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B734, Brisbane Australia, 2001

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Summary
On 18th January 2001, a Qantas Boeing 737-400 encountered a Microburst while conducting a go-around at Brisbane Australia.
Event Details
When January 2001
Actual or Potential
Event Type
Loss of Control, Weather
Day/Night Day
Flight Conditions VMC
Flight Details
Aircraft BOEING 737-400
Operator Qantas
Domicile Australia
Type of Flight Public Transport (Passenger)
Origin Sydney
Intended Destination Brisbane Airport
Actual Destination Maroochydore/Sunshine Coast Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed No
Flight Phase Descent
ENR / APR
Location - Airport
Airport vicinity Brisbane Airport
LOC
Tag(s)
WX
Tag(s) Low Level Windshear
Safety Net Mitigations
Malfunction of Relevant Safety Net No
Wind Shear Escape Guidance Effective
Outcome
Damage or injury No
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) Aircraft Operation,
Air Traffic Management
Investigation Type
Type Independent

Description

On 18th January 2001, a Boeing 737-400 being operated by Qantas on a scheduled passenger flight from Sydney to Brisbane encountered a Microburst shortly after commencing a go-around from 500 ft during an approach to runway 19 at destination due to the onset of severe weather.

Synopsis

This is an extract from the executive summary from the official report into the incident published by the Australian Transport Safety Bureau (ATSB).

"...The aircraft commenced to climb normally at about 3,600 ft/min18.288 m/s
, however, shortly after the go-around was initiated, the climb performance substantially reduced to less than 300 ft/min1.524 m/s
due to the effects of the microburst downdraft and from flight through heavy rain. The pilot in command applied maximum engine thrust to improve the aircraft’s climb performance, and advised the Aerodrome Controller that the aircraft had encountered severe windshear. The crew then diverted the aircraft to Maroochydore, where it landed without further incident."

"…For some time before the occurrence, air traffic controllers in the Brisbane aerodrome control tower were concerned about the visual appearance of the approaching thunderstorm, and its image on their weather radar display. However, the terminology and language used by air traffic controllers did not convey their concerns about the intensity of the thunderstorm to the crew of TJX until the aircraft was on final approach."

"…The occurrence…again highlights that thunderstorms and convective activity in terminal areas are a significant issue…It also illustrates the significant adverse effect of heavy rain on aircraft performance. The hazards associated with those weather conditions are not solely confined to the presence of severe thunderstorms, and should not be underestimated. Whenever thunderstorm activity is forecast, there is a potential for microburst windshear and heavy rain. Aircraft in the landing, take-off, missed approach or goaround phases of flight are particularly vulnerable in or near thunderstorms. The effects of microburst windshear and, to a lesser extent, the aerodynamic penalties imposed by flight through heavy rain, can place an aircraft in a potentially-high-risk situation…"

The following 19 Safety Recommendations were issued as a result of the Investigation:

  • that Airservices Australia review air traffic controller initial and periodic recurrent training programs to ensure they adequately address the effect of convective weather on aircraft performance and the limitations of airborne weather radar

[R20020168]

  • that Airservices Australia expedite the development 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.

[R20020169]

  • that Airservices Australia increase the emphasis in its controller training programs to ensure that all appropriate sources of weather information, such as meteorological forecasts, controller observations, radar information, and pilot reports are provided to flight crews.

[R20020170]

  • that Airservices Australia develop a comprehensive convective weather refresher course as part of recurring training for all personnel actively engaged in the control of air traffic.

[R20020171]

  • that Airservices Australia in conjunction with the Bureau of Meteorology and the Civil Aviation Safety Authority develop a standard scale of thunderstorm intensity for use within the aviation industry.

[R20020172]

  • that Airservices Australia in conjunction with the Bureau of Meteorology develop a position in major air traffic control locations, to be staffed with Bureau of Meteorology meteorologists, to be the focal point for weather information coordination.

[R20020186]

  • that the Bureau of Meteorology in conjunction with Airservices Australia and the Civil Aviation Safety Authority develop a standard scale of thunderstorm intensity for use within the aviation industry.

[R20020176]

  • that the Bureau of Meteorology ensure that all public weather warnings expected to affect the airspace of an air traffic control facility be transmitted to that facility by the most expeditious means possible.

[R20020180]

  • that the Bureau of Meteorology expedite the development, testing, and installation of advanced weather radar systems to detect hazardous wind shears in high risk airport terminal areas.

[R20020181]

  • that the Bureau of Meteorology expedite the research and development program to examine wind shifts and wind shear, with the objective to improve the detection and forecasting of wind shifts and the detection of windshear in the vicinity of high risk airport terminal areas.

[R20020182]

  • that the Bureau of Meteorology in conjunction with the Civil Aviation Safety Authority review the meteorology syllabus for initial and periodic recurrent training of all pilots and air traffic controllers to ensure that the syllabus includes comprehensive information on convective weather phenomena and (their effect) on aircraft performance.

[R20020183]

  • that the Bureau of Meteorology expedite a program to record output data from all available wind sensors and Low Level Wind Shear Alert Systems, and to retain that data for a minimum period of 30 days for use in reconstructing pertinent windshear events and as a basis for studies to effect system safety and improvement.

[R20020184]

  • that the Bureau of Meteorology in conjunction with Airservices Australia develop a position in major air traffic control locations, to be staffed with Bureau of Meteorology meteorologists, to be the focal point for weather information coordination.

[R20020185]

  • that the Civil Aviation Safety Authority in conjunction with the Bureau of Meteorology and Airservices Australia develop a standard scale of thunderstorm intensity for use within the aviation industry.

[R20020173]

  • that the Civil Aviation Safety Authority in conjunction with the Bureau of Meteorology review the meteorology syllabus for initial and periodic recurrent training of all pilots and air traffic controllers to ensure that the syllabus includes comprehensive information on convective weather phenomena and its effects on aircraft performance.

[R20020174]

  • that the Civil Aviation Safety Authority ensure that operators increase the emphasis in their initial and periodic recurrent training programs on the effective use of all available sources of weather information, such as pre-flight meteorological briefings, ATIS broadcasts, controller provided reports, airborne weather radar, and visual observations, and provide detailed guidance to pilots regarding the degradation on aircraft performance during flight through intense convective weather, and operational decisions involving takeoff and landing operations which could expose a flight to hazardous weather conditions.

[R20020175]

  • that the Civil Aviation Safety Authority place greater emphasis on the hazards of low-level flight through thunderstorms and on the effect of windshear encounter during initial and periodic recurrent training programs for all pilots.

[R20020177]

  • that the Civil Aviation Safety Authority ensure that operators of aircraft equipped with weather radar provide pilots with initial and periodic recurrent training on the use and interpretation of weather radar, and its limitations.

[R200201791]

  • that the Civil Aviation Safety Authority coordinate the activities of the Civil Aviation Safety Authority, Airservices Australia and the Bureau of Meteorology in respect of implementation of the recommendations arising from (this) ATSB report

[R20020178]

The Final Report of the Investigation was released on 20 September 2002.

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