Boeing Co 767-238, VH-EAL

1. An intense thunderstorm developed in a short time-frame ahead
   of the main line of thunderstorms, producing heavy rain, hail and
   windshear, which the aircraft encountered shortly after
   take-off.
2. Air traffic control and Bureau of Meteorology staff did not
   mutually exchange information regarding the thunderstorm as it
   developed and approached Coolangatta aerodrome.
3. Coolangatta Air Traffic Services staff did not ensure that the
   crew were aware of the changed weather conditions and the new
   Automatic Terminal Information Service broadcast advising that
   thunderstorms were in the area.
4. The crew did not have a complete and timely picture of a
   hazardous and rapidly deteriorating meteorological situation from
   which to make an accurate assessment of that situation.

2.1 Introduction

The occurrence involving EAL involved a number of issues
including the limitations of airborne weather radar, the mutual
exchange of information between BoM and air traffic control, and
provision of information to the B767 crew. Further, the occurrence
involving EAL displayed a number of similarities with a Boeing 737
microburst encounter at Brisbane Airport on 18 January 2001.

2.2 The aircraft

2.2.1 Aircraft weather radar

The aircraft weather radar did not have the capability to
provide predictive forward-looking windshear detection and
avoidance information to the crew, nor was there a requirement for
it to do so. That capability would have provided an early alert to
the crew about the hazardous conditions that existed ahead of the
aircraft and may have assisted them to avoid or minimise those
hazards.

The presence of red or magenta on the aircraft weather radar
display is a measure of rainfall intensity. The crew reported areas
of red on the display, with no hooks, fingers, contours, scalloped
edges or U-shaped returns that could have indicated the presence of
hail or other adverse weather conditions. In addition, they
reported that they assessed the areas of red on the weather radar
display as heavy rain only. The crew could see heavy rain
approaching the aerodrome, but were not aware of any associated
adverse weather conditions, such as thunderstorm activity and hail.
In the absence of any indications of adverse weather from either
the aircraft weather radar or ATS, they would have been unaware of
the presence of adverse weather conditions in the takeoff flight
path.

2.2.2 Aircraft flight path

The crew reported that they increased thrust in accordance with
the operator's published windshear escape manoeuvre. However,
recorded FDR data indicated that, throughout the windshear
encounter, both EPR and thrust lever angle (TLA) remained in the
take-off position until climb thrust was set when clear of the
encounter. The investigation was unable to resolve the
discrepancy.

2.2.3 Other aircraft movements

A number of other aircraft movements into and out of Coolangatta
Airport occurred in the short time before EAL took off. None of
those aircraft reported encountering adverse weather, including the
Boeing 737 that took off from runway 32 about 15 minutes before EAL
was issued clearance to takeoff from the same runway. The absence
of any reports of adverse weather encounters likely contributed to
the crew of EAL assessing that the weather conditions that they
could see visually, and which were displayed on the aircraft
weather radar, consisted of heavy rain only.

2.3 Organisational issues

2.3.1 Bureau of Meteorology

The BoM reported that the thunderstorm encountered by EAL
developed in a short time-frame ahead of the main line of
thunderstorms. Forecasters became aware of the severity of the
thunderstorm 9 minutes before EAL was cleared to take-off. Despite
observing the storm cell move towards and pass over Coolangatta
aerodrome, forecasters did not contact Coolangatta ATS to advise of
the approaching hazardous weather.

2.3.2 Air Traffic Services

ATIS Echo was current until 1337:41. ATIS Foxtrot was issued at
1338:22. The crew requested taxi clearance, notifying receipt of
ATIS Echo, 45 seconds after ATIS Foxtrot was issued. Accordingly,
the crew had not been advised that thunderstorms were present
within 5 NM of Coolangatta Airport.

The SMC controller did not inform the crew that the ATIS had
changed and did not advise the crew of the change in weather
conditions. Accordingly, an opportunity was missed to provide the
crew with updated information of the prevailing meteorological
conditions at the time that the aircraft was intending to
take-off.

Coolangatta ATS controllers could see that the thunderstorm was
approaching and that weather conditions were deteriorating,
however, they did not contact BoM staff to ascertain the severity
of the approaching weather. Consequently, neither BoM nor
Coolangatta controllers had a complete picture of the deteriorating
meteorological situation. In turn, the crew of EAL was not provided
with a complete picture of the meteorological situation in the
vicinity of Coolangatta Airport and their intended departure flight
path.

Coolangatta ATS reported that they had access to the BoM
PC-based METRAD/RAPIC display. Controllers were aware that
information depicted on those displays could be up to 10 minutes
behind actual time. Due to the rapid development of the
thunderstorm cell encountered by EAL, the investigation was unable
to confirm if the METRAD/RAPIC display would have been able to
provide Coolangatta controllers with sufficient information to
advise the crew of EAL of approaching hazardous weather.

2.4 Previous occurrence

The occurrence involving EAL displayed a number of similarities
to a Boeing 737 microburst encounter that occurred at Brisbane
Airport on 18 January 2001. The circumstances of the occurrence
involving EAL indicate that the ATSB recommendations published in
ATSB investigation report BO/200100213 remain valid.

1.1 History of the flight

1.1.1 Overview

On 26 October 2003, at about 1346 Eastern Standard Time, a
Boeing 767-238 aircraft, registered VH-EAL, with two pilots, seven
cabin crew and 207 passengers, took off from Coolangatta Airport,
Queensland, on a scheduled regular public transport service to
Sydney, NSW. The aircraft had arrived at Coolangatta earlier that
day, having flown the first sector from Sydney to Coolangatta.
Shortly after takeoff, passing through an altitude of about 800 ft,
the aircraft encountered heavy rain, hail and windshear. The crew
reported that they increased thrust in accordance with the
operator's published windshear escape manoeuvre. During the
windshear encounter, the aircraft descended about 130 ft and a
ground proximity warning system (GPWS) Mode 3 aural alert 'DON'T
SINK' sounded.

During the subsequent climb, the cabin crew reported to the
flight crew that there was damage, in the form of dents, to the
leading edges of the wings. After diverting out to sea around the
weather, the flight continued to Sydney. The crew configured the
aircraft early in the approach to Sydney, in the event of flap and
leading edge device extension difficulties due to the damage,
however an uneventful landing was conducted.

1.1.2 Sequence of events

1.2 Injuries to persons

No injuries to persons were reported.

1.3 Damage to aircraft

A post-flight technical examination revealed substantial damage
to the leading edge slats, leading edge wedge panels, horizontal
stabiliser, vertical stabiliser, radome, fuselage area above the
pilots' windows, nose-cowls of both engines and fan blades on both
engines (see Figures 1 and 2).

1.4 Other damage

Nil.

1.5 Personnel information

1.5.1 Pilot in command

Type of licence: Air Transport Pilot (Aeroplane) Licence

Medical certificate: Class 1

Flying experience (total hours): 11,126

Hours on the type: 5,156

Hours in the preceding 30 days: 47

1.5.2 Copilot

Type of licence: Air Transport Pilot (Aeroplane) Licence

Medical certificate: Class 1

Flying experience (total hours): 3,614

Hours on the type: 924

Hours in the preceding 30 days: 52

Both pilots last completed windshear training as part of the
operator's recurrent training matrix during the period December
2002 to January 2003.

1.6 Aircraft information

Manufacturer: Boeing Commercial Airplane Group

Model: 767-238

Serial number: 23306

Registration: VH-EAL

1.6.1 Aircraft weather radar information

The aircraft was fitted with a Collins WXR-700X weather radar
system, which did not include a windshear warning or a predictive
windshear warning function. The weather radar display was
superimposed on the aircraft navigation displays and indicated
rainfall intensity in different colours, with green depicting light
precipitation, yellow medium precipitation and red or magenta heavy
precipitation. The radar manufacturer's documentation stated that
red was equivalent to a rainfall rate of 12.7 to 50.8 mm per hour,
indicating a storm category of 'strong to very strong'.

Specific guidance on the use of the weather radar was provided
to crews in the operator's Flying Manual and a training CD-ROM. A
document was also provided to crews on the operator's intranet
site. Use of the weather radar was covered as part of the
operator's recurrent training matrix.

The crew reported that the weather radar was set according to
the operator's requirements for takeoff. During taxi, and the time
taken to negotiate a departure heading with ATS, the crew scanned
the weather ahead of the aircraft flight path. They reported areas
of red on the display, with no hooks, fingers, contours, scalloped
edges or U-shaped returns that could have indicated the presence of
hail. They reported that they consequently assessed the areas of
red on the weather radar display as heavy rain only.

1.7 Meteorological information

1.7.1 Prevailing weather conditions during the afternoon
of the occurrence

An intense surface trough was moving across the south-east
inland of Queensland, towards the south-east corner and was
forecast to move off the south coast by about 1800 to 1900. The
atmosphere was very unstable ahead of the trough and scattered to
widespread showers and thunderstorms were forecast from about 1400.
Computer model output and morning temperature and moisture
profiles, obtained from weather balloon flights, indicated very
favourable conditions for the development of thunderstorms, and the
possibility of associated severe weather phenomena.

During the afternoon, the BoM issued a number of amended
forecasts and warnings including area forecasts (ARFORs), TAFs and
Airport Warnings for Coolangatta. Those forecasts included
reference to thunderstorm activity expected to affect Coolangatta
aerodrome after 1400. The Airport Warning for Coolangatta, issued
at 1250, indicated that the thunderstorms may produce strong wind
gusts and large hail. A SIGMET for the Brisbane Flight Information
Region, valid from 1300 to 1900, was issued to warn of a line of
active thunderstorms from Dalby to Stanthorpe moving east at 30
kts.

The aircraft operator provided the crew with a meteorological
briefing package prior to departure from Sydney. In addition, the
crew reported discussing the meteorological situation with the BoM
meteorologist, positioned in the operator's flight dispatch
organisation, prior to departure from Sydney. Further, they were
aware of the line of storms to the west and south-west of
Coolangatta, having negotiated past them during the first sector
from Sydney to Coolangatta. During the turn-around at Coolangatta,
the crew updated the Sydney TAF using the aircraft communications
addressing and reporting system (ACARS) and obtained Coolangatta
ATIS Echo.

The operator reported that the meteorologist was aware of the
development of the thunderstorm in the vicinity of Coolangatta
Airport, from the weather radar monitor located in the operator's
flight dispatch area. That information was passed to the operator's
port staff at Coolangatta, however, it was not passed to the crew
of EAL, as the operator did not have a procedure for disseminating
such information to crews once they had commenced taxiing.

1.7.2 Bureau of Meteorology - weather radar

The BoM received three-dimensional radar data for the Brisbane
to Coolangatta area from weather radars located at Brisbane Airport
and Marburg. The Marburg radar was situated on the Little Liverpool
Range between Marburg and Rosewood about 50 km west of
Brisbane.

The BoM reported that forecasters first became aware of the
severe nature of the thunderstorm involved in the occurrence at
about 1336. It continued to intensify and quickly moved to the
Coolangatta area, passing over Coolangatta Airport between about
1340 and 1349. EAL was issued a takeoff clearance at about 1345.
Images of the thunderstorm passing over Coolangatta at 1340 and
1350, including the aircraft flight path from takeoff to 10,000 ft,
are depicted at Figures 3 and 4 respectively.

Two-dimensional images from BoM's weather radars were displayed
at various air traffic control working positions by means of a
PC-based system known within Airservices Australia as METRAD
(Meteorological RADar) and within the military as RAPIC (RAdar
PICture). The use of METRAD/RAPIC by Air Traffic Services (ATS)
controllers is described at paragraph 1.17.1.

1.8 Aids to navigation

Not a factor in this occurrence.

1.9 Communications

All communications between ATS and the crew were recorded by
ground based automatic voice recording equipment for the duration
of the occurrence. The quality of the aircraft's recorded
transmissions was good.

An ATIS broadcast provided advice of conditions pertaining to
the operation of aircraft within 5 NM of the respective aerodrome
reference point. Coolangatta ATIS Echo was current until 1337:41.
ATIS Echo included runway 32 (active runway), wind from 350 degrees
at 22 kts, crosswind maximum 15 kts, visibility greater than 10 km
and three to four eighths of cloud at 2,500 ft.

At 1338:22 ATIS Foxtrot was issued. It included information to
expect a VOR/DME approach, runway 32 wet, wind at 350 degrees at 20
kts, crosswind maximum 15 kts, visibility reducing to 5,000 m in
rain and thunderstorms, five to seven eighths of cloud at 2,500 ft
and one to two eighths of cloud at 1,500 ft.

At 1339:07, 45 seconds after ATIS Foxtrot was issued, the crew
requested taxi clearance and advised having received ATIS Echo. The
SMC controller did not advise the crew of the changed ATIS or
provide them with the changed conditions.

1.10 Aerodrome information

Runway 32 at Coolangatta was sealed and level. It was 2,042 m
long, 45 m wide and aligned on a magnetic heading of 319
degrees.

1.11 Flight recorders

The aircraft was equipped with a Honeywell solid state flight
data recorder (FDR). The FDR data indicated that EAL encountered
windshear at about 800 ft above ground level. The encounter lasted
about 30 seconds and included an 11-second period where the
aircraft descended, resulting in a total altitude loss of about 130
ft. The pitch attitude changed from about 20 degrees nose up to 6
degrees nose up during this period. A GPWS Mode 3 aural alert
'DON'T SINK' was recorded for 4 seconds. Take-off thrust was
de-rated giving an engine pressure ratio (EPR) of 1.39 and the
power setting did not vary during the event. The de-rate is
equivalent to a thrust reduction of 9 per cent.

The recorded FDR data indicated that, throughout the windshear
encounter, both EPR and thrust lever angle (TLA) remained in the
take-off position until climb thrust was set when clear of the
encounter.

Recorded FDR data, indicating aircraft pitch attitude and GPWS
Mode 3 alert, is depicted at Appendix 1.

1.12 Wreckage information

Not a factor in this occurrence.

1.13 Medical information

The crew reported no physiological or medical condition that
could have impaired their performance.

1.14 Fire

Nil.

1.15 Survival aspects

Not a factor in this occurrence.

1.16 Tests and research

Nil.

1.17 Organisational information

1.17.1 Air Traffic Services information

The manual of air traffic services (MATS) was a joint document
of Airservices Australia and the Department of Defence. The manual
was based on rules published by both those organisations and the
Civil Aviation Safety Authority (CASA). Section 5.1.7 of MATS
permitted ATS controllers to use the BoM PC-based METRAD/RAPIC
two-dimensional weather radar displays, in conjunction with
information obtained from other sources, to provide as much
information that was available to crews on hazardous weather
avoidance. Those displays, which were also available to the general
public, were updated every 10 minutes and therefore, could have
been up to 10 minutes behind the actual time. Coolangatta ATS
reported that they had access to METRAD/RAPIC. ATS did not offer,
nor did the crew request, weather information accessed from the
METRAD/RAPIC display.

1.18 Additional information

1.18.1 Aircraft flight path information

After encountering the adverse weather, the crew reported that
they stopped the cleared turn and attempted to divert around the
conditions being experienced. ATS radar data indicated that the
aircraft continued on easterly headings to about 70 NM east of the
coast, before turning south towards Sydney. The crew was unable to
regain the cleared flight-planned route.

1.18.2 Other aircraft movements

There were a number of other aircraft movements into and out of
Coolangatta aerodrome preceding the occurrence flight. A Boeing 767
landed on runway 32 at 1328, a Boeing 737 took off from runway 32
at about 1330, a CT4 landed on runway 35 at about 1335 and a B200
Super King Air landed on runway 35 at about 1340. The landing
aircraft had approached Coolangatta from the south. No reports of
thunderstorm activity, heavy rain, hail or windshear were received
from any of those aircraft, except to say that the line of storms
was approaching from the west and south-west.

1.18.3 Previous similar occurrence

The occurrence involving EAL displayed a number of similarities
to a Boeing 737 microburst encounter that occurred at Brisbane
aerodrome on 18 January 2001 (see ATSB investigation report
BO/200100213). As a result of that occurrence, the ATSB issued a
number of safety recommendations to Airservices Australia, BoM and
CASA. Those recommendations included, but were not limited to:

• a review of air traffic controller initial and recurrent
  training programs to ensure they adequately addressed the effect of
  convective weather on aircraft performance and the limitations of
  airborne weather radar
• expediting the introduction of an integrated weather radar/air
  traffic control radar video display system capable of providing
  multiple weather echo intensity discrimination without degradation
  of air traffic control radar information
• an increased emphasis in air traffic controller training
  programs to ensure that all appropriate sources of information,
  such as meteorological forecasts, controller observations, radar
  information, and pilot reports are provided to flight crews
• development of a standard scale of thunderstorm intensity for
  use within the aviation industry
• BoM meteorologists to act as focal points for liaison with air
  traffic control units.
• As a result of the occurrence and safety recommendations, the
  following safety actions were implemented:
• Airservices Australia produced a hazardous weather training
  program for its air traffic controllers
• with the assistance of BoM and the radar manufacturer, the
  operator produced a CD-ROM based weather radar training program for
  issue to its crews
• the operator included information regarding operation of the
  weather radar and flight in heavy rain in its Flying Manual
• BoM integrated a qualified meteorologist into the operator's
  flight dispatch organisation.

1.19 New investigation techniques

Not relevant in this occurrence.