[Peetwo]

Has been a bit quiet on here of late, however with a couple of significant heavy tin investigation final reports being released by the ATSB, & causing much discussion in various forums,...

Examples from PT -  Virgin Australia gets wake up call over botched Melbourne 777 approach   or; Qantas acts over too low approach by A330 to Melbourne

...I thought now might be a good opportunity to liven things up...

So here are the links for the 2 completed ATSB investigations currently under discussion:

Investigation number: AO-2013-047

Investigation status: Completed
 

• Summary
  
• Photo
  
• Safety Issue
  

Download final report
[PDF: 1.69MB]
  
Alternate: [DOCX: 1.47MB] 

[*]Investigation number: AO-2013-130

Investigation status: Completed
 

• Summary
  
• Photos
  
• Safety Issue
  

[*]
Download final report
[PDF: 1.7MB]
 
 Alternate: [DOCX: 1.32MB]

[*]
The Qantas A330 incident was opened up to discussion in the P7 thread - ATSB - Qantas Melbourne. However with the release yesterday of the ATSB Virgin YMML incident final report -  even though very much related - the discussion has diverged slightly away from the analysis of the actual ATSB final reports.

So here is where we ended up when looking at the probable causal chain (contributory factors) in regards to the breakdown of situational awareness in the Qantas A330 incident:

...Okay now a bit of historical relevance and in the aftermath of the Lockhart River tragedy the ATSB of old took on-board some of the findings from their investigation and decided to conduct a research project that was coupled with a survey of 748 GA IFR pilots endorsed on the RNAV (GNSS) approach.

Here is the abstract of that report, from that man again Dr Stuart Godley:

Abstract

Area navigation global navigation satellite system (RNAV (GNSS)) approaches have been used in Australia since 1998 and have now become a common non-precision approach. Since their inception, however, there has been minimal research of pilot performance during normal operations outside of the high capacity airline environment. Three thousand five hundred Australian pilots with an RNAV (GNSS) endorsement were mailed a questionnaire asking them to rate their perceived workload, situational awareness, chart interpretability, and safety on a number of different approach types. Further questions asked pilots to outline the specific aspects of the RNAV (GNSS) approach that affected these assessments. Responses were received from 748 pilots, and answers were analysed based on the aircraft performance category1. For pilots operating Category A and Category B aircraft (predominantly single and twin-engine propeller aircraft), the RNAV (GNSS) approach resulted in the highest perceived pilot workload (mental and perceptual workload, physical workload, and time pressure), more common losses of situational awareness, and the lowest perceived safety compared with all other approaches evaluated, apart from the NDB approach. For pilots operating Category C aircraft (predominantly high capacity jet airliners), the RNAV (GNSS) approach only presented higher perceived pilot workload and less perceived safety than the precision ILS approach and visual day approach but lower workload and higher safety than the other approaches evaluated. The different aircraft category responses were likely to have been due to high capacity aircraft having advanced automation capabilities and operating mostly in controlled airspace. The concern most respondents had regarding the design of RNAV (GNSS) approaches was that they did not use references for distance to the missed approach point on the approach chart and cockpit displays. Other problems raised were short and irregular segment distances and multiple minimum segment altitude steps, that the RNAV (GNSS) approach chart was the most difficult chart to interpret, and that five letter long waypoint names differing only by the last letter can easily be misread.

   
Now if you cut to the business end of the Godley report you will see that their was several Safety Recommendations that were promulgated due to the findings of that report:

7.4 Recommendations

Recommendation R20060019

Safety issue: RNAV (GNSS) approach pilot workload and situational awareness
Pilot workload was perceived as being higher, and reported losses of situational
awareness were reported as more common, for the area navigation global navigation
satellite system (RNAV (GNSS)) approach than all other approaches except the nondirectional beacon (NDB) approach, which involved similar workload and situational
awareness levels.

This was especially a concern for pilots operating Category A and Category B
aircraft. Further research into pilot workload and losses of situational awareness
associated with RNAV (GNSS) approaches is warranted.

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety
Authority address this safety issue.

Recommendation R20060020

Safety issue: RNAV (GNSS) approach chart design and interpretability
The most common concern identified by respondents about the design of RNAV
(GNSS) approaches was that the charts did not use references for distance to the
missed approach point throughout the approach on the global positioning system
(GPS) or flight management system (FMS) displays, and distance references on the
approach charts were inadequate. Approach chart interpretability was assessed as
more difficult for the RNAV (GNSS) approach than all other approaches by
respondents from all aircraft performance categories. Respondents considered that
the information presented on RNAV (GNSS) approach charts, including distance
information, may not be presented in the most usable way, and consequently may
lead to loss of situational awareness.

The Australian Transport Safety Bureau recommends that Airservices Australia
address this safety issue.

Recommendation R20060021

Safety issue: Sub-optimal RNAV (GNSS) approach design
The 21.5% of Australian area navigation global navigation satellite system (RNAV
(GNSS)) approaches deviates from the optimum design parameters (short and
irregular segments less than 5 NM and/or multiple steps within segments, and/or
multiple minimum segment altitude steps) particularly approaches in the vicinity of
high terrain. This was identified as a major concern by many pilots. A review to
determine whether designs closer to the optimum approach profile could be
developed, within the ICAO Pans-Ops limitations, was considered appropriate.

The Australian Transport Safety Bureau recommends that Airservices Australia
address this safety issue.

Recommendation R20060022

Safety issue: RNAV (GNSS) approach chart waypoint naming convention
The naming convention of using five capital letters for waypoint names, with only
the final letter differing to identify each segment of the approach, was reported to
cause clutter on the charts and GPS and FMS displays, and also increase the chance
of a pilot misinterpreting a waypoint. This can lead to a loss of situational awareness.
With the growing body of international experience using RNAV (GNSS) approaches,
it may be timely to review the naming convention.

The Australian Transport Safety Bureau recommends that Airservices Australia
address this safety issue.

Recommendation R20060023

Safety issue: RNAV (GNSS) approach late notice of air traffic control clearance
Late notice of clearance by air traffic control to conduct an RNAV (GNSS) approach
was identified as the most common difficult external condition affecting an RNAV
(GNSS) approach, particularly for high capacity airline pilots. An examination of
opportunities to improve training and/or procedures for air traffic controllers to help
ensure timely approach clearances is warranted.

The Australian Transport Safety Bureau recommends that Airservices Australia, in
conjunction with the Civil Aviation Safety Authority, address this safety issue.

Recommendation R20060024

Safety issue: RNAV (GNSS) approach late notice of air traffic control clearance
Late notice of clearance by air traffic control to conduct an RNAV (GNSS) approach
was identified as the most common difficult external condition affecting an RNAV
(GNSS) approach, particularly for high capacity airline pilots. An examination of
opportunities to improve training and/or procedures for pilots to help ensure timely
approach clearances is warranted.

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety
Authority, in conjunction with Airservices Australia, address this safety issue.

If you follow the SR links provided and read the responses etc. ; you can make up your own mind on the following questions.

 Q1) Were the Safety Recommendations proactively acted on?; & if so Q2) were the identified significant safety issues appropriately risk mitigated?

Now at no time do I suggest that the design, of either the STAR or the RNAV (GNSS approaches) is the primary cause for the breakdown of SA in any of these incidents/accidents. However I do believe there is a common theme here, that coupled with other factors like pilot fatigue, breakdown of CRM etc. could be one of the holes in Reason's Swiss cheese model.  

[*]{Comment: One of the points of contention with the two reports yesterday - which IMO also goes to probity - was Ben Sandilands discovery that the Virgin Investigation was not classified as 'serious' whereas the Qantas investigation was?? See here -  ATSB tweets that Qantas Melbourne incident was an accident that nearly happened }

[*]Ok finally here is an extremely relevant comment from the Ferryman posted this AM on the PT blog:

[*] Sam Jackson
Posted July 16, 2015 at 9:13 am | Permalink

777 Steve – agreed, but there’s more, much more which could be added to all the incidents, those which have been glossed and polished to a fare-thee-well. The ‘system’ is collapsing around our ears. Perhaps someone could fetch DPM Truss a fiddle to play while Rome burns. That would at least entertain us.

NZGhost, the CVR data is not really available; not without a gabfest and hoops; a transcript may be provided in the final report, sometime in the future. Any and all of these increasing incidents could, with very trouble or expense be simulated. It’s pretty routine to revisit (time permitting) an incident scenario; most instructive. The tape I would most like you to hear is any one night’s peak hour approach control radio traffic for Tulla; it’s not for the feint hearted.

But we must be thankful for small mercies; at least the Essendon- Tulla comms link was working, I’d hate to think what may have happened, if the VA low pass event transpired during another three hour ‘breakdown’ of service. No worries we’ll always have the “poster’ depicting the ASA vision splendid; all we now need is courage badges, for all.

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Much MTF..P2