved to be fatal but none of the six occupants of the helicopter was injured.
Conclusions
The pilot made a normal approach for landing and, when the aircraft was hovering with approximately four feet of clearance above the centre of the helipad deck, a catastrophic tail fin structural failure suddenly occurred, and deprived the pilot of directional control. The helicopter descended quickly onto the helipad deck and slewed through approximately 160 degrees about a vertical axis. During and immediately subsequent to this circumstance the principal injuries to bystanders occurred as a result of them coming into contact with the rotors or with pieces separating from the main rotor as it came into contact with the helipad deck.
The cause of this accident was that, during the assembly of the tail rotor, the inadvertent omission or loss of a trunnion thrust washer was not detected.
On 3 March 2014, the flight crew of a Tiger Airways Australia Pty Ltd (Tigerair) Airbus A320 were preparing for a scheduled passenger service from Sydney, New South Wales to Perth, Western Australia. The flight crew had earlier completed uneventful sectors from Sydney to the Gold Coast, Queensland, and return. As part of that preparation, the flight crew reviewed the operational flight plan (OFP) for the sector. The OFP was produced by the operator’s Operations Control Centre. That OFP contained significant errors in the aircraft weights, and as a consequence the required fuel upload for the sector was also significantly in error. The aircraft captain chose to re-calculate the required fuel load using resources available on the flight deck. The resultant required fuel load calculated and uplifted by the captain did not include the operator's requirement to carry a '60-minute top-up' additional fuel, resulting in the fuel upload being below that required under the operator's operations manual. The aircraft’s flight computers, however, identified that the aircraft would arrive at its destination with more than the minimum inflight fuel requirements. During the subsequent flight, the flight crew regularly checked the fuel usage and expected arrival fuel at Perth. All company and regulatory inflight fuel requirements for the flight from Sydney to Perth were met, and the aircraft landed with fuel in excess of the required fuel reserves.
What the ATSB found
There were deficiencies within the processes and procedures used by the operator's Operations Control Centre that permitted incorrect plans to be produced and subsequently provided to flight crew. This increased the risk that, in the time pressured environment of pre-flight planning, flight crews could either overlook incorrect data and accept an incorrect flight plan, or err in the calculation of the required fuel upload. Further, the operator provided limited guidance and assistance for flight crews on the processes and procedures for correcting identified fuel planning errors. For the occurrence flight crew, this lack of guidance, as well as the remoteness of resources that could assist, resulted in the decision to determine a correct required fuel load calculation using only those resources available on the flight deck. Due to the short layover between sectors, which was further aggravated by curfew restrictions, this increased the risk of critical fuel planning considerations being overlooked.
Safety message
A correctly calculated flight plan not only provides assurance to both the captain and the operator that all operational factors likely to influence the flight have been considered and accounted for, it also forms an important inflight validation tool to allow crews to monitor and continually assess those decisions made at the pre-flight stage. Where variances are noted, timely alternative plans can be implemented to ensure that aircraft arrive at either the destination or an alternate aerodrome with required fuel reserves preserved.
The occurrence
On 3 March 2014, the flight crew of a Tigerair Airbus A320 were rostered to conduct three scheduled passenger services. The crew commenced duty at 1700 Australian Eastern Daylight-saving Time[1] in Sydney, New South Wales. The sectors were:
Sydney to the Gold Coast, Queensland, with a departure time of 1800
Gold Coast to Sydney, with a departure time of 2000
Sydney to Perth, Western Australia, with a departure time of 2155.
At the commencement of duty, the flight crew received two of the three operational flight plans (OFP) for the upcoming sectors. The third was obtained about 10 minutes later. It was not until during the pre-flight stage of the third sector that the flight crew identified gross errors in the OFP for the Sydney to Perth sector. These errors resulted in a significant error in the calculated fuel required for the Sydney to Perth sector. Due to time and resource availability constraints, the captain chose to re-calculate the required fuel load using resources available on the flight deck. The captain did not upload sufficient fuel to meet the operator’s flight fuel requirements. The flight proceeded to Perth uneventfully and landed with a fuel reserve greater than that required under the regulations.
The operational flight plan
The OFP contained essential information necessary for the conduct of the relevant flight. It also formed the basis for the air traffic services (ATS) flight plan, which was included within the OFP. The OFP was required to contain specific information concerning that flight, including:
aircraft registration, type and variant
air traffic services flight plan data, including flight identification, place and time of departure, route, and place and time of arrival
aircraft weight data, including dry operating weight, number of passengers and payload weight, take-off weight and landing weight
fuel calculations, including a breakdown of all specific fuel quantities as required by regulation and the operator’s operations manual (OM)
route segments with waypoints, distances, time intervals and tracks, planned cruising speed, altitudes/flight levels, and expected wind velocity
for all en-route waypoints, a section for recording the estimated time of arrival, actual time of arrival and fuel remaining at that waypoint.
The section of the OFP that detailed the aircraft weights and fuel calculation also included information on the effect that an increase in weight would have on fuel burned during flight.
For multi-sector trips, all OFPs were required to be delivered via email to the operating flight crew at least 90 minutes before the scheduled start of the first flight.[2] Flight crews were required to check the OFP for correct fuel load, flight details, as well as a number of other essential flight planning components.
Operations control centre
Flight planning was performed by the operator’s Operations Control Centre (OCC), which was located in Melbourne. The OCC was ‘responsible for the safe, efficient and cost effective utilisation of aircraft and flight crews ensuring that regulatory compliance and company requirements are achieved’.[3] In fulfilling these functions, operations controllers (OC) were responsible for various operational tasks, including flight planning and load control for each flight. With respect to flight planning, OCs produced a number of products that were necessary for the proper planning and conduct of flights, including the OFP. On completion of the OFP, the OC was required to email the OFP to the flight crew and submit the ATS flight plan to the relevant ATS authority.
The operator had a structured training program for OCs that led to the issue of a certificate of competency. Once qualified, OCs were then required to maintain competency through the periodic completion of a recurrent training program.
The operator’s fuel policy in the operations manual
Background
The Civil Aviation Regulations (1988) (CAR) rr. 233-234 required the aircraft captain and the operator to ensure that an aircraft has sufficient fuel supplies for the safe conduct of the flight. CAR r. 234 also enabled the publication of fuel guidelines, which were contained within Civil Aviation Advisory Publication (CAAP) 234-1 Guidelines for aircraft fuel requirements.
CAAP 234-1 included guidelines for calculating the fuel required for a flight, as well as specific inflight fuel requirements. A component of the required fuel calculation, as well as inflight fuel requirement, was the fixed fuel reserve (FFR). The FFR was an amount of fuel that would enable 30 minutes of holding at 1,500 ft above an aerodrome at standard atmospheric conditions.
For an aircraft operator, CAR rr. 215 and 220 required:
the operator to provide an OM
the operator’s staff to comply with the OM
that the OM include specific instructions for the computation of fuel quantities for all routes.
The operator’s fuel policy was contained within the OM Part A. It covered a number of general topics, including the captain’s authority, the fuel calculation, fuel monitoring, and in-flight fuel monitoring.
Captain’s authority
This section of the OM contained an overarching policy concerning fuel. It included the following statement:
It is the Captain’s responsibility to ensure that sufficient fuel is carried to operate the aircraft safely and efficiently in accordance with Company policy and procedures. Adequate fuel to cover the requirements of the trip, Variable Reserve, alternate (when required), reserve, required holding and taxi must be loaded prior to departure. Captains will uplift the minimum fuel quantity listed on the authorised OFP to achieve the operational requirements…
Fuel calculation
The section titled ‘fuel calculation’ was the means by which the OM detailed the fuel necessary for a flight, thereby meeting the CAR requirement that sufficient fuel be carried. It reflected the guidelines contained in CAAP 234-1. This section contained the components for determining the fuel required for a flight, and included the following:
taxi fuel
expected fuel usage for the flight
should an alternate be required, fuel to meet that alternate requirement
a variable fuel reserve of 10 per cent of the expected fuel usage and any additional alternate fuel (up to a maximum of 1,000 kg)
a fixed reserve amount of 30 minutes fuel
holding fuel, if traffic or weather conditions required it.
In addition, the policy required that if the sum (in minutes) of fixed reserve fuel plus any alternate fuel or holding fuel was less than 60 minutes, then an amount of fuel to reach that time was to be loaded. This extra fuel was known as the ‘60-minute top-up’. If the flight was limited by take-off performance or landing weight, the 60-minute top-up fuel was not to be applied before off-loading payload.
The fuel calculation in an OFP contained information on the expected increase in fuel burn for the flight that would result from an increase in take-off weight. The operator’s fuel policy did not include any guidance on this information, such as:
the limit to the accuracy of the information as take-off weight increases
at what point any change in take-off weight becomes sufficient to require a new OFP to be produced.
Fuel monitoring
This section of the OM contained a number of before flight requirements, including that ‘[t]he fuel on board agrees with the figure on the OFP, load sheet and is sufficient for the proposed flight’.
Inflight fuel monitoring
This section of the OM contained specific inflight fuel requirements. This included that, at each check, the expected fuel remaining on touchdown at the destination exceeded any alternate fuel requirement, including alternate variable reserve, plus reserve fuel. Reserve fuel was not defined, however, this section also stated that ‘[i]t is a legal requirement to touch down with not less than 30 minutes fixed reserve fuel intact’.
The pre-flight planning and the first two sectors
The OC responsible for producing the three OFPs and associated documentation recalled that the OFPs were produced and ready for transmission via email before 1800. These emails were recorded as being sent at 1636.
The captain recalled arriving at the operator’s Sydney crewing office about 30 minutes early to commence flight preparation. On arrival, the OFPs for the first two sectors were available, but the third OFP for the Sydney to Perth sector was missing. The captain reported calling the OCC on two occasions to ascertain the whereabouts of the missing OFP. It was finally delivered, via email, 10 minutes after the scheduled sign-on time of 1700. The Captain stated that, due to the need to concentrate on the first sector, there was insufficient time to review the Sydney to Perth OFP. The intent was to review this OFP after completing the second, Gold Coast to Sydney, sector.
The crew departed Sydney for the Gold Coast on schedule. The Sydney to Gold Coast and return sectors were uneventful, with the aircraft arriving back into Sydney 15 minutes ahead of schedule, at 2105.
The Sydney to Perth sector
The incorrect OFP
On arrival back in Sydney the flight crew commenced preparations for the final sector to Perth. This commenced with a review of the sector’s OFP. It was at that point that the flight crew first noticed that this OFP contained significant errors. The number of passengers recorded on the OFP was zero, as was the aircraft’s payload. The OFP showed a trip fuel of 9,368 kg, and a required fuel load of 12,296 kg. Finally, the fuel calculation section of the OFP stated that the additional fuel burn per 1,000 kg increase in take-off weight was 140 kg.
The actual passenger number was 177, representing a payload weight of 13,949 kg, while there was also additional payload in cargo totalling another 1,175 kg. The consequence of the omitted weight was that the fuel required for the flight was based on an aircraft weight that was significantly less than the actual weight. As a result, the fuel calculation figures were significantly less than that required for the flight. The OFP error meant that the fuel load would need to be recalculated before commencing the flight.
The curfew restrictions
Sydney airport curfew restrictions required weekday departing flights to be airborne no later than 2300. Additionally, departures between 2245 and 2300, known as the ‘shoulder period’, were required to use the southerly runways. When a departure was near the shoulder period and weather conditions required a northerly runway, aircraft were to commence taxi with sufficient time to ensure that the take-off commenced no later than 2245.
The captain reported that a few weeks earlier, another company flight had been refused permission to take off during the curfew shoulder period and had returned to the terminal, with a full load of passengers. That return to the terminal had resulted in significant disruption to both the passengers and the company’s operation.
Recalculation of the required fuel
The captain reported that a number of considerations were critical in making the decision on whether to seek an updated OFP:
As the new OFP would be emailed to the flight crew, access to a computer terminal was required to obtain a printed copy. Such facilities were only available in the Sydney terminal, which required a walk of about 10 minutes each way, and the time required for the OCC to deliver the new OFP was unknown.
There were no operational support personnel at the terminal to assist the flight crew with the compilation of a new OFP. The personnel present were for passenger and loading services only.
The airport weather information was reporting the wind as 020 degrees at 10 kt, requiring a departure to the north. Any delay obtaining a new printed OFP had the potential to infringe on the shoulder period.
The actual passenger and cargo load was available to the flight crew through the load sheet data provided by the terminal staff. This load sheet data provided accurate aircraft weights.
The aircraft’s Flight Management Guidance System (FMGS) had the functionality and capacity to calculate an accurate required fuel load when the aircraft weights and many other variables regarding the route and flight were loaded into the system.
The weather at Perth and at suitable en-route diversion airports was fine.
The OFP included the contact phone number for the OC who produced it, however, the OC was not contacted by the flight crew after the OFP errors were identified. The captain also had access to the phone number of the Duty Pilot, whose role included providing assistance to flight crew. The captain stated that attempts were made to contact the Duty Pilot, but that these calls were not answered.
Having discussed the matter with the first officer, the captain elected to determine the fuel load requirements using resources available on the aircraft’s flight deck, in this case the FMGS, and proceed with the flight to Perth without seeking an updated OFP with a hard copy. The captain and first officer independently calculated a required fuel load, and from these calculations and subsequent discussions the captain decided to upload 13.6 t of fuel. The captain was satisfied that this amount of fuel sufficiently met variable and mandatory fixed reserve fuel requirements, and that a number of airports along the route provided suitable options should an in-flight diversion become necessary.
Records identified that refuelling was completed at 2132, with the final fuel load being 13,520 kg. The captain stated that the FMGS was, at that time, showing an arrival fuel at Perth of 2.4 t.
The flight
The aircraft commenced taxiing at 2158. Take-off commenced at 2210.
The flight crew reported that, during the flight, they independently monitored the amount of fuel on board and fuel usage, knowing that the original OFP had been in error. As part of the process of continually monitoring the remaining fuel on board the aircraft, the flight crew recorded the fuel remaining at the top of the climb from Sydney, and at a number of waypoints along the route. They then reconciled the fuel remaining against the figures on the OFP[4] for each leg and monitored the FMGS calculated arrival fuel to ensure the flight met the regulatory requirements. The flight crew also reported carrying out point-of-no-return calculations to ensure that, when the aircraft reached the point where they would be committed to the destination, the weather reports and fuel amounts would be sufficient to allow a safe landing. The monitoring process used by the flight crew was in excess of the OM’s requirement for inflight fuel monitoring, which for a flight from Sydney to Perth required a fuel check about every hour.
The flight continued uneventfully and the aircraft landed in Perth with about 1.9 t of fuel remaining. The captain subsequently reported the OFP inaccuracy to the operator, and in particular the concern about the safety implications if OFP inaccuracies were undetected by flight crew.
The operator’s internal investigation and audits
Operator’s investigation into the occurrence
In an internal report on the occurrence, the operator found that the:
flight crew had been issued with an incorrect OFP that did not have any passengers or cargo included in the aircraft’s weight
flight crew elected to add additional fuel above the figure required by the incorrect OFP, however, the amount of fuel the aircraft departed with did not meet the operator’s departure fuel 60-minute top-up requirement
the correct 30-minute FFR for the adjusted aircraft weight was 1,139 kg
the OFP had been delivered to the crew later than the time required by the OCCPPM
the aircraft landed with 1,914 kg of fuel, which was above that required under the regulations.
The report made a number of recommendations, including that:
the operator reinforce to flight crews:
the need to exercise vigilance in checking OFP data
that the duty pilot was an added resource available to assist flight crews
the need to request a new OFP where gross error exists
OCC personnel receive adequate training in preparation of OFP’s using the new flight planning system.
The report stated that the correct minimum fuel upload for the flight was 15,343 kg. It also identified a number of areas requiring further investigation, including any guidance provided to flight crew regarding allowable errors in the OFP. With respect to this, the report stated that an examination of company documentation indicated that there was no specific guidance provided on allowable payload variations, nor on when a re-issued OFP was required.
Operator’s pre-occurrence audit of the OCC
An internal audit of the OCC conducted in September 2013 stated that the ‘overall operation of the OCC was considered to be satisfactory’. Management and the OCC staff were stated to be experienced and competent, while the operators demonstrated good knowledge of their duties and responsibilities. The audit contained two findings of an administrative nature, neither of which had a relationship to the production of OFPs.
Operator’s post-occurrence audit of the OCC
The operator’s internal investigation spawned a further internal investigation into errors in OFP’s issued to flight crew, as well as a further audit of the OCC. The error investigation identified a further three reported occurrences during 2014 of OFP’s that contained errors similar to that encountered by the occurrence flight crew.
The audit, conducted in July 2014, included the following statement in the executive summary:
Given the continued use of the Geneva (Day of Operations planning) and Navtech (Flight Planning) systems into the near term, the main areas of risk are in process development and staff training. In particular, flight plan preparation is considered to be of medium risk.
This statement appeared to relate to a number of audit observations and comments. The observations stated that there was little automated integration between the numerous systems that were used by the OCC staff during the production of an OFP. This resulted in a high level of manual data entry with the consequent high likelihood of errors being encountered. The comments identified that data update processes within the systems could result in incorrect data being processed manually into flight plans. The auditor also commented that the work environment (high workload and numerous distractions) could adversely affect the OFP production process.
With respect to the automated integration of the OCC systems, the audit also stated that the OCC introduced a new flight planning software package about 7 months before the occurrence. This resulted in many of the previously automated processes used to complete an OFP either being discontinued or becoming unstable. Further, when errors occurred in the production of an OFP, there were no automated warnings to alert the OC to this condition, resulting in error detection being reliant on the vigilance of the individual. The OC who produced the OFPs for the subject three sectors had not completed a formal training program for the new software, but had been provided a few ad hoc hands-on training sessions with an OCC duty manager. The July 2014 internal audit also noted that the OCC’s daily output of OFPs had increased substantially over the previous few years.
The audit contained four findings, none of which related to the processes involved in producing an OFP. One finding, concerning staff training records and syllabus, indirectly related to the internal investigation report’s recommendation that OCC staff receive adequate training in the preparation of an OFP.
Flight planning functions post February 2015
Tigerair advised that, as a result of the completed acquisition of Tigerair by the Virgin Australia Group in February 2015, Virgin Australia has subsequently assumed responsibility for all Tigerair flight planning functions.
Tiger Airways Australia Pty Ltd used an Operations Control Centre (OCC) to provided flight planning support for the flight crew of their regular public transport flights. Operations controllers (OC) were responsible for the production of flight planning and supporting documentation, which included generating the operational flight plan (OFP) and associated air traffic services flight plan.
There are various reasons for using an OCC for flight planning, including cost and duty time considerations. The use of an OCC system to produce flight planning products enables operators to reduce the flight crew’s flight planning task from gathering information and developing the flight plan, to one of reviewing prepared documentation and a finalised OFP. This has enabled operators to significantly reduce the time spent by flight crew in the flight preparation phase. Under regulation and the operator’s own policy and procedures, however, the aircraft captain was responsible for the proper planning and conduct of a flight.
The production of a correct OFP is essential for the safe completion of a flight. It ensures, amongst other things, that:
the calculated fuel upload contains all required components
the fuel upload is sufficient for the required flight given the conditions expected for that flight
there is an accurate method of tracking inflight fuel usage
the aircraft will arrive at the destination with sufficient fuel to ensure a safe landing.
Fuel requirements
In accordance with the Civil Aviation Regulations (1988) rr. 215 and 220, the relevant fuel requirements for the occurrence flight were contained within the operator’s operation manual (OM). The OM contained two distinct fuel requirements for a flight that were differentiated by temporal criteria:
the flight planning fuel requirements, referred to in the OM as the ‘fuel calculation’
the in-flight fuel requirements.
Pre-flight fuel requirement
The fuel calculation required the flight crew of the occurrence flight to upload the ‘60-minute top-up’ fuel as part of the flight planning fuel calculation. With respect to the occurrence flight, the OCC provided the flight crew with an OFP that contained gross errors in the aircraft's payload and resultant operating weights. This in turn led to a fuel calculation that was significantly in error. These errors were detected by the flight crew during pre-flight. As a result, the flight crew re-calculated the required fuel upload based on actual load data information using resources available on the flight deck, and in particular the aircraft's flight computer. The required fuel load calculated and uplifted by the aircraft captain did not include the operator's requirement to carry a '60-minute top-up' additional fuel, resulting in the aircraft’s uploaded fuel being below that required under the operator's OM.
Inflight fuel requirement
While the aircraft did not meet the flight planning fuel upload requirement, all company and regulatory in-flight fuel requirements were met for the flight from Sydney to Perth. The flight crew monitored the fuel usage during the Sydney to Perth sector in accordance with, and most likely in excess of, the OM inflight fuel monitoring requirements. This, and the actual arrival fuel being in excess of the regulatory and OM required minimum fuel reserves, indicate that the aircraft met the inflight fuel requirements for the Perth to Sydney sector.
The 60-minute top-up requirement
There were a number of factors about the top-up requirement that are relevant:
This additional fuel represented a more conservative approach to fuel safety than that contained in the guidance material provided by the Civil Aviation Advisory Publication 234-1.
The top-up fuel component was not a component of the inflight fuel requirement.
The safety basis of the top-up requirement can be diminished due to the operator’s policy of offloading this fuel component instead of payload when aircraft operating limitations became an issue.
OCC deficiencies
The inaccurate OFP was the result of deficiencies within the processes and procedures used by the operator's OCC. While the operator’s 2013 internal audit of the OCC did not identify any deficiencies in processes or procedures, particularly along the lines of those exposed by this occurrence, the subsequent investigations initiated as a result of the occurrence and the 2014 audit identified a number of relevant deficiencies.
The 2014 audit identified an increased risk to the production of an OFP due to process issues and training of OCC staff. Specifically related to this occurrence were the audit’s comments and observations identifying that there were no system defences able to detect errors introduced through manual data entry or automated updating before the OFP was transmitted to flight crew. Therefore, the principal defence in identifying any errors was the vigilance of the flight crew. This increased the risk that, in a time pressured environment of pre-flight planning, flight crews could either overlook incorrect data and accept an incorrect OFP, or as occurred in this occurrence, identify the error and be required to calculate the fuel upload requirement themselves. However, on this occasion and the other three occasions identified in the internal investigation, the flight crew did discover the error.
Guidance on OFP errors
Correcting the occurrence flight’s OFP error was further complicated by the limited guidance and assistance that the operator provided to correct errors in fuel calculation. While the OFP contained information with respect to increased fuel burn for every one tonne increase in take-off weight, there was no guidance on the limits to which this information could be used, nor at what point gross error in the take-off weight required a new OFP to be produced. For the occurrence flight crew, this lack of guidance, as well as the remoteness of resources that could assist, influenced the decision to determine a correct required fuel load calculation using only those resources available on the flight deck. Due to the short layover between sectors, which was in turn further aggravated by curfew restrictions, this increased the risk of critical fuel planning considerations being overlooked.
Findings
From the evidence available, the following findings are made with respect to the flight planning error involving Airbus A320 registered VH‑VNJ that occurred at Sydney airport, New South Wales, on 3 March 2014. These findings should not be read as apportioning blame or liability to any particular organisation or individual.
Contributing factors
On identifying that the operational flight plan for the Sydney to Perth sector had been based on an incorrect aircraft weights, resulting in the fuel calculation and subsequent fuel plan being significantly in error, the aircraft captain chose to re-calculate the required fuel load using resources available on the flight deck. The required fuel load calculated and uplifted did not include the operator's requirement to carry a '60-minute top-up' additional fuel, resulting in the aircraft departing with a fuel load that was below that required under the company's operations manual.
There were deficiencies within the processes and procedures used by the operator's Operational Control Centre that permitted incorrect operational flight plans to be produced and subsequently provided to flight crew.
The operator provided limited guidance and assistance for flight crews on the processes and procedures for correcting identified fuel planning errors. For the occurrence flight crew, this lack of guidance, as well as the remoteness of resources that could assist, resulted in the decision to determine a correct required fuel load calculation using only those resources available on the flight deck.
Other findings
All company and regulatory in-flight fuel requirements for the flight from Sydney to Perth were met, and the aircraft landed with fuel in excess of the required fuel reserves.
Sources and submissions
Sources of information
The sources of information during the investigation included the:
The captain of VH-VNJ
Tiger Airways Australia Pty Ltd
The Civil Aviation Safety Authority
Submissions
Under Part 4, Division 2 (Investigation Reports), Section 26 of the Transport Safety Investigation Act 2003 (the Act), the Australian Transport Safety Bureau (ATSB) may provide a draft report, on a confidential basis, to any person whom the ATSB considers appropriate. Section 26 (1) (a) of the Act allows a person receiving a draft report to make submissions to the ATSB about the draft report.
A draft of this report was provided to the Civil Aviation Safety Authority, the crew of VH-VNJ and Tiger Airways Australia Pty Ltd.
Submissions were received from the aircraft captain, Tiger Airways Australia Pty Ltd, and the Civil Aviation Safety Authority. The submissions were reviewed and where considered appropriate, the text of the report was amended accordingly.
Purpose of safety investigations
The objective of a safety investigation is to enhance transport safety. This is done through:
identifying safety issues and facilitating safety action to address those issues
providing information about occurrences and their associated safety factors to facilitate learning within the transport industry.
It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action.
Terminology
An explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue.
Publishing information
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During the evening on 15 February 2014, and Airbus A320, registered VH-VNQ, was preparing to depart Hobart, Tasmania, for a flight to Melbourne, Victoria. The crew completed pre-departure activities including entry of take-off reference speeds and the flex temperature (for a flex temperature take-off) into the aircraft’s Flight Management Guidance System (FMGS). The crew started engines and taxied for runway 12, but thunderstorms in the area delayed departure.
After holding for about 75 minutes, waiting for the weather to clear, the crew entered runway 12 and backtracked to the threshold. As they backtracked, the crew were able to gain a better appreciation of the weather in the direction of departure, and assessed their departure options. The crew entered their planned departure procedure into the FMGS, but noticed that the navigation display called for a right turn after take-off, contrary to the published procedure which called for a left turn.
The crew attempted to clear the departure anomaly by changing the departure runway to the reciprocal runway, then re-selecting the correct runway. This action failed to clear the anomaly, so the crew elected to continue with the departure and use heading mode to command a left turn at the appropriate time, rather than allow the auto-flight system to guide the aircraft into a right turn. The crew was unaware at the time, but by changing the departure runway in an attempt to clear the anomaly, take-off reference speeds and the flex temperature previously entered into the FMGS, were removed.
As the flex temperature take-off commenced, the crew noticed that flight mode annunciations were not as they would normally appear. An electronic centralised aircraft monitoring system caution then alerted the crew that the thrust levers were not correctly set, and the crew noticed that the take-off reference speeds were not displayed on the primary flight display airspeed indicators. The captain elected to continue the take-off and advanced the thrust levers to the take-off/go around setting, commanding maximum available thrust. The captain also restored previously entered take-off data by pressing the appropriate line select key on one of the multi-purpose control and display units. As the take-of continued, auto-flight modes became active and the crew selected heading mode to manually command a left turn as planned. The flight to Melbourne then proceeded uneventfully.
The operator’s investigation into the incident identified issues relating to the consistency of their before take-off checklist with that published by the aircraft manufacturer, and the status of the FMGS software installed in the flight simulators used by the operator. In response to the incident, the operator implemented a number of initiatives, including alignment of the before take-off checklist with that published by the aircraft manufacturer, implementation of a revised crew briefing format, provision of relevant educational material to flight crew and implementation of a flight simulator software upgrade.
For operators, this incident highlights the need for robust checklists and checklist management procedures that effectively cater for a wide range of operational scenarios, the importance of ensuring that the performance of training equipment accurately reflects the performance of operational equipment, and the importance of consistently accurate FMGS aeronautical data. For flight crew, this incident serves to highlight the importance of careful attention to FMGS aeronautical data and highlights the need for extra caution following an interruption to the normal sequence of events during preparation for departure. The incident also reinforces the importance of Airbus ‘Golden Rules for Pilots’, particularly the first rule: Fly, navigate and communicate (in this order and with appropriate task sharing).
On 5 March 2014 at about 1044 Eastern Standard Time, an ATR 72 aircraft, registered VH-FVI (FVI), was about 25 NM southeast of Moranbah, Queensland on descent to the airport.
The captain of FVI broadcast on the common traffic advisory frequency (CTAF), advising that the aircraft was inbound and planned to conduct a non-directional beacon (NDB) approach, with an estimated arrival time of 1049 overhead the airport. At about 1047, the captain broadcast when 10 NM SE tracking NW to conduct an NDB A approach. At 1049, the captain broadcast tracking outbound in the approach and that they “should be turning straight in for a landing runway 16”.
At about 1050, following the report of a suspected birdstrike by the aircraft just landed, the aerodrome reporting officer (ARO) on duty was in the airport terminal when asked by airport ground staff to conduct a runway inspection. At about 1052 the ARO broadcast on the CTAF advising that the vehicle was preparing to enter the runway for a runway inspection. The ARO then conducted a thorough lookout for aircraft approaching and on the runway with no aircraft sighted. He then broadcast a call entering the runway and commenced driving north along the runway. When at the northern threshold, the vehicle turned and drove south along the runway.
The crew of FVI did not hear either broadcast from the ARO. At about 1055, when at about 20 ft above ground level (AGL), the captain looked up out of the cockpit along the runway and sighted the safety vehicle on the white runway aiming point markings near the far end of the runway. The captain immediately broadcast “car vacate”. The ARO immediately drove the vehicle off the runway and once clear, broadcast that the safety vehicle had now vacated all runways.
This incident highlights the importance of radio communications and the benefits of alerted see-and-avoid practices.
On 1 March 2014, Aquarosa was transiting the Indian Ocean en route to Fremantle, Western Australia, when its freefall lifeboat was inadvertently released during a routine inspection. A ship’s engineer, the only person in the lifeboat at the time, was seriously injured in the accident.
About 5 hours after its release, the ship’s crew recovered the lifeboat and resumed the voyage. On 8 March, the ship berthed in Kwinana, near Fremantle, and the injured engineer was transferred to hospital.
What the ATSB found
The ATSB found that when the lifeboat on-load release was last operated before the accident, it was not correctly reset. Consequently, when the engineer operated the manual release pump to inspect the equipment, the incorrectly-reset release tripped unexpectedly. The simulation wires, designed to hold the lifeboat during a simulated release, failed and the lifeboat launched.
The investigation found that although there was an indicator to show that the hook was in the correct position, there was nothing to indicate that the tripping mechanism was correctly reset. It was also found that the design and approval process for the lifeboat’s simulated release system had not taken into account effects of shock loading on the simulation wires.
What's been done as a result
Aquarosa’s shipboard procedures were revised shortly after the accident. Changes included the introduction of a requirement to notify the officer of the watch before entering the lifeboat. Notices were posted at the on-load release hydraulic pump positions, stating that the pumps must not be operated without the master’s permission.
Via a circular, Aquarosa’s managers, V.Ships, notified all ships in its fleet of the accident and its internal investigation findings. The circular also required the masters of all ships fitted with the same type of on-load release, to similarly revise the instructions for its operation and resetting. In addition, masters were required to review the simulation wire maintenance and inspection regime.
On 17 March 2014, the ATSB contacted V.Ships, the ship’s flag State (Malta), Bureau Veritas, the lifeboat manufacturer, the International Association of Classification Societies and the Australian Maritime Safety Authority (AMSA) and advised them of the ATSB’s preliminary findings. The parties were asked to identify ships equipped with similar freefall lifeboat arrangements and to advise operators of those ships to take safety action to prevent a similar accident.
In response, AMSA informed its surveyors of the accident and the ATSB’s preliminary findings, and asked them to pay particular attention to these issues during flag and Port State inspections.
Safety action by the manufacturer included placing alignment marks on the release segment of new on-load releases mechanisms, to indicate when they are correctly reset. A lock-out ‘maintenance pin’ is also being provided for all new on-load releases to ensure the release cannot trip while maintenance is being performed.
Safety message
When designing and certifying equipment such as on-load release systems for lifeboats, all facets of the equipment’s possible operation, use and environment must be taken into account and allowed for. Only then can fully comprehensive instructions be documented, enabling seafarers and others to safely use and maintain the equipment under all conditions.
Preliminary report
Report release date: 31/03/2014
Safety summary
The information contained in this preliminary report is derived from the initial investigation of the occurrence. Readers are cautioned that it is possible that new evidence may become available which alters the circumstances as depicted in the report.
What happened
On 1 March 2014, the 190 m Maltese registered bulk carrier Aquarosa was on a voyage from Singapore to Kwinana, Western Australia, when its freefall lifeboat was inadvertently released during a routine inspection.
A ship’s engineer, who was in the lifeboat at the time of its release, sustained serious injuries. The lifeboat was retrieved on board the ship about 5 hours after its release and the voyage to Kwinana was resumed.
What the ATSB found
The ATSB’s initial analysis of the incident indicates that the lifeboat release mechanism was not fully and correctly reset after it was last exercised and that the hook was released when the engineer topped up the release system hydraulic oil reservoir and manually operated the pump to pressurise the system.
Initial analysis also indicates that the two simulation wires, which were designed to hold the lifeboat when the hook was released during a simulated release, failed at a load significantly below their rated safe working load.
What's been done as a result
On 17 March 2014, the ATSB contacted Aquarosa’s managers, the lifeboat manufacturer, Bureau Veritas, the International Association of Classification Societies, the Malta Merchant Shipping Directorate and the Australian Maritime Safety Authority. These organisations were advised of the incident and the initial findings of the ATSB safety investigation. They were also urged to identify ships fitted with similar freefall lifeboats and to advise operators of those ships to take appropriate safety action to prevent similar accidents from occurring.
Investigation direction
The investigation is ongoing and will focus on determining how the lifeboat release mechanism could be reset incorrectly without an obvious visual indication and why the simulation wires failed.
On 4 March 2014, at about 0809 EST, a Piper Saratoga aircraft, registered VH-XKS (XKS) departed Mareeba Airport on a private flight to Normanton Airport, Queensland. The direct flight was planned under the visual flight rules and the pilot was the sole person on board.
The flight went normally until approaching Normanton. Approaching the 10 NM boundary, the pilot broadcast his intentions on the Normanton CTAF and realised the second radio, COMM 2 had failed. He was unable to get COMM 1 operational.
Due to being low on fuel, he had little time to trouble shoot any further, so joined the circuit at Normanton for runway 14. He continued to make broadcasts on the radio in the hope that it may still be transmitting.
At the same time, a Beech 200 King Air aircraft, registered VH-SBM (SBM) was completing a short leg of a charter flight from nearby Karumba. After obtaining the weather from the AWIS at Normanton, and broadcasting his intentions on the Normanton CTAF, he elected to conduct a straight in approach to runway 14.
As the King Air descended through 800 ft, the pilot noticed movement in his left periphery below him. The Saratoga was partly obscured by SBM/s engine nacelles and the colour merged into the swollen river below. The two aircraft were on converging tracks and about 50 m apart. The pilot of the King Air initiated a go-around and the pilot of the Saratoga, still unaware of the near collision landed on runway 14.
Pre-flight preparation is an essential part of safe flying operations. This incident highlights the importance of reviewing all available information appropriate to the intended operation, including having a thorough knowledge of aircraft systems.
On 26 February 2014 at about 1645 Central Standard Time (CST), a Beech 58 aircraft, registered VH-SBS, departed Darwin for Gove, Northern Territory, on a private ferry flight with a supervising pilot and pilot-in-command-under-supervision (ICUS) on board.
At about 1815, the crew detected fumes and smoke emanating from the left side circuit breaker panel. The pilot ICUS immediately switched off the electrical master switch. The supervising pilot seated in the right seat took control of the aircraft and commenced an immediate descent. The pilot ICUS retrieved the BCF extinguisher from underneath his seat and extinguished the fire.
The crew opened the vents and the fumes dissipated. To determine what electrics were available, the pilot selected the master switch on. The fire then reignited and he immediately selected the master switch off. The crew established that the most likely cause of the fire was an electrical malfunction, and opted to continue the remaining 40 NM to Gove aerodrome, where emergency services were available on the ground if required.
The crew observed that both suction indicators showed zero. They increased their lookout for other aircraft, cognisant that they were no longer able to maintain radio contact.
After joining downwind for runway 31, the crew briefly selected the master switch on and used the electric gear lever to lower the landing gear. They could smell fuel so the pilot conducted a closer circuit than normal and landed the aircraft. After parking the aircraft, the crew observed fuel dripping from beneath the aircraft fuselage.
An engineering inspection found that exhaust gas temperature (EGT) wiring had penetrated through the heater supply fuel line causing it to arc out and burn a hole in the fuel line.
This incident provides a valuable reminder for all pilots to know the location and operation of the aircraft fire extinguisher.
On 2 March 2014, at about 1300 Eastern Standard Time (EST), the pilot of a Robinson R44 helicopter, registered VH-YYS, prepared for a private flight from Mareeba, Queensland.
The helicopter lifted off and the pilot reported all engine indications were normal and the blades appeared to be tracking normally. During the translation from hover to forward flight, the helicopter yawed to the left. The pilot raised collective and rolled the throttle on and the helicopter then spun quickly about 90 degrees to the right. The pilot heard an increase in engine noise as a loud buzz. The helicopter then pitched up and down, and as he attempted to control it with the cyclic, the helicopter very quickly yawed about 180 degrees to the left. The helicopter rolled to the left and the pilot noticed the main rotor blades flapping.
The pilot eased the collective into the ground and as the helicopter touched down, it started to roll to the left. He moved the cyclic right, reduced the throttle and the helicopter rocked from side to side and then settled. During the event, the rotor blades contacted the tail boom resulting in substantial damage.
The investigation did not establish any mechanical, maintenance or training issues relevant to the investigation.
