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Updated: 3 May 2016

This report is in the final stages of completion following consideration of the comments from directly involved parties. It is anticipated that it will be released to the public in June 2016.

 

 

Updated: 25 November 2015

The draft investigation report is in the final stages of review by the ATSB Commission prior to it’s release to directly involved parties (DIP) for comment in December 2015. Feedback from those parties over the 28-day DIP period on the factual accuracy of the draft report will be considered for inclusion in the final report, which is anticipated to be released to the public in March 2016.

 

 

Updated: 22 May 2015

As part of its normal procedures, the ATSB has completed its initial review of the investigation and draft investigation report. Additional analysis is underway as a result of this review to further understand the implications for safety of the occurrence. Additional evidence has also been collected and work is underway to integrate relevant aspects of ATSB research investigation AR-2013-200 into the draft report. This will ensure a full understanding by readers of the reliability of Bureau of Meteorology meteorological products and the provision of this information to flight crew and operators.

The draft investigation report is now anticipated for release to directly involved parties (DIP) for comment in the third quarter of calendar year 2015. Feedback from those parties over the 28-day DIP period on the factual accuracy of the draft report will be considered for inclusion in the final report, which is anticipated to be released to the public early 2016.

 

 

Updated: 5 June 2014

As forecast in its interim factual report of 19 December 2013, the ATSB convened a safety forum on 31 March 2014 involving a number of industry participants. The forum identified a number of issues, most of which are pertinent to this occurrence and more widely across the aviation industry. These included:

  • differing levels of expectation in relation to the provision of amended meteorological products
  • inconsistencies in standard aviation reference documentation in relation to the use of meteorological products
  • differing levels of understanding and awareness of the availability of meteorological products, including limitations relating to automated weather broadcast systems
  • the effect of international obligations and restrictions on the provision to flight crews of updated weather information
  • limitations associated with the staged introduction of new technologies
  • the need for a coordinated education program to update and deconstruct many long held beliefs and misconceptions within the aviation industry.

The investigation is continuing, with the majority of the initial evidence collection complete. In addition to its analysis of this initial evidence, the ATSB is continuing to work with sections of the aviation industry to enhance its understanding of the issues that were identified at the safety forum and identify any safety issues. This additional work, and any implications for aviation safety, will be included the ATSB’s final investigation report, which is now expected to be released to the public in November 2014.

Should any significant safety issues emerge during the intervening period, the ATSB will immediately bring those issues to the attention of the relevant authorities or organisations and publish them as required.

 ______________________

The information contained in this web update is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this web update. As such, no analysis or findings are included in this update.

 

 
Download Interim Report
[ Download PDF: 1013KB]
 
 
 

Updated: 7 April 2014

The ATSB is continuing its investigation and further information is being obtained. A Safety Forum with directly involved parties (DIPs) was held on 31 March 2014. The final report is anticipated for release to DIPs for comment in May 2014. Feedback from those parties on the factual accuracy of the draft report over the DIP period will be considered for inclusion in the final report, which is anticipated to be released to the public in August 2014.


What happened

On the morning of 18 June 2013, a Boeing Company 737 (B737) aircraft, registered VH-YIR and operated by Virgin Australia Airlines Pty Ltd was conducting a scheduled passenger service from Brisbane, Queensland to Adelaide, South Australia. On board were 6 crew members and 85 passengers.
 
On the same morning, another B737 aircraft, registered VH-VYK and operated by Qantas Airways Limited, was conducting a scheduled passenger service from Sydney, New South Wales, to Adelaide. On board were 6 crew and 146 passengers.
 
Due to unforecast weather in Adelaide, both aircraft diverted to an alternate airport at Mildura, Victoria. This airport was also affected by unforecast fog and low cloud at the time of their arrival.

Safety action

As a result of its developing understanding of the occurrence, the ATSB has commenced the following safety action:
 
Safety forum regarding the provision of operational information
The ATSB is planning to convene a safety forum in respect of the provision of operational information to the flight crews in this occurrence, and more generally. This forum is planned to include representatives from the Civil Aviation Safety Authority, Airservices Australia, the Bureau of Meteorology, the operators of VH-YIR and VH-VYK, and other relevant parties.
 
Reliability of aviation weather forecasts
As a result of this and other occurrences involving observed but not forecast weather, the ATSB has commenced research investigation AR-2013-200 Reliability of aviation weather forecasts. This investigation will analyse Bureau of Meteorology data across Australian airports, with a focus on those supporting regular public transport operations, and is subject to the availability of long-term data holdings of aviation forecasts and observations.

The investigation is continuing and will:

  • examine the accuracy of aviation meteorological products in Australia
  • examine the procedures used to provide information to flight crews from air traffic services and management of  changes to those procedures
  • examine the provision by the operators of information to the respective flight crews
  • examine the relevant recorded data
  • review the distribution, dissemination and sharing of operational information to the aviation industry as stipulated by the Civil Aviation Safety Authority, and enacted by Airservices Australia and the Bureau of Meteorology.

The final report is anticipated for release to the public by June 2014.

 


The information contained in this Interim report is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the ongoing investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this Interim report. As such, no analysis or findings are included in this report.

Download Interim Report
[ Download PDF: 1013KB]
 
 
 
 
Download Preliminary Report
[ Download PDF: 1.42MB]
 
 
 

Preliminary report released 18 July 2013

On the morning of 18 June 2013, a Boeing 737 aircraft, registered VH-YIR and operated by Virgin Australia, was conducting a scheduled passenger service from Brisbane, Queensland to Adelaide, South Australia. On board were six crew members and 85 passengers.
 
On the same morning, another B737 aircraft, registered VH-VYK and operated by Qantas Airways, was conducting a scheduled passenger service from Sydney, New South Wales, to Adelaide. On board were six crew and 146 passengers.
 
Due to poor weather in Adelaide, both aircraft were forced to divert to an alternate airport (Mildura, Victoria). This airport was also affected by unforecast poor weather at the time of their arrival.
 
The ATSB’s ongoing investigation will examine the:

  • provision of information to flight crews from Air traffic services (ATS)
  • ATS policies and procedures affecting the flights
  • provision by the operators of information to the respective flight crews
  • the basis for the sequencing of the aircraft landings at Mildura
  • Bureau of Meteorology meteorological services and products as they applied to these flights
  • accuracy of aviation meteorological products in Australia.

The final report is anticipated for release to the public by June 2014.

_________

The information contained in this preliminary report is derived from the initial investigation of the occurrence. Readers are cautioned that there is the possibility that new evidence may become available that alters the circumstances as depicted in the report.

 


History

 

Updated: 2 July 2013

The ATSB is continuing its investigation into the circumstances surrounding the diversion of a B737 aircraft, registered VH-YIR (YIR) and operated by Virgin Australia, to Mildura, Victoria on 18 June 2013. The reduced visibility at Adelaide Airport, South Australia that led to the diversion also affected a number of other aircraft, including another B737. This aircraft, registered VH-VYK and operated by Qantas, was en route from Sydney, New South Wales to Adelaide before also diverting to Mildura.

As a result of its increased understanding of events, the ATSB has expanded the scope of its investigation to examine both of these diversions and their broader context. The investigation title has been amended to reflect this expanded investigation focus, which will include examination of the:

  • forecasting and distribution of weather information by the Bureau of Meteorology
  • provision of weather and operational information by Airservices Australia to all aircraft that were affected by the reduced visibility at Adelaide
  • provision of weather and operational information to those aircraft by the operators
  • influence on the flight crews’ decision making of that information flow.

A preliminary factual report into the circumstances of the occurrence is anticipated by 18 July 2013, and the final report is expected to be completed within 12 months.

 

_________

The information contained in this web update is released in accordance with section 25 of the Transport Safety Investigation Act 2003 and is derived from the initial investigation of the occurrence. Readers are cautioned that new evidence will become available as the investigation progresses that will enhance the ATSB's understanding of the accident as outlined in this web update. As such, no analysis or findings are included in this update.

 

 

 

 

Updated: 19 June 2013

At about 1015 EST on 18 June 2013 air traffic control advised the ATSB of a fuel related occurrence involving a Boeing 737-8FE (B737), registered VH-YIR, at Mildura Airport, Victoria. The aircraft, operated by Virgin Australia, was en route from Brisbane, Queensland, to Adelaide, South Australia, with five crew and 86 passengers on board when the crew diverted the aircraft to Mildura.

The aircraft had departed Brisbane at about 0630 that morning and carried sufficient fuel for the flight to Adelaide. On the basis of the weather forecasts at the time the aircraft departed Brisbane, there was no requirement to provide for an alternate airport to Adelaide. As the aircraft approached Adelaide, fog reduced the visibility at the airport to below the minimum required for landing. The crew diverted to Mildura and the aircraft landed safely at Mildura Airport at about 1010 following two instrument approaches.

The fog at Adelaide was not forecast when the aircraft left Brisbane. A number of other aircraft, in addition to the B737, returned to their departure airports or diverted to alternate airports as a result of the reduced visibility at Adelaide Airport.

The ATSB commenced an investigation at about 1100 on 18 June 2013 and the cockpit voice recorder and flight data recorder were removed from the aircraft and forwarded to the ATSB’s facilities in Canberra for download. The investigation is continuing and will involve:

  • examination of the recorded information
  • interviews with the flight crew of this and other affected aircraft
  • examination of the operator’s procedures
  • review of the relevant radio and radar data
  • examination of the relevant weather observations and forecasts.

It is anticipated that the investigation will be completed in March 2014.

Download Preliminary Report
[ Download PDF: 1.42MB]
 
 
 
 
General details
Date: 18 Jun 2013 Investigation status: Active 
Time: 10:15 EST Investigation type: Occurrence Investigation 
Location   (show map):Mildura Airport Occurrence type:Low fuel 
State: Victoria Occurrence class: Operational 
Release date: 05 Jun 2014 Occurrence category: Serious Incident 
Report status: Pending Highest injury level: None 
Expected completion: Jun 2016  
 
Aircraft 1 details
Aircraft manufacturer: The Boeing Company 
Aircraft model: 737 
Aircraft registration: VH-YIR 
Serial number: 39925 
Operator: Virgin Australia 
Type of operation: Air Transport High Capacity 
Sector: Jet 
Damage to aircraft: Nil 
Departure point:Brisbane, Qld
Destination:Adelaide, SA
Aircraft 2 details
Aircraft manufacturer: The Boeing Company 
Aircraft model: 737 
Aircraft registration: VH-VYK 
Serial number: 34183 
Operator: Qantas 
Type of operation: Air Transport High Capacity 
Sector: Jet 
Damage to aircraft: Nil 
Departure point:Sydney, NSW
Destination:Adelaide, SA
 
 
 
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Last update 03 May 2016