Moorabbin Airport Midair Collision between UPY and CGT Aircrafts on 27th August 2008 - Case Study Example

Aviation Accident Moorabin Airport midair collision between UPY and CGT Aircrafts on 27th August 2008. Name Institution Name Instructor’s Name Course Name and Code Date Abstract This report provides an extensive analysis of the mid air collision between the UPY and CGT occurred on 27 August, 2008 3km away North-West of Moorabin Aerodrome, Victoria. The cause of this aviation accident was mainly due to human factors including poor situational awareness of the solo pilot in the UPY aircraft, work overload of the air traffic controller, lack of situational awareness of student pilots bin either aircraft, poor visual acquisition, and poor separation of traffic flows at the aerodrome. This report specifically provides the description of events that lead to the collision, human factors that contributed to the accident, and more importantly, the report gives recommendations as to what should be done to enhance the quality of human factors. Table of Contents Abstract 2 Table of Contents 3 Introduction 4 Accident Background 4 Contributory Factors 7 Poor situational awareness 7 The two pilots being unaware of each other in sufficient time 8 Visual acquisition 9 Workload of the Air traffic controller 9 Traffic flows separation at the Aerodrome 10 The Alerts Review Management System 11 Accuracy of Contributory Factors 12 Latent threats in the system 13 Quality of human factors Recommendations 13 Conclusion 14 References 15 Introduction The mid air collision between the UPY aircraft CGT aircraft occurred on 27 August, 2008 3km away North-West of Moorabin Aerodrome, Victoria. This aviation accident mainly occurred due to human factors. The solo pilot in the UPY aircraft was a rookie with poor operational experience of the aircraft; for instance, he was unable to effectively manage his situational awareness, he could not communicate effectively with the air traffic controller at the aerodrome, and above all, he could not keep track of his allocated 31left runway. Accordingly, due to workload that the air controller was handling at the aerodrome made it impossible for the controller to effectively communicate with pilots in their respective aircrafts. Poor transmission of relevant air traffic information to the aircrafts caused the pilots in the CGT aircraft to have poor situational awareness, which on the other hand caused them to collide with UPY. This report largely provides the history of vents prior to the midair collision; provide extensive analysis of human contributing factors and lastly the report gives recommendations on what should be done. Accident Background The mid air collision between UPY and CGT occurred on 27 August, 2008 3km away North-West of Moorabin Aerodrome, Victoria. The two aircrafts were being flown by student pilots: a solo student pilot in UPY aircraft and a student pilot under instruction in the CGT aircraft (Hare and McGovern 2013). The UPY solo pilot was on touch-and-go landings circuit training as an essential training for his solo flying career. However, during his first touch-and-go landing circuit, he misaligned the downwind leg parallel tracking which led him to diverge 340 from 35 left runway to 31 left runway. Similarly, the UPY solo student pilot was unable to locate CGT according to the radio transmissions from his aircraft, despite the fact that the instructions from the ADC-W immediately after the start of the downwind leg (ATSB 2008). Prior to the collision, the Aerodrome Controller West (ADC W) was performing multiple duties including air traffic control together with surface movements (Franza and Fanjoy 2012). This is one of the major contributors to the midair collision. Given the increased air traffic in the air control zone, the ADC W could not manage handling the massive traffic at the airport. In this regard, his execution of directions to aircrafts and approving aircraft requests was not effective enough. The solo student pilot in the UPY aircraft was also unable to effectively control his aircraft; for instance, after the ADC W discovered that the student had deviated from the original intended circuit, he was for to clear him twice for the touch-and-go immediately after the student’s first circuit for which the he never responded. The touch-and-go was rather completed on runway 31l instead of 35l runway (Hare and McGovern 2013). Accordingly, after the touch-and-go of the first circuit, the solo pilot was given instruction to follow the PA-28 aircraft VH-NDR (NDR); the UPY pilot performed the second circuit without the clearance from NDC W. The student pilot reported to the ADC W after approximately two minutes acknowledging to be on his third downwind leg and consequently complied with the controller’s instructions by following NDR aircraft (ATSB 2008). When CGT student pilot reported to be 11 km away and north-west of the aerodrome flying at 1,500 ft inbound, UPY solo student pilot was on the base leg of the circuit. The air traffic controller acknowledged and gave instructions the student pilot in CGT to rejoin the circuit on the downwind leg for 31left runway. Accordingly, the CGT pilot was to report in again at 6km from the aerodrome (Hare and McGovern 2013). Immediately after, the ADC W cleared NDR for a touch-and-go while UPY’s solo student approached after NDR to complete his third round. Consequently, MGV takeoff clearance was acknowledged and thus was allowed to line up between NDR and UPY. Moments after, the ADC W repeatedly issued take-off instructions to MGV aircraft pilot before the pilot acknowledged and complied. The UPY student pilot completed third circuit after acknowledging clearance from the controller (Franza and Fanjoy 2012). When the student pilot of CGT was 6 km away from the aerodrome; he checked in and reported that was now at 1000 ft above and in the control zone, the air controller communicated severally to other two aircrafts taxiing for takeoff at the aerodrome (ATSB 2008). The controller acknowledged this report immediately and he never gave further information regarding air traffic at the aerodrome as well as sequencing instructions. One of the pilots in the taxiing aircrafts had scanty information with respect to the layout of the aerodrome and procedure, hence he needed an extra ADC W tax guidance while the pilot in the second aircraft was in preparation to conduct a flight under with regard to flight rules, this need massive communication between the controller and the pilot (Hare and McGovern 2013). At this juncture, the instructor in of the CGT student pilot, advised the pilot to use the one stage of flap in order to reduce the aircraft’s speed. The controller proceeded with communicating with the pilots in the two taxiing aircrafts as well coordinating the control zone air traffic. After a short while, the controller discovered three aircrafts were on late crosswind and in close proximity and hence immediately informed pilots in CGT that there was too much traffic in the control zone. Immediately after the radio transmission, CGT and UPY collided. Contributory Factors Poor situational awareness The UPY student pilot had insufficient aircraft operation experience thus the workload related to aircraft operations together with skill consolidation during the flight was immense (ATSB 2008). Additionally, the student’s flying instructor emphasis on the student to improve his flying skills and techniques particularly on his solo flight, it is largely probable that the aircraft operation was entirely taken up by substantial attention of the student (AAIB 2012). Early solo fights has been proved to be hard as the workload is usually large; in this regard student pilots are required to visually look out for other aircrafts in the area they are flying and effectively listen to radio transmissions for them to successfully sequence appropriately into the circuit as well as be aware of the situation (Hare and McGovern 2013). Given this understanding, the solo pilot would have heard radio transmissions between other aircrafts operating in and using the same circuit pattern and the controller. The radio transmissions understanding and analysis would have enhanced the situational awareness of solo student pilot; however, this had the potential of elevating the workload of solo pilot. For instance, ADC W instruction to the arriving CGT could have enhanced the solo pilot’s situational awareness (Franza and Fanjoy 2012). Similarly, it has been established that initial knowledge of presence together with location of another aircraft significantly impacts that probability of the pilot actually being able to see that aircraft in sufficient time to engage actions for avoidance. For this reason, an attempt to alert CGT’s student pilot could have potentially assisted the student pilot to see UPY in time and hence initiate the relevant control actions that would have avoided the collision. From this analysis, hardships and difficulties the solo student pilot encountered in maintaining situational awareness and radio transmissions monitoring in his early solo flights clearly show that his workload was increased substantially, which on the other hand extensively affected his situational awareness (ATSB 2008). Accordingly, the wrong downwind track on the first round, acceptance of the controller’s instructions that were mystifying together with numerous touch-and-go circuits without acknowledging clearance from the controller also confirms that the solo pilot in UPY was overloaded beyond what he could handle. This also explains why there was no evidence showing that UPY pilot was aware of CGT when the aircrafts collided. The solo student’s flying instructor failure to give direction about actions to be taken when such an occurrence occurs; elevated circuit traffic, significantly increased the student’s risk of becoming overloaded together with loss of situational awareness. The two pilots being unaware of each other in sufficient time Circuit joining instructions transmitted by the ADC W to the CGT pilots together with the student pilot’s acknowledgement report at 6km from the airdrome with no directed traffic information from the controller influenced the CGT pilots to compile a picture of traffic in the circuit through listening to the radio transmissions between the traffic and ATC (Flight Safety Australia 2009). The step that was taken by the instructor by advising the student pilot in CGT to reduce the speed of the aircraft was influenced by his knowledge with regard to heavy air traffic in the circuit, which on the other hand was meant to improve the situational awareness of the student pilot at rejoin (Hare and McGovern 2013). However, regardless of the instructor’s awareness that MGV aircraft was on crosswind, his seating position in the right seat of the aircraft and being above the UPY climbing height probably obscured him from seeing the aircraft. Consequently, there is possibility that if information with regard to UPY was provided to CGT, the chances of the student pilot who was alert would have increased the chances to identify UPY early enough to avoid the collision (ATSB 2008). Visual acquisition Due to the brightness of the ambient conditions, it is unlikely that the additional lighting provided the aircrafts would substantial have made any changes in the conspicuity of the aircrafts (ATSB 2008). Accordingly, absence of significant colour together with the contrast in the background and either aircraft relative movement integrated the potentiality that no student pilot would recognize the converging and unexpected aircraft (The Florida Department of Transportation 2012). However, it is likely true that each respective student pilots could have seen the converging aircraft near the edge of the windscreen (Hare and McGovern 2013). Nevertheless, they would be unable to replicate unevenness of the head of the viewing pilot together with the position of seating in the aircraft similarly aggravated the likelihood of the accident; they were obscured visually from each. For the case of the instructor in CGT aircraft, the magnetic compass on the windscreen obscured his view. Workload of the Air traffic controller Prior to the midair collision, the air traffic controller was overloaded and in accordance with this he continuously delivered wrong instructions with regard to air traffic in the control zone; absence of appropriate, correct and/or relevant transmission of air traffic information to the aircrafts coupled with lack of understanding of aircrafts disposition is evidence enough that the controller was not up to the task (Franza and Fanjoy 2012). In this regard, his situational awareness, management of aircrafts within his area of responsibility was extensively degraded. While on duty, ADC W acknowledgement of not working at full capacity, additional responsibility for surface movement coordination combined with the increased air traffic density and complexity before the collision significantly shows that the controller’s workload was more than he could handle (Hare and McGovern 2013). ADC W’s performance workload was heavily increased by SMC returning together with the addition of several surface management control operational tasks; the aggravated communication with the two taxiing aircrafts. This on the other hand hindered the controller’s capacity to recognize and immediately react to a collision potential between UPY and CGT. There are various informal workload-management strategies including seeking help, delaying, and/or aircraft clearances amendments to ensure reduced density in air traffic in the area of responsibility of the controller (ATSB 2008). Contrastingly, at Moorabin aerodrome none of the aforementioned workload management strategies was used. For example, there was no means or guidance to identify, manage or mitigate increased workload situations of the controller particularly on their occurrence. Nonetheless, management and assessment of the workload singularly depended on the judgement of controller. Traffic flows separation at the Aerodrome Across the GAAP aerodromes, there are no standards separations for aircraft visual flight rules; however, with regard to this particular accident, the strategic separation assurance could significantly enhance safety in a busy GAAP aerodrome (ATSB 2008). In Australia, separation strategies for arriving and departing aircrafts are applied vertically until an aircraft reaches a designated position or receives instructions for joining the circuit. Accordingly, lateral aircraft separation strategies are used at other GAAP aerodromes for outbound and inbound aircrafts. Moorabin aerodrome lacked both vertical and lateral separation strategies between traffic flows, which on the other hand potentially increased the probability of aircraft proximity events that involve merging flows of traffic (Franza and Fanjoy 2012). In essence, there were no comprehensive Air Traffic Control strategies to aid the controller in transmitting traffic information that is directed together with other information to help departing or arriving aircraft crews to identify as well as avoid other aircrafts (Hare and McGovern 2013). Accordingly, the hot spots identification and management; these are locally based risk management labels that represents a local strategy to separate air traffic. There were no strategies for separating traffic flows at Moorabin aerodrome. Accordingly, the provision of instructions for circuit joining of the two aircrafts when they were approximately 11km away from the circuit increased the midair collision probability. Accordingly, the ADC W provision of accurate information to the two student pilots could have increased their level of situational awareness; however, this was not the case, the controller’s intervention came in shortly prior to the emergence of increased traffic at the aerodrome (Allee, Mayer and Patryk 2013). The Alerts Review Management System The opportunity for the Airspaces to identify the aggravated risk at Moorabin aerodrome and create risk management strategies was largely compromised by lack of action by Airservices Australia to evaluate indicators of performance in all GAAP aerodromes in Australia. Accordingly, the staffing level at Moorabin was wanting; regardless of the standardization supervisor recommending for the aerodrome to have staffing levels that would ensure the continued safe and efficient operations, nothing had been taken into consideration. For instance, there was no assistant surface movement controller (SMC) who could have helped in the event that the main SMC was just from rest. Due to this, the ADC W was overloaded with both air traffic controls together with surface movement coordination. Given the magnitude of operational needs at the time of midair collision, much was being demanded from the ADC W, which he could not manage. Low staffing levels at the Moorabin aerodrome hugely contributed to this accident. Accuracy of Contributory Factors i. Neither did the UPY’s Solo pilot see CGT nor CGT’s pilot see UPY in time to prevent the collision. The lack each pilot to see their respective aircrafts is one of the major factors that caused the midair collision. ii. The lack of the aerodrome controller to transmit relevant and appropriate traffic information to CGT and UPY in time to aid in collision avoidance iii. The high workload conditions that the aerodrome controller was operating under during the time of the accident (Franza and Fanjoy 2012). iv. Prior to the collision, provision of appropriate and relevant air traffic information was either late or wrong (ATSB 2008). v. The lack of Airservices Australia to take action to come up with recommendations for safety relating to reviewing of critical indicators to performance of GAAP airspace operations (Franza and Fanjoy 2012) vi. The solo student pilot of UPY never displayed any inability to solely and safely operate in a high traffic environment; furthermore, he was never provided with any guidance regarding situations where circuit activities changed during a solo flight by his flight instructor. Latent threats in the system The General Aviation Aerodrome Procedure Training had the following significant safety threats with regard to training at the GAAP aerodromes (Hare and McGovern 2013). i. Lack standardization within individual flying schools and at specific GAAP locations is another threat to General Aviation Aerodrome Procedure training ii. Poor or lack of understanding of basic GAAP procedural concepts Quality of human factors Recommendations In accordance with the above human contributing factors to the midair collision between two a solo student pilot in UPY and student pilot under instruction in CGT; this reports recommends for the following to be undertaken by GAAP to ensure quality of human factors: i. GAAP should work to ensure that future strategic safety enhancements and specific safety enhancements are put in place across all GAAP aerodromes ii. Plans should be put in place for managing changes for future airport activities with potential to negatively impact on safety, and above all, procedures to implement change should also be developed particularly if the change is deemed necessary (ATSB 2008). iii. ATSB recommendation of 2004 should be acquitted iv. The number of aircrafts operating on a GAAP circuit patterns should be limited v. Only pilot students with relevant flight skills including maintenance of situational awareness should be allowed solo flight training (Franza and Fanjoy 2012). Conclusion The report discussed above describes the events that led to the mid air collision between the UPY CGT occurred on 27 August, 2008 3km away North-West of Moorabin Aerodrome, Victoria. In the same line of discussion, the report has discussed the human factors that contributed to the accident including poor situational awareness of the solo pilot in the UPY aircraft, work overload of the air traffic controller, the lack of awareness of each other in time, poor visual acquisition, and poor separation of traffic flows at the aerodrome. Similarly, specific contributing factors have been well described; furthermore, recommendations have also been listed for the Australian GAAP to implement in order to improve human quality factors. References Air Accidents Investigation Branch (AAIB), 2012, Piper PA-28-161 Cherokee Warrior II, G-BOER. Available at http://www.aaib.gov.uk/publications/bulletins/june_2012/piper_pa_28_161_cherokee_warrior_ii__g_boer.cfm Allee, J, Mayer, T and Patryk, R 2013, Product Liability, London: Law Journal Press ATSB Transport Safety Report, 2009, Midair collision 3 km NW of Moorabbin Airport, Vic 27 August 2008 VH-UPY, Cessna Aircraft A150M and VH-CGT, Piper Aircraft PA-28-161, Available at http://www.atsb.gov.au/media/2486211/ao2008059.pdf Australian Transport Safety Bureau (ATSB), 2008, Mid-air collision VH-UPY Cessna A150, VH-CGT Piper PA-28-161 3 km NW Moorabbin, Vic. Available at https://www.atsb.gov.au/media/51251/AO-2008059_Prelim.pdf Flight Safety Australia, 2009, Situational Awareness, Available at http://www.casa.gov.au/wcmswr/_assets/main/lib91193/nov-dec09.pdf Franza, A and Fanjoy, R 2012, Contributing Factors in Piper PA28 and Cirrus SR20 Aircraft Accidents, Journal of Aviation Technology and Engineering, vol. 1, no. 2, pp. 90-96. Available at http://docs.lib.purdue.edu/cgi/viewcontent.cgi?article=1042&context=jate Hare, B and McGovern, F 2013, Product Liability Case Digest, 2014-2015 Edition. Sydney: Aspen Publishers Online The Florida Department of Transportation, 2012, Basic Aircraft Guide, Available at http://www.dot.state.fl.us/aviation/pdfs/Aviation_Emergency_Response_Aircraft_Guidebook_compressed.pdf Read More