"ATSB"

Several safety actions have been made or are planned in response to a close proximity event that occurred between two 737 aircraft at Sydney Airport last year, an Australian Transport Safety Bureau final report details.

On 29 April 2023, a Qantas-operated Boeing 737 was lined up to take off from Sydney’s runway 16L, while a second Qantas 737 was on approach to land on the same runway.

The Australian Transport Safety Bureau (ATSB) has now released its final report detailing the event and the subsequent actions taken to enhance aviation safety protocols.

Incident Overview

On April 29, 2023, a potentially hazardous situation unfolded as a Qantas-operated Boeing 737-838 registered VH-VZM prepared for takeoff from Sydney’s runway 16L while another Qantas 737-838 registered VH-VZW was on final approach to land on the same runway.

Shortly after VH-VZM commenced the take-off roll, the aerodrome controller identified the spacing between the 2 aircraft had reduced to a distance that could result in compromised runway separation.

In response to the imminent risk, the controller instructed the approaching aircraft VH-VZW to initiate a go-around and discontinue its approach.

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However, amidst the high workload and a momentary delay caused by an inadvertent interjection, the crew of the second aircraft misinterpreted the controller’s directive.

This misinterpretation led them to maintain the runway heading instead of executing the prescribed left turn, resulting in a critical reduction in separation between the two aircraft.

During the missed approach, the separation between the 2 aircraft reduced to 0.8 NM (1.5 km) horizontally and 330 ft vertically as they climbed away from the runway.

Post-Incident Safety Measures

Following the incident, Airservices Australia, the air traffic services provider, initiated several safety enhancements in collaboration with the ATSB.

These measures aim to fortify the resilience of the aviation system and mitigate the likelihood of similar incidents in the future. Among the proposed actions outlined in the final report are:

Enhanced Analysis of Landing Runway Occupancy Times

Airservices Australia commits to conducting a thorough analysis of landing runway occupancy times at Sydney Airport and potentially other major airports.

This analysis will determine expected runway occupancy times under various aircraft types and operational conditions, facilitating better traffic management and coordination.

Implementation of Defensive Controlling Techniques

To bolster air traffic control procedures, defensive controlling techniques will be integrated to improve situational awareness and responsiveness during critical phases of flight, such as go-arounds.

These techniques will empower controllers to effectively manage traffic flow and maintain adequate separation between aircraft.

Assurance Review of Go-Around Scenarios

An assurance review of go-around procedures at Sydney Airport involving a second aircraft requiring controller intervention will be conducted.

This review aims to identify and address any deficiencies in existing protocols, ensuring swift and decisive actions in similar situations in the future.

Expansion of Compromised Separation Training

Night-time go-around scenarios will be incorporated into compromised separation training to prepare controllers and flight crews for challenging conditions during low visibility periods.

This expanded training regimen will enhance overall operational safety and preparedness in complex airspace environments.

A full copy of the ATSB final report can be accessed here.

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Recent events surrounding a hard landing incident involving a Virgin Australia 737 at Sydney Airport have prompted significant actions and introspection within the aviation industry.

Safety actions have been taken by the operator Virgin Australia and a type rating training provider following a hard landing involving a Boeing 737 in March this year, an Australian Transport Safety Bureau (ATSB) final report reveals.

The Landing Incident

On the morning of March 10, 2023, a Virgin Australia 737, with 179 passengers and 6 crew members, experienced a hard landing at Sydney Airport.

The aircraft involved was a Boeing 737-8FE, registered VH-YQR and operated by Virgin Australia as flight number VA916 on a scheduled air transport flight, operating from Brisbane, Queensland to Sydney, New South Wales.

Although the aircraft sustained no damage, and there were no reported injuries, the incident sparked a thorough investigation by the Australian Transport Safety Bureau (ATSB).

Root Causes Revealed

The ATSB’s final report unveiled critical details surrounding the incident. The first officer had flared the aircraft later than usual during the final approach, coupled with the throttle not being reduced to idle prior to the initial touchdown. This resulted resulting in the aircraft bouncing approximately 3 feet.

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During the bounce, the ground spoilers and speed brakes deployed, resulting in a hard landing of 2.96 G on the second touchdown. This effectively surpassing the defined threshold for hard landings.

Further investigation revealed that the international training provider contracted to Virgin Australia had been instructing pilots to flare the aircraft at a higher altitude than the manufacturer’s recommendation of approximately 20 feet.

This deviation from the manufacturer’s recommendation for the aircraft in question increased the risk of unstable and hard landings.

Insights into Training Practices

The first officer, relatively new to the aircraft type, had completed the type rating with the international training provider.

Despite awareness of the operator’s requirement for a flare at 20 ft, the first officer felt more comfortable with the originally trained altitude of 30 ft.

On the day of the incident at Sydney Airport, flying with a check captain led to a last-minute decision to follow the operator’s procedures, introducing unfamiliarity and uncertainty.

Proactive Measures Implemented

In response to the incident, the training provider and Virgin Australia have taken significant steps to prevent similar occurrences in the future.

The training provider conducted a thorough risk assessment in pilot training, reviewing and amending all relevant courseware.

Virgin Australia, on its part, reviewed all hard landing events since 2017 to identify common trends, increased oversight on external type rating providers, added more simulator sessions to the training regime, and conducted an independent review of its checking and training department.

Summary

The incident underscores the importance of aligning external training providers with the operator’s flight procedures.

The operator has completed the following safety actions:

• reviewed hard landing events from 2017 to identify any commonalities or trends in the events
• increased oversight and focus with the external type rating providers and the Training and Standards team to ensure alignment of training with standard operating procedures
• added Zero Flight Time (ZFT) advanced simulator sessions into the operator’s conversion course (OCC) program (the ZFT occurs approximately halfway through the line training to reconfirm the take-off and landing techniques while also being able to introduce more challenging conditions)

The ATSB found that the training provider, contracted by the operator to conduct Boeing 737 conversion training, was training pilots to initiate the flare at 30 ft; however the flight crew training manual required that the aircraft be flared at approximately 20 ft.

This variation increased the risk of unstable and/or hard landings. A full copy of the ATSB Report can be accessed here.

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The Australian Transport Safety Bureau (ATSB) is investigating a flight below minimum altitude involving a Batik Air Boeing 737-800 arriving at Canberra Airport.

The aircraft, registered PK-LDK, was about 19 km south of Canberra Airport, Australian Capital Territory, when the incident occurred on 14 June 2024.

Batik Air ID6015 Denpasar-Canberra

The aircraft was operated by Batik Air as flight ID6015, scheduled from Denpasar, Indonesia to Canberra.

During an instrument landing system approach into Canberra, the crew elected to hold at the waypoint MOMBI. During the holding phase, the aircraft was then operated below the minimum holding altitude.

Minimum Safe Altitude (MSA)

The minimum safe altitude (MSA) is the lowest level at which an aircraft can safely operate considering the terrain, obstacles, and potential emergencies.

It provides a buffer zone in case of engine failure or other issues, allowing the pilot to perform a safe emergency landing without hitting obstacles.

Flight Details

Flight data shows that Batik Air flight ID6015 had made a delayed departure out of Bali Denpasar airport (DPS) on 14 June.

The flight made an actual time of departure of 2231 local time, against the scheduled departure time of 2110 local.

The flight then proceeded normally, claiming to flight level FL350 (35,000 feet) for the southerly route to Australia.

Descent and arrival procedures were conducted normally, and the aircraft entered the standard holding pattern to the south of the airport prior to making an instrument approach.

During the holding procedure, flight data indicates the aircraft descended to approximately 4500 feet.

The aircraft conducting the ID6015 service from Denpasar was a Boeing 737-800, registered PK-LDK. This is an 8.7 year old narrowbody aircraft belonging to the carrier Batik Air.

The Australian safety body ATSB will now investigate the incident.

The evidence collection phase of the investigation will involve a series of steps. These include interviewing involved parties, retrieving and reviewing recorded data, and the collection of other relevant information.

A final report will be released at the conclusion of the investigation. Should a critical safety issue be identified during the investigation, the ATSB will immediately notify relevant parties. This will permit appropriate safety action to be taken.

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Flight path design should minimise the potential for conflict and the need for interventions, an Australian Transport Safety Bureau (ATSB) investigation into a close proximity event at Sydney Airport highlights.

The ATSB investigation report details that in the early evening of 5 August 2019, a Qantas Boeing 737 was on approach to land on Sydney Airport’s runway 34 right, while a Qantas A330 was awaiting a clearance to line up and take off from the same runway.

The Near Miss at Sydney Airport

On the evening of August 5, 2019, two Qantas aircraft, a Boeing 737 and an A330, found themselves on a collision course at Sydney Airport.

The 737 was approaching to land on runway 34 right, while the A330 was awaiting clearance for takeoff on the same runway. The situation was further complicated by a Dash 8 that had just landed and vacated the runway.

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The Controller’s Decision

In the Sydney air traffic control tower, an aerodrome controller, still under training, was supervising this intricate operation.

Initially, the A330 was given clearance for an immediate takeoff. However, as the controller assessed the situation, concerns about insufficient runway separation arose. To avert disaster, the 737 was instructed to initiate a go-around.

A Critical Turn

The 737 complied and began climbing on the runway heading but failed to make the required right turn when passing 600 feet as per the missed approach procedure.

About 10 seconds later, the controller issued the correct turn command. Meanwhile, the A330, as instructed, followed the standard instrument departure track by making a right turn shortly after takeoff.

A Close Call

As both aircraft turned right and climbed, their flight paths began to converge. The onboard Traffic Collision Advisory System (TCAS) on the A330 alerted the flight crew about the approaching 737.

The first officer of the A330 spotted the 737 climbing behind and to the right, with separation reduced to just 800 meters laterally and 150 meters vertically.

Thankfully, the controllers maintained visual contact with both aircraft throughout the sequence, and a collision was narrowly avoided. ATSB Chief Commissioner Angus Mitchell emphasized, “The risk of a collision was low.”

The ATSB’s investigation uncovered that this close proximity incident was not caused by a single error but rather a series of events. Individually, these events might have been minor concerns, but combined, they escalated into a serious incident. The series of events included:

1. Reduced spacing between arriving aircraft without proper coordination.
2. The 737’s speed during the final approach exceeding allowable limits without informing the controller.
3. The controller and instructor’s mental models not fully accounting for the 737’s delayed turn, leading to an erroneous expectation of greater separation between the A330 and the 737.
4. The absence of safety alerts or avoiding action advice to both flight crews to increase their situational awareness.
5. The controller’s failure to modify the A330’s flight path to increase distance between the aircraft.
6. The instructor’s failure to provide effective prompts or intervene, as the trainee controller was expected to work without intervention.

Identifying Safety Issues

The ATSB identified several safety issues related to procedures, controller training, and operational risk assessments.

One key safety issue was the need for controller intervention when aircraft departed from low altitudes and at night. The existing procedures at Sydney Airport did not adequately address such scenarios.

Responses to Investigation

In response to the investigation, Airservices made crucial changes to enhance safety:

The missed approach procedure for Sydney Airport’s runway 34 right was redesigned to improve separation with other departing aircraft.

The Sydney tower controller instructor guide now includes compromised separation scenarios involving low-altitude aircraft at night.

The training program also includes a missed approach with a preceding departure in instrument meteorological conditions.

Qantas, too, took proactive steps to prevent a recurrence. They updated the missed approach coding in their 737 flight management computers, and incorporated related scenarios into cyclic training sessions.

The airline also improved its flight data analysis program to closely monitor approach speeds and traffic collision avoidance system data.

The ATSB Final Report into the near miss incident can be accessed here.

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