Train in vain? - Civil Aviation Safety Authority

Train in vain? - Civil Aviation Safety Authority
‘15 years of aviation safety’
A review of the state of play
Nov-Dec 2010
Issue 77
‘Train in vain?’
Continuing discussion on making a pilot
15th Ann
1-6 March 2011 Geelong Victoria
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ISSUE NO. 77, NOV-DEC 2010
John McCormick
Gail Sambidge-Mitchell
Margo Marchbank
Robert Wilson
Fiona Scheidel
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Flight Safety Australia
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© Copyright 2010, Civil Aviation Safety
Authority Australia.
Copyright for the ATSB and ATC
supplements rests with the ATSB and
Airservices Australia respectively–
these supplements are written, edited and
designed independently of CASA.
All requests for permission to reproduce
any articles should be directed to
FSA editorial (see correspondence
details above).
‘15 years of aviation safety’
A review of the state of play and a dash of ’90’s nostalgia.
‘Macarthur Job’
The aviation safety doyen retains his eagle eye.
‘The more things change … ’
A fond look back at FSA’s predecessor, Aviation Safety Digest.
20 ’Firmly on the ground’
Flight simulators can be even better than the real thing … sometimes.
23 ‘Look out – locusts about’
They may be small, but there are billions of them.
‘Train in vain?’
The discussion rolls on about the many ways to produce a pilot.
28 ‘Firebombing is tough enough’
Bushfires are no place for airborne sightseers.
’Maintenance safety: a new way of thinking’
New and simpler legislation for aircraft maintenance.
38 ‘Transponders and ADS-B’
Don’t let yours transmit gibberish – or wrong data.
40 ‘Is your ELT fit for an emergency?’
Your beacon can’t save you if it isn’t wired in correctly.
44 ‘Poised for take-off’
The unmanned sector is maturing rapidly.
58 ‘Reforming airspace usage’
Changes happening on 18 November.
62 ‘Laser surgery and the aviator’
A pilot’s guide to ‘getting your eyes done.'
Flight Bytes–aviation safety news
ATC Notes–news from
Airservices Australia
Accident reports–International
Accident reports–Australian
Airworthiness pull-out section
33. SDRs
41. Directives
46 Close Calls
46 ‘Friday afternoon fever’
48 ‘Wire worry’
50 ‘Tasmania or bust’
Registered–Print Post: 381667-00644.
ISSN 1325-5002.
COVER: Fiona Scheidel
ATSB supplement
Av Quiz
Quiz answers
who was the Foundation’s editor of
publications from 1981 until shortly
before his death in 1988 at age 61.
Flight Safety Australia has won a
Brownlow ‘medal’, not for football of
any type but for kicking journalistic
goals. The Flight Safety Foundation Australia’s Airways museum at
bestowed the 2010 Cecil A. Brownlow Essendon Airport is a fascinating
place for any aviation-minded visitor.
Publication Award on the magazine.
Its 2010 open day on Saturday 13
The award recognises significant
November focuses on firefighting.
contributions by journalists to aviation
safety awareness. Candidates for the Before 1955, rescue and fire-fighting at
prestigious international Brownlow Australia’s civil airports was provided
award may be individuals, publications by a combination of a few regular
or organisations. Nominations may firefighters at the capital city airports,
be for long-term achievement or for backed up by volunteers drawn from
outstanding articles, books or works airport and airline personnel.
in electronic media published or
In 1955 the Department of Civil
broadcast in a 12-month period.
Aviation Fire Service was formally
Previous winners of the award established and a program undertaken
include Aviation Safety Digest editor to construct and equip airport fire
Macarthur Job, who won in 1972 stations at the major airports.
for his editorship of Flight Safety
Today the civil ARFF Service is
Australia’s predecessor. The Digest
operated by Airservices Australia
won again in 1987. Other past winners
and employs 725 firefighting and 45
include Robert N. Buck, author of the
support staff at 21 airports around
classic books Weather Flying and The
Pilot’s Burden; Flight International, and
its operations editor David Learmount The 2010 Airways Museum Open Day
(separate awards); and the Australian will feature the history of the ARFF
Service with the opening of a new
Transport Safety Bureau.
photographic exhibition, and guest
First presented in 1968 as the FSF
speakers and films throughout the
Publication Award, the award was
day. Airservices Australia will also
renamed in 1988 in memory of Cecil
provide one of the latest Mark 8 Ultra
A. Brownlow, a veteran newspaper,
Large Fire Vehicles, which will be
wire service and magazine journalist
open for public inspection.
The Guild of Air Pilots and Air
Navigators (Australian Region) in
conjunction with Assessment Services
Pty Limited are pleased to announce
two new scholarships for 2011. One
is for a full set of commercial pilot
licence (CPL) examinations and the
other for a full set of air transport pilot
licence (ATPL) examinations, and both
scholarships include the associated
CASA examination fees. Scholarship
applications will be available in early
2011 from the
website, where you can also apply for
membership. Further details of this
scholarship will be announced in the
January-February 2011 issue of Flight
Safety Australia.
Which is worst, from a green point of
view? Aircraft or other vehicles?
A team of researchers led by Jens
Borken-Kleefeld of the International
Analysis in Austria has quantified
and compared for the first time, the
climate impacts of various passenger
and freight transportation modes over The International Civil Aviation
Organization (ICAO) bas conferred
five, 20 and 50-year periods.
the highest honour in the world
Although CO2 emissions, which of civil aviation, the 39th Edward
remain in the atmosphere for over 100 Warner Award, on Romanian/
years, are considered the main culprit Canadian lawyer Nicolas Mateesco
for global warming, other short- Matte, in recognition of his eminent
lived components and compounds contribution to the development,
contribute significantly to the climate promotion and understanding of
impact of transportation, with the air and space law around the world.
magnitude varying over time.
Dr Matte is 97 and still working in
Because of the high contribution from aviation and space law.
contrails and cirrus clouds, aviation
has a far higher climate impact in
the short term than all other forms of
transport, but over the longer term,
car travel has an equal or higher
impact per passenger kilometre, the
study finds.
Over the long-term horizons the
researchers found the transport
specific climate impact of car travel
was larger than air travel on global
average. Both are about three times
higher than the impact from bus and Dr Matte obtained his first doctorate
rail travel.
of law from the University of
‘This once more underlines the Bucharest in 1939. After World War II,
importance to address aviation- he moved to Paris where he obtained
induced cloud effects as the single a doctorate of international law from
biggest warming agent from aviation,’ the Université de Paris. He moved to
say the researchers, who call for more Canada in 1950, at a time when his
studies into non-CO2 climate warming writings in the field of air law had
already made him a well-known
proponent of a new international legal
The findings are laid out in the order.
American Chemical Society’s journal
Environmental Science & Technology.
Airline pilots in Dallas, Texas, US got
an eyeful when they flew past a strip
club - but not in the way you might
think. A powerful spinning searchlight
on the roof of Bombshells club, flooded
the flight deck of a Southwest Airlines
flight from Albuquerque as it prepared
to land at Love Field Airport, in August
a local radio station reported. The
incident happened when the flight
was on final approach, about 1000ft,
officials said.
The pilot reported a laser strike,
thinking a hand-held laser pointer
had been aimed at the flight deck.
However, he was not harmed and
landed safely. Police later asked the
club owner to switch off the light.
The venue complied and manager
Zach Carson said it had not intended
to flash pilots. The light was installed
at an angle which the venue had
been told would not interfere with
air traffic.
He promised not to turn the light back
on until the FAA gave approval.
We forwarded Ian Drummond from Ontario, Canada, an article on aviation myths he requested, and he responded: ‘I can’t resist sending
you a photo taken a couple of months ago of my plane on a local lake, on a beach inside a ring of islands from an old volcanic cone.’
President of the ICAO Council Roberto
Kobeh said: ‘At 97, Dr Matte continues
to work, travel and dispense his
knowledge and experience with
generosity and conviction. Just as
he was teacher, advisor and mentor
to all those who walked the halls of
universities and institutions where
he taught, he continues to play these
roles in the tenth decade of his life
to his many colleagues and former
Mr. Kobeh said: ‘One day soon, the
world will need to create a legal and
regulatory framework for commercial
flights in sub-orbital space and no
doubt that the writings of Dr Matte will
prove once again of immense benefit
to deliberations in a forum like ICAO.’
The Scientist-Practitioner Gap and
Barriers to Research Application in
Human Factors/Ergonomics
Contact: David Parker:
[email protected]
An outline of some of the aviation
research projects being undertaken
in Australian universities.
Description: This study aims to
determine the practical relevance of
HF/E research published in peerreviewed scientific journals as well as
the key barriers in the application of
research findings for practitioners.
Researchers: Dr Steve Shorrock and
Amy Chung
Contact: Amy Chung:
[email protected]
Predicting Pilots’ Risk-Taking
UNSW–Department of Aviation
Improving Pilots’ Risk Management
Description: This study examines the
utility of various training techniques
to improve pilots’ risk management
Contact: Dr Brett Molesworth:
[email protected]
Being Heard: The Effects of NoiseCancelling Headphones on the
Comprehension of Safety Related
We are investigating whether noisecancelling headphones improve
intelligibility of safety related
material in the cabin.
Researchers: Dr Brett Molesworth
& Marion Burgess (UNSW ADFA).
Contact: Dr Brett Molesworth:
[email protected]
The Link between Attitude, Risk
Perception and Behaviour with
GA Pilots
Description: This study examines the
relationship between attitude, risk
perception, age, flight experience and
risk-taking behaviour.
Contact: Justin Drinkwater:
[email protected]
Flight Safety and its Reliance on
Cultural Attributes of Cabin Crew:
Can Ideal Values be maintained
Description: This study examines the
impact of various cultures on cabin
crew performance.
Contact: Morteza Tehrani:
[email protected]
Automation in ATC
Regulatory Oversight and its Effect
on Compliance
Description: The main focus of this
research is to investigate the link
between regulatory oversight and
compliance in commercial aviation.
I>B:IDH6K :A> K : H
Description: Some pilots take more
risk than others when flying. This
research seeks to determine if there
are certain characteristics that set
these pilots apart.
Contact: Daniel Kwon:
[email protected]
Description: This study examines
the drivers underpinning ATCOs’
willingness to accept increased
utilisation of automation within
their role.
Contact: Marek Bekier:
[email protected]
UNSW–School of Psychology
Optimising Flight Rehearsal
Description: This project tests
alternative methods of metacognitive
reflection in promoting generalised
compliance with an aviation safety
Contact: Professor Jim Kehoe:
[email protected]
UNSW–Australian Defence
Force Academy (ADFA)
Contact: Dr Dominique Estival:
[email protected]
Contact: Dr Matthew J W Thomas:
[email protected]
Edith Cowan University
Threat and Error Management –
Enhancing Flight Crew Performance
Evolving civil aviation safety
Description: Issues associated with an
outcome-based legislative framework
are indicated in this study.
Contact: Devinder Yadav:
[email protected]
This research examines the specific
mechanisms of threat and error
detection by flight crew, using data
from both simulator-based training
and line observations.
Contact: Dr Matthew J W Thomas:
[email protected]
University of South Australia
Effect of laser safety glasses on LCD
cockpit display visibility
Non-Technical Skills – Training and
Subtle Pressures on Small
Commercial Pilot Decision Making
Description: We are investigating the
use of laser safety glasses to protect
pilots from increasingly hazardous
attacks from green laser pointers.
Researchers: Sean O’Byrne, Martin
Copeland, Susan Burdekin, Raymond
Lewis, Andrew Neely.
Contact: Dr Sean O’Byrne:
[email protected]
This research, undertaken with a
number of airline partners, explores
current and innovative approaches to
the training and assessment of nontechnical skills.
Contact: Dr Matthew J W Thomas:
[email protected]
This research seeks to identify and
reduce the subtle pressures on small
commercial pilots that can lead to
sub-optimal flight decisions.
Contact: Dr Chris Bearman:
[email protected]
University of Sydney
This study aims to identify difficulties
in radio communication in general
UniSA works with a wide range of
aviation organisations in relation
the design and implementation of
scientifically defensible Fatigue Risk
Management Systems.
This research examines the
identification and resolution of
breakdowns in coordination between
distributed flight personnel.
Contact: Dr Chris Bearman:
[email protected]
continued on page 7
Effective Communication in
General Aviation
Fatigue Risk Management Systems
Breakdowns in Pilot/Controller/
Dispatcher Coordination
Iceland is normally a long way from the epicentre of
the aviation world. But the eruption of Eyjafjallajökul in
April changed that. In September, aviation leaders from
industry and government gathered in the country’s capital
Reykjavik for the Atlantic Conference on Eyjafjallajökul
and aviation. CASA’s manager of operations in the Office
of Airspace regulation, Graeme Rogers, was among the
‘With all of Europe involved, the tensions generated by
the closure provided considerable fodder for discussion at
the conference,’ he says.
and get in early!
‘Following the European experience, the International
Civil Aviation Organization (ICAO) has established a high
level task force to review volcanic ash procedures.’
Christmas and New Year holidays. Normal
CASA services will NOT be available from:
Rogers says the eruption, and its subsequent impact,
both economically and socially, have provided significant
impetus to a number of big European issues such as
placing the ‘Single European Sky’ project, long an ambition
of many aviation bodies, firmly back on the agenda.
24 DECEMBER 2010
(close of business)
until 4 JANUARY 2011
Plan ahead and act now if you’ll need
CASA services during the holiday break.
Services such as licence renewals or AOC
variations will not be available during the
holidays. Of course, CASA will be working
to deal with urgent aviation safety matters.
If you need URGENT
safety assistance call:
131 757
Further details available from
And, as the widespread closure of airspace only affected
turbine aircraft, it created rare opportunities for other
parts of the aviation community, such as allowing some
vintage Moth aircraft the rare opportunity to fly in
formation over Heathrow Airport.
continued from page 5
Human Factors Implications of
NextGen Technologies
This research, conducted with NASA,
examines some the potential human
factors implications of the new
technologies that will be introduced
into the Next Generation US airspace
Contact: Dr Chris Bearman:
[email protected]
Heightened Emotional Activity HEA
This research, conducted as part of a
LOSA, observed affective responses
to perceived threats on the flight
deck as part of threat and error
Contact: Douglas Drury:
[email protected]
Fatigue and Heightened Emotional
Activity HEA
This research examined data from a
LOSA conducted by UniSA into the
relationship between restricted sleep
and affective responses to perceived
threats on the flight deck.
Contact: Douglas Drury:
[email protected]
University of Newcastle
Airmanship in Australian Aviation
A comparison of the views of
Australian aviators in military and
civilian sectors.
Contact: Kirstie Carrick:
[email protected]
Pilot training innovations
This joint research between UniSA
and ATSB examines some recent
pilot training innovations and their
underpinning principles.
Contact: Melanie Todd:
[email protected]
Laser-Gard™ protects pilots from
flash blindness caused by lasers.
dyes and proprietary lens
technology to reduce the threat
posed by laser pointers during the
Around the globe aviation pilots are day and night.
increasingly exposed to the safety
hazards of hand held red and green Two lens options are available:
laser pointers.
The Bronze lens provides protection
Laser pointers can cause temporary against red and green lasers during
flash blindness, creating extremely the day and also protects from sun
hazardous situations especially
glare and U.V rays. The Salmon lens
during take-off and landings.
provides protection against green
A 5mW laser can easily cause glare lasers and are suited for night use.
and distract pilots up to 3700ft.
For more information call our
Sperian Laser-Gard eyewear
product manager (03) 9565 3585
combines narrow band notch laser or visit
Flight Safety celebrates its fifteenth anniversary
with a look at aviation safety trends since 1995.
It was 1995 and Australia had a population of 17.1 million.
About 2.6 million had mobile phones, mostly on the analogue
system, and a few thousand of us watched pay television,
which had just been introduced that year. A similarly small
number used an academic curiosity, the internet, which had
16 million users around the world. In Australian aviation the
major story of the year was the privatisation of Australia’s
overseas airline, Qantas, which was yet to absorb Australian
Airlines (although it already owned the domestic carrier). In
the business context, Virgin related to a chain of stores selling
CDs and videocassettes. DVDs would not be introduced for
another four years.
The world of general aviation was welcoming the cautious
return of small numbers of new Cessna and Piper aircraft,
back in production in the United States following US President
Bill Clinton’s signing of the General Aviation Revitalization
Act the previous year. Also in 1995, an Australian company,
Jabiru, which had been making ultralight aircraft, as kits or
fully assembled since 1991, introduced its second own engine
design, a 2.2-litre flat four.
Issue 1, Summer 1995-6
‘Volcano fires debate’
There was another aviation revival in the summer of that year.
From 1953 to 1991 Australian pilots and aircraft engineers
had been reading the Aviation Safety Digest, received by
subscription, or for a period, free of charge. That publication
had closed in 1991, and for four years the role of ‘crash comic’
was fulfilled by publications from the former Bureau of Air
Safety Investigation.
The fallout from Eyjafjallajökull
Sept-Oct 2010
Issue 76
‘AOD 12 months on’
Reviewing the AOD program
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In 1995, Leroy A. Keith, the then Director of Aviation Safety,
commended the first edition of the Civil Aviation Safety
Authority’s new journal, Flight Safety Australia, to the
industry. But from the start, this new magazine was not
simply a crash comic. As well as stories of near misses, the
first issue contained a summary of the then-new GPS satellite
navigation system, and its recent approval for IFR primary
navigation. There were also stories on aviation medicine, an
explanation of the new ICAO-based airspace classifications,
and a quiz on IFR operations.
Cockpit noise and pilots’ ears
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Issue 76, September-October 2010
This was a publication aimed at a wider readership than
private pilots. It promised to be ‘a quality safety magazine
that meets the needs of Australia’s aviation industry …
Technological change … will be a focus’, the first editorial
said, and true to its word Flight Safety Australia gained an
‘internet address’ in 1996.
In 2010 there are 22.5 million Australians–with 21.6 million
mobile phone accounts–two billion internet users around the
world, and 1.5 million passengers carried on Virgin Blue. The
intervening 15 years in aviation safety have been a mix: some
things have changed, while others have stayed the same.
Hours flown by high-capacity regular public transport
aircraft – the major airlines – went from 666,000 in
1995, to 1.2 million in 2008, and according to Bureau of
Infrastructure, Transport and Regional Economics (BITRE)
figures, passenger numbers grew from 23.4 million to
44 million.
General aviation hours flown grew from 1.76 million in 1995,
to 1.857 million in 2008, although private flying hours declined
as a proportion of general aviation hours.
A 2010 ATSB report found private flying accounted for 44 per
cent of all accidents and over half of fatal accidents between
1999 and 2008. ‘These figures far surpassed the proportions
for any other flying category, even though private operations
contributed to less than 15 per cent of the hours flown in that
decade,’ the report said.
It found three occurrence types accounted for the majority
of fatal accidents: collision with terrain (90 per cent); loss of
control (44 per cent); and wire strikes (12 per cent).
‘What’s killing pilots in the GA sector is lack of planning, lack
of situational awareness and lack of hands and feet skills,’
says CASA’s head of strategic safety analysis and research,
Bruce Dowdall.
‘You’re getting a lot of situations of VFR into IMC, flight
into terrain. These come back, invariably, to flight planning.
They’re highly preventable accidents and the pattern
remains the same.’
Although he says these were two crashes, and 23 deaths
too many, Dowdall says the overall picture is encouraging.
‘Through the early 2000s the fatal accident rates were
effectively flat-lined on zero. In high-capacity RPT there’s
been nothing. We’re one of a very few countries in the world
to have that accident record.’
However, he says even the best set of figures gives no
cause for complacency. ‘It’s a little like the stock market:
past trends do not necessarily indicate future performance,’
he says.
‘You’re only as good as your last flight.’
‘When you’re talking high capacity RPT, the aircraft are
getting larger, so that while safety performance has been
very strong, there has also been an increase in terms of the
outcome of any risk. A fatal single hull-loss accident ten
years ago would typically involve about 150-200 deaths.
Today it could potentially involve more than 400.’
Looking at the global safety picture, operations editor
of Flight International, David Learmount, says the first
decade of the 21st century has seen a flattening of the
previous long-term and seemingly inevitable trend towards
improved safety.
‘With a few irrelevant spikes, the trend has always been to
get better, and that trend continued until about 2003, after
which it flattened out,’ he says.
‘The question is: have we got as good as it can get? All you
have to do to find the answer is look at the accidents that are
still happening.
There may not be many of them, but when the reports come
out it’s clear they are accidents that didn’t need to happen.
We haven’t stopped improving because we can’t possibly
get better: we’ve just stopped improving.’
Learmount says advances in air safety in the 1990s owed
much to two ground-based technologies with no direct
relation to flying: the computer and the internet.
‘What happened was during the 1980s the industry was
computerised, and instead of accident and incident reports
being disseminated to people who’d forget them a few
weeks later, that information could be digitised and put
into a database. During the 90s the industry got quite good
at assembling trends from data, looking at things like the
difference in risk between precision and non-precision
15 YEARS ...
Then, as now, high-capacity RPT and private flying
represented opposite ends of the aviation safety spectrum.
Over the 15 years from 1995-2009 high-capacity RPT aircraft
had an average of 1.9 accidents a year, none of them fatal.
Over the same period, private and business general aviation
had an average of 69.2 accidents a year, many of them fatal.
(In terms of fatal accidents, general aviation had about 20
fatal accidents per million hours in 2008). There was a trend
towards improvement in general aviation with an average
accident level for 2005-09 of 54.8 compared with the 19952000 level of 81.5.
Dowdall says Australian commercial aviation has had a
remarkable safety record. Since 2000, low-capacity RPT
has been marred by only two fatal crashes, that of a Whyalla
Airlines Piper Chieftain in 2000, and of a Transair Metro at
Lockhart River, Queensland in 2005.
High Capacity Regular Public Transport
Hours Flown (000’s)
Hours Flown (000’s)
‘It became possible to prioritise safety programs. They
became, as the Flight Safety Foundation said, data-driven,
rather than based on the experience of a safety manager.
‘The other huge benefit is that you can share data. Everybody:
the FAA, the JAA in Europe (now EASA), CASA, the UK AAIB,
was able to benefit. And what emerged was they all had the
same sorts of problems.
‘But since 2003 nothing much has changed. It doesn’t matter
whether you’re looking at absolute figures or accident rates.
Since that time both have been level.’
But this technology has also brought problems, Learmount
says. He says a recent cluster of loss-of-control accidents
points to problems in the way some pilots are engaging with
advanced systems on the flight deck.
The US-based Aviation Safety Network found during the ten
years from 1997-2006, 59 per cent of fatal aircraft accidents
were associated with loss of control.
High-profile crashes such as the January 2004 Flash Airlines
Flight 604 into the Red Sea near Sharm el Sheikh, Egypt;
Armavia Flight 967, near Sochi, Russia in May 2006; Kenya
Airways Flight KQ 507 near Douala, Cameroon, in May 2007;
and Turkish Airlines Flight 1951 near Amsterdam Schiphol
Airport, Netherlands, in February 2009, have all been
attributed to loss of control of a flyable aircraft by the pilots.
In 2008, the Flight Safety Foundation director of technical
programs, Jim Burin, told the International Aviation Safety
Seminar loss of control had taken over from controlled flight
into terrain (CFIT) as the jet accident category that killed
more crew and passengers than any other.
Boeing’s Statistical Summary of Commercial Jet Airplane
Accidents 1959-2009 found loss-of-control accidents killed
1759 passengers and crew and 89 people on the ground
between 2000-2009, almost twice the death toll of CFIT
crashes, which in the same period killed 961 passengers and
crew, but no bystanders.
CFIT crashes, described by the Foundation as the kind of
crash least likely to have survivors, have declined as a
crash type among commercial jets since the mandatory
use of terrain awareness and warning systems (TAWS) on
jet airliners.
The Foundation recorded no CFIT crashes between 2005
and 2009 for such aircraft equipped with TAWS. However,
CFIT remains a major cause of crashes in commercial
turboprop aircraft. ‘A substantial proportion of turboprop
major accidents continued to be CFIT accidents, and none of
those aircraft had a TAWS installed, according to preliminary
information, the Foundation reported in December 2009.
‘The trouble was he hadn’t done it for so long. The pilots in
that accident were not monitoring airspeed. Why weren’t
they? Because the system had never let them down, until one
day when there was a glitch [in the radar altimeter, which
under-read], the autothrottle started pulling the throttles
back and they didn’t notice it until they were out of energy:
too low, too slow.’
‘My theory is that automation has finally got through to the
pilot,’ Learmount says. ‘It took quite a long time: we’ve had
autopilots since the Second World War, but they took quite
a lot of monitoring and you had to keep your mind in the loop
at all times.’
Bruce Dowdall adds to that: ‘Fully serviceable aircraft are
still being flown into the ground which indicates issues in the
crew’s performance.’ He describes the problem in terms of
situational awareness rather than complacency.
‘You could mount an argument that pilot skills have been
affected by the advent of high-level automation, but the other
factor is the pilots being aware of what’s going on with the
aircraft. What the automation tends to do is take the pilot
out of the loop. But what the automation can’t fix, it tends to
dump on the pilot. ‘
By contrast, a modern autopilot coupled to a flight director
can largely be left to its own devices, he says.
‘Pilots can select various flight plans and let the aircraft fly
them. That’s great, it’s absolutely fine until one day when the
system isn’t performing properly and the pilot has to revert
to basic flying.’
‘Their hands and feet skills might be up to the task, if only
they knew what was going on with the aeroplane.’
Dowdall says there is a growing mindset that automation
should be allowed to fly the aircraft whenever possible.
He says this has become a problem in at least one in-flight
incident where the crew re-engaged the autopilot after it
made abrupt and uncommanded manoeuvres.
continued on page 14
15 YEARS ...
Learmount says the high performance and reliability of
modern flight automation has led to pilot complacency.
Commenting on the Schiphol crash he says: ‘The Turkish
Airlines captain was brought up in the round-dial era, so he
had plenty of practice in monitoring and integrating flight
information the old-fashioned way.’
Private / Business
Hours Flown (000’s)
Hours Flown (000’s)
Macarthur Job
Aviation Safety Digest editor 1964-1978
‘There were severe restrictions on light aircraft flying in
He no longer flies, but Macarthur Job still has his gaze
anything other than visual conditions. There was no night
turned to the skies—with the same hawk-like focus on
cross-country permitted; there was no night VFR rating,
aviation safety that characterised his editorship of Aviation
the only night flying done was night circuits at aerodromes.
Safety Digest. After 14 years and 64 editions at the helm of
Virtually no light aeroplanes
the highly-regarded and awardwinning magazine, he remains a
It was an afternoon of analysis, were fitted for IFR because
the equipment was too big and
contributor to its successor, Flight
not reminiscence, in which
too heavy.’
Safety Australia, with his next
story scheduled for the January/
he reflected, with a certain
‘In that era there was no such
February issue 2011.
disappointment, that many of the thing as a restricted pilot’s licence:
either you were a private pilot, or
Job spoke to Flight Safety Australia
trends and truisms he observed you weren’t,’ he says.
at the Civil Aviation Historical
Society’s Airways Museum in between 1964 and 1978 still apply.
‘The private pilot syllabus hadn’t
Essendon, Melbourne. It was
changed from the open cockpit
an afternoon of analysis, not reminiscence, in which he
biplane days. In those sort of aeroplanes if you got caught in
reflected, with a certain disappointment, that many of the
cloud, and could maintain airspeed, you’d probably come out
trends and truisms he observed between 1964 and 1978
the other side, but the new clean aeroplanes that had only just
still apply.
been introduced would wind up in a spiral dive very quickly if
you couldn’t keep your attitude right on instruments.
But he dismisses the idea that pilots were any better or
worse in that era. Then, as now, the decision to pursue or
‘There was no instrument training required for a private
ignore airmanship was the individual pilot’s choice.
licence—none whatever. As a result people kept spearing
into cloud, becoming disorientated, losing control and
He says crash rates, and types reflected how aviation was
spiralling into the ground. We had accident after accident of
changing in the ’60s and ’70s. ‘At the time I took over the
that sort.
Digest in ’64 we weren’t very long into the modern aircraft era
… but the departmental attitude was still in the early days,
‘I found it terribly hard to convince pilots that this was the
the biplane era. It hadn’t caught up with the new technology.’
greatest source of fatalities in general aviation. We preached
about it: we ran issue after issue on accidents of this sort,
On reflection, he says general aviation of the early ’60s
but it all seemed to fall on deaf ears because they kept
resembled sport aviation today.
happening.’ Eventually a requirement was introduced for
private pilots to complete three hours of instrument flying
training ‘under the hood’ as part of the syllabus.
‘When that happened the pattern of
accidents changed from getting out
of control in a spiral dive to flying into
cumulus granitis clouds – clouds with
rocks in them,’ Job says. ‘That was a
distinct change.’
Part of the reason pilots were encountering hard-centred
clouds was the complacency engendered by the comfort of
the new easy-to-fly aircraft in deteriorating weather, and
the need for greater accuracy in navigation. It was another
hangover of the wood and fabric era being challenged by the
greater performance of a newer generation of aircraft, Job
says. Pilots getting lost, sometimes by hundreds of nautical
miles, was enough of a concern for the Digest to devote a
special issue to navigation.
‘Navigation techniques were unchanged since the biplane
era, basically a map, compass and watch. When these were
applied to fast new, longer-range aeroplanes that’s when
trouble started,’ he says.
Another theme that emerged in the pages of the Digest as
aeroplanes became more sophisticated was cockpit checks.
‘I wouldn’t say it was a frequent cause of accidents but it
was sometimes a cause of accidents,’ Job says ‘We used to
emphasise it a lot.’
Another difference was a succession of Australian high
capacity airline crashes to write about. In the decade from
1960-70 there were six major crashes involving Australian
airliners: a TAA Fokker Friendship crash off Cairns in 1960;
a DC-4 freighter lost in 1961; a Qantas Super Constellation
hull loss the same year in a take-off crash; a Viscount lost
over Botany Bay in a severe thunderstorm, also in 1961; a
Viscount crash near Winton after an in-flight fire in 1966; and
a Viscount that broke up in flight near Port Hedland in 1968.
The great difference between then and now was that general
aviation was a mainstream and growing activity, he says.
‘All the flying schools were choc-a-bloc with people learning
to fly, and flying was a lot cheaper. I can remember waiting
for a clearance to take off at Moorabbin in a departmental
aircraft for 20 minutes! There was one after another
aeroplane coming in to land. I was glad I wasn’t paying!’
‘I don’t have a tremendously optimistic view of general
aviation—it’s becoming increasingly expensive for private
pilots to be involved. General aviation will continue at a
corporate level where money’s no object, but the era of the
private pilot is at risk.’ But he thinks recreational aviation will
continue to bloom. ‘Some of the newer recreational aircraft
types appear to be well-designed and good performers: quite
sound little aeroplanes and economical to operate. I think
that will replace much of what has been GA.’
And aviation publishing is essentially the same, judging
from the former editor’s recollections. Then as now, it was
impossible to please everyone: ‘I always found the bouquets
were few and far between compared to the brickbats. But I
did enjoy it, in a masochistic sort of way. It was always a joy
to get each issue out.’
15 YEARS ...
‘A Tiger Moth had a cruising speed of 78kt and endurance
of about two and a half hours, so you’re really not going
to go very far. You couldn’t get very lost. In a new modern
aeroplane such as a Bonanza, you could cruise at 160kt and
get completely lost.’
Among the differences Job perceives between then and now
was the tone of instruction. The style and ethos of Second
World War military instruction still pervaded flying training
in the ’60s, he says, but has faded in recent years. While
conceding that some of its severity may be out of alignment
with modern mores, he approves of its stringency.
continued from page 11
‘Most of the time automation does a pretty good job, but when
it goes wrong it goes seriously wrong. What’s disturbing is
the flight crew reliance on automation we’re seeing. Even
when it’s reasonably clear that the automation is what’s
causing the problem, crews are still relying on it.’
Dowdall says this suggests that similar issues of mode
confusion and degraded situational awareness that were
involved in the first commercial glass cockpit accidents are
potentially recurring in similarly-equipped general aviation
‘When things do go wrong in highly-complex aircraft, the
automation tends to spit out a lot of data, there are a lot of
bells and whistles going off, and important clues may be
buried deep in a menu,’ he says. ‘The aircraft will provide the
crew with a lot of data, but it’s not the same as information.’
‘It’s an emerging issue that we’ll be looking at, and considering
its implications in terms of training and education,’ he says.
‘The technology has clear advantages that it seems aren’t
being realised.’
‘Something relatively small and
unforeseen will cascade throughout
the entire system.’
Dowdall says automation issues are becoming evident in GA,
with that sector’s increasing use of glass cockpit technology.
He notes a US National Transportation Safety Board study
of general aviation crashes for aircraft with glass cockpits,
compared with crashes of aircraft with conventional
According to that report, ‘The percentage of accidents
resulting in fatality was about twice as high for the glass
cockpit cohort as for the conventional cohort.’ The report
found glass cockpit aircraft had lower total accident rates.
But accident and fatal accident rates were higher for the
glass cockpit group in IMC and at night.
March 1998
July-August 1999
After looking back, what of the future? The year 2025 is as
far ahead as 1995 is in the past. New technologies, if they
appear at the same rate as they have in the past 15 years,
could change the face of aviation. Very light jets (VLJs) are
an example, combining advanced concepts in structures,
engines and avionics to promise business jet performance in
relatively cheap aircraft. The business environment has not
been kind to VLJ makers in recent years, but the US FAA sees
them growing as a sector.
It forecasts a US market of 270 to 300 VLJs a year, totalling
4,875 aircraft by 2025. The exact safety implications of this
new type taking to the skies en masse are hard to predict,
but in general terms the issue is clear. Pilots of the future
will have to do as pilots have always done: learn to deal with
the most advanced technology of the day, with discipline, an
understanding of its limits and an understanding of the only
unchanging element in aviation - the human factor.
March-April 2000
The more things change …
A hallmark of Flight Safety Australia’s predecessor, the
Aviation Safety Digest, was its strongly worded editorials,
many of which could be described as homilies, sermons or
lectures. Many of the themes railed about from 1953 to the
Digest’s demise in 1991, remain surprisingly current and, with
allowance for the writing style of an earlier era, much of what
it said we couldn’t put better ourselves.
From the Aviation Safety Digest No 3, January 1954: ‘Although
the Department of Civil Aviation tries to give you as much
latitude as possible in the conduct of your flying, at the
same time the Department is morally obliged to act should
it appear that you and your passengers are in any possible
danger. In other words, we are concerned with the safety of
aircraft operations irrespective of whether the aircraft is a
Constellation or a Tiger Moth.’
'We have done our utmost to make the path of the light
aircraft operator as smooth as possible. However, the
successful operation of any system can only be accomplished
by the cooperation of all parties concerned.'
Readers suggested topics including navigation, principles of
flight and aviation medicine. (At the risk of sounding smug, all
of these have been covered in Flight Safety Australia in 2010).
Another evergreen comment was: ‘Difficulty in interpreting
Departmental requirements and procedures are mentioned
by quite a number who would welcome articles explaining
and commenting on these things.’
Another response said: ‘The editor’s comments read like
headmaster’s sermons!’
Then, as now, opinions included a degree of nostalgia. ‘Some
think past issues were more stimulating than those we are
producing at present,’ Job wrote.
With a still discernible note of relief, the editor remarked
that: ‘Only two readers were blunt enough to suggest we
should stop production altogether.’
And he also offered a lament that is – lamentably – still
relevant: ‘Though places and circumstances differed,
the same sorts of accidents seemed to go on repeating
themselves over and over again.’
In 1977, the Digest conducted a survey of 2000 readers to
mark 25 years and its 100th issue. The responses were frank,
to judge from editor Macarthur Job’s summary in issue 100.
March-April 2001
March-April 2005
January-February 2008
15 YEARS ...
Financial pressures and priorities have changed, however,
and some things we take for granted today were big-ticket
items in the early '50s. 'Any form of assistance to an aircraft
in flight or in possible distress, invariably involves expensive
long distance phone calls,’ the Digest thundered in issue
number 3.
‘A significant number think the Digest should be more diverse
in its approach,’ Job wrote. ‘Rather than confining ourselves
to actual accidents and incidents we should include more
technical articles on various aspects of aircraft operations.’
International Accidents/Incidents 24 August - 6 October 2010
Fatalities Damage Description
24 Aug
Embraer 190LR
near Yichun Lindu
Airport, Cina
Aircraft crashed 1500m short of the runway and was destroyed by fire.
Crash is second loss and worst accident for Embraer 190.
24 Aug
Dornier 228-101
near Bastipur,
Aircraft crashed after crew decided to turn back and divert to Simara Airport due
to poor weather at Kathmandu. News reports said the aeroplane had a generator
failure. Crash site was a hillside about 18nm from Kathmandu and at 9000ft.
25 Aug
Let 410
near Bandundu
Republic of Congo
Aircraft reportedly came down in village while on final approach to nearby airport.
Media reports suggested fuel starvation, but an operator spokesman said there
was 150 litres of fuel in the tanks.
25 Aug
Embraer 145
Vitória da
Conquista Airport,
Written off Aircraft was substantially damaged in a runway excursion accident.
Two people were injured.
26 Aug
Fokker 100
Tabriz Airport, Iran 0
Substantial Aircraft lost control soon after landing and plunged into a nearby canal.
Two passengers were injured.
31 Aug
Cessna 550
Citation II
Misima Island
Airport, Papua
New Guinea
Aircraft skidded off the runway into trees while landing in heavy rain, and burst
into flames. The co-pilot survived with critical injuries. One of the dead passengers
was reported to be the Australian co-owner of the airline.
3 Sep
Boeing 747-44AF near Dubai Airport, 2
United Arab
After 22 minutes of flight to Germany crew declared emergency, saying there was
smoke on board. Aircraft missed approach to Dubai airport and crashed nearby.
7 Sep
Tupolev 154M
Written off At FL350 crew reported electrical failure, including the fuel pumps, leaving
Izhma Airport,
the aircraft with 3300kg of usable fuel. After emergency descent below cloud
level crew saw an abandoned air strip. The strip was 1325m: the Tu-154
requires 2200m to land. Aircraft overran runway by 160m into pine forest.
13 Sep
near Puerto Ordaz 17
Airport, Venezuela
Aircraft came down in an industrial area about 4nm short of runway.
1 Oct
Cessna 550
Citation II
near Manteo-Dare 0
County Regional
Airport, North
Carolina, US
Substantial Corporate jet ran beyond runway and into water of Croatan Sound on landing.
6 Oct
Cessna 501
Citation I/SP
off Coatzacoalcos, 8
Business jet crashed in sea soon after take-off for unknown reason.
Notes: compiled from information supplied by the Aviation Safety Network (see www. and reproduced with permission. While every effort is made to ensure accuracy,
neither the Aviation Safety Network nor Flight Safety Australia make any representations about its accuracy, as information is based on preliminary reports only. For further information refer to final
reports of the relevant official aircraft accident investigation organisation. Information on injuries is unavailable.
Australian Accidents/Incidents 7 August - 28 September 2010
7 Aug
Diamond DA 42
Robinson R22
Aerodrome, SA
Mount Garnet (ALA), Nil
E M 19km, QLD
7 Aug
Cessna 152
near Moorabbin
Aerodrome, VIC
8 Aug
Robinson R22
10 Aug
Cessna 210J
Robinson R22
Cessna U206F
Aerodrome, 270° M
46km, QLD
Corowa Aerodrome,
Wombungi (ALA),
270° M 4km, NT
Aerodrome, NW M
6km, QLD
7 Aug
10 Aug
12 Aug
The crew did not lower the landing gear.
During mustering, the helicopter's main rotor struck struck a wedge tail
eagle. The pilot landed on grass that was subsequently set alight by
the R22's exhaust.
On base leg for runway 35L, the pilot reported an engine failure.
The aircraft undershot the runway and hit terrain south of the aerodrome.
The investigation is continuing.
During mustering, the tail rotor collided with a tree. The helicopter
landed heavily.
During landing, the landing gear collapsed. Engineering inspection revealed
a fault in the hydraulic system.
Helicopter landed in long grass, which was set alight by the engine
exhaust pipe.
During initial climb, the pilot reported an engine failure and conducted a
forced landing on Wiggan Island. There were seven people on board.
The investigation is continuing.
Australian Accidents/Incidents 7 August - 28 September 2010
14 Aug
Ballarat Aerodrome, Nil
S M 37km, VIC
19 Aug
Bell 206B
26 Aug
Cessna 182B
30 Aug
Robinson R44 II
near Maryborough Nil
(Qld) Aerodrome,
Aerodrome, 284° M
53km, NSW
Aerodrome, WA
31 Aug
Mooney M20C
Aerodrome, WA
3 Sept
near Commonwealth Minor
Hill (ALA), SA
6 Sept
Enstrom F-28F
7 Sept
Cooma Aerodrome, Nil
305° M 37km, NSW
Kilcoy (ALA), QLD
10 Sept
Robinson R22
During cruise, the engine lost power and began running roughly. The pilot
conducted a precautionary landing on a nearby road. On final approach,
the aircraft encountered turbulence, resulting in a hard landing and the
landing gear collapsing. An engineering inspection found evidence of fuel
contamination in the fuel filters, needle and seat.
During powerline inspection, the engine out light illuminated and the
turbine RPM began to decline. The helicopter was autorotated and hit the
ground hard. An engineering inspection could find no fault with the engine.
While landing in a gusty crosswind, the aircraft bounced and then landed
hard to the right of the strip. The nose landing gear leg sheared and the
aircraft flipped over.
As the helicopter became airborne, the pilot lost control and the main rotor
blades struck the concrete apron. The helicopter rolled and came to rest on
its right hand side. The investigation is continuing.
During the landing roll, the right main landing gear collapsed resulting in
the aircraft running off the runway and coming to rest on the grass.
The engineering inspection revealed the eye bolt on the push rod failed.
While mustering, the aircraft engine lost part of its power. The pilot
attempted a precautionary landing but conducted a go-around from short
final due to windy conditions. The engine was unresponsive to throttle
movement and the aircraft collided with a tree. The company subsequently
advised that carburettor icing was the likely cause.
While inspecting an area for aerial spraying at 100 ft AGL, the helicopter's
engine failed. The pilot conducted a forced landing.
During the take-off run, the aircraft veered left off the grass airstrip and
struck a fence. The sole occupant was uninjured but the aircraft was
seriously damaged.
During mustering, the engine began running roughly and lost power. While
the pilot was attempting to land, the helicopter collided with trees before
hitting the ground.
During takeoff, the aircraft collided with terrain.
The investigation is continuing.
14 Sept
Pantijan (ALA), 091° Nil
M 33km, WA
During the landing roll, the aircraft veered to the right and the pilot
initiated a go-around. The left landing gear subsequently collapsed and the
propeller struck the runway.
During initial climb, the low rotor RPM buzzer sounded and the helicopter
descended. The pilot conducted a forced landing but the helicopter
landed heavily.
While recovering from a manouevre at low level, the helicopter collided
with the ground, damaging the landing gear. During the subsequent
landing, the helicopter encountered ground resonance. During the
recovery, the main rotor severed the tail boom and the helicopter
rolled forward.
During a crop spraying run, the aircraft struck a powerline and hit
the ground.
During a touch-and-go landing, the aircraft veered off the runway onto
sodden earth. The front nose landing gear collapsed and propeller struck
the ground.
20 Sept
Robinson R44
20 Sept
Schweizer 269C Moorabbin
Aerodrome, VIC
23 Sept
Air Tractor AT402A
Cirrus SR22
Echuca Aerodrome,
349° M 24km, VIC
Dalby (ALA), QLD
114 Commander
Cessna T210L
near Geelong
On approach, the aircraft struck powerlines, crashed and caught fire.
The investigation is continuing.
It was reported the aircraft ditched into water. There were no
fatalities. The investigation is continuing.
24 Sept
25 Sept
28 Sept
Gurney Airport, NE Nil
M 46km, Other
Text courtesy of the Australian Transport Safety Bureau (ATSB). Disclaimer – information on accidents is the result of a co-operative effort between the ATSB and the Australian aviation
industry. Data quality and consistency depend on the efforts of industry where no follow-up action is undertaken by the ATSB. The ATSB accepts no liability for any loss or damage suffered by any person
or corporation resulting from the use of these data. Please note that descriptions are based on preliminary reports, and should not be interpreted as findings by the ATSB. The data do not include sports
aviation accidents.
19 Sept
Wrotham Park
(ALA), W M 46km,
Cessna A188B/ Geraldton
A1 Agtruck
Aerodrome, E M
30km, WA
Pitts Special S-1 Aerodrome, NSW
With flight simulators poised to take a greater role in both
initial and recurrent pilot training, Flight Safety Australia
hears from the experts about their benefits and limitations.
You’ve all heard the jokes: a perfect landing in a simulator is as
relevant as doing successful surgery on a cadaver, or about as exciting
as dancing with your sibling. But the role of simulators in pilot training
and checking is a serious question, undergoing serious consideration.
In December 2009, the Civil Aviation Safety Authority began
investigating whether mandatory simulator training should be made
more widespread. Currently it is only required for low-visibility
flight situations, but a notice of proposed rule-making due to go to
press about the same time as this issue of Flight Safety Australia will
announce CASA’s intention to mandate the use of flight simulators for
non-normal training exercises in aircraft with 10 or more passenger
seats (or over 8618kg MTOW) if a simulator is available.
The crash of 22 March 2010, in which two pilots died while performing
an asymmetric take-off in an Embraer EMB-120 Brasilia at Darwin
Airport, made a strong and tragic case for simulator training - the
same exercise could have been carried out without leaving the ground
in a simulator. But with the prospect of simulator sessions becoming
more widespread - both for recurrent and initial training - the question
of how to maximise their benefit is more topical than ever.
In common use, the word simulator covers a range of training devices,
from full immersion motion simulators with authentic flight decks
and six degrees of freedom on a platform of six hydraulic rams, to
personal computer-based systems and, at the most basic extreme,
‘paper tiger’ procedure trainers.
Each type brings its own advantages and issues. Personal computerbased part task trainers don’t replicate aircraft motion or cockpit
layout, but can be almost trivially inexpensive compared to the cost
of operating even the most basic aircraft.
The same cannot be said for full mission
simulators, which, while cheaper than the
aircraft they represent, can still have running
costs of up to $1500 an hour including
All the flying instructors interviewed by Flight
Safety Australia for this story approved of
simulators, with reservations only about the
detail of how they should be used.
Chief flying instructor of New England Flight
Training, Stewart Hignett, is a regional flying
instructor whose operation specialises in
training private pilots. He finds would-be
pilots come to him from their computers with
some preconceived ideas, thanks to simulator
‘You get it with young guys whose parents
have bought them a TIF (trial introductory
flight) for their birthday,’ he says.
‘You explain how you’re flying the aeroplane
by attitude and set it up for them - their eyes
aren’t even outside - they’re flying by artificial
horizon, because that’s what you do on flight
sim. You can pick it straight away.’
But Hignett says a simulator of any standard
is potentially a very valuable teaching tool.
‘It’s a great place to make a mistake,’ he says.
‘We do the first hour of basic instrument flight
in it. I wish I had done more synthetic training
when I was learning instrument flight.
‘The beauty of it is you can stop it. Flying
an NDB approach, which is one of the more
tricky things to learn, you can stop and ask
“where’s the needle?”’
Other instructors say the pause button on
a simulator can be overused. Chief flying
instructor of Coffs Harbour-based Professional
Pilot Training, Robert Loretan, remembers an
experience early in his career that taught him
a hard lesson about how to use simulators
The incident happened when he was an
exchange instructor in the US Air Force on the
Northrop T-38 Talon supersonic trainer.
‘The images were very real and I was scared
by the experience. I became determined not
to let my jet get into that situation. However,
she was relaxed and just hit the reset button
to put us back on to finals as though nothing
had happened.’
‘She went flying with another instructor
a day later - they got in the same situation,
she delayed her reaction because she did not
understand the outcome, and they hit the
approach lighting just short of the runway.
Fortunately they got the ’burner in on the
second engine just as they hit, and they got
enough vertical trajectory to eject safely as
the aeroplane broke up.’
‘I blame myself a bit - I let her crash in the
simulator and taught her the wrong thing
when I thought I was doing the right thing. The
problem of practising dangerous activities in a
simulator is that you do not have the outcome
of death to motivate your reactions: if you let
However, Loretan says the safest place to practise dangerous activities
is in a simulator.
‘As an experienced pilot, I transferred the aeroplane skills to the
simulator to build my situational awareness for operations in the
aeroplane. She took the same experience in the simulator to the
aeroplane and damaged her situational awareness.’
Loretan allows his airline cadets unlimited time on PC simulators and
approved synthetic trainers. ‘It’s costing me next-to-nothing and the
benefits are worthwhile, but we still limit the experiences they are
allowed to experiment with,’ he says.
He estimates that one hour of instruction in an aircraft is worth
about three in an average general aviation synthetic trainer (part task
trainer), but says simulated flight instruction becomes more useful
as the student gains more aircraft experience and negative transfers
diminish as actual flying hours build.
Full flight simulation (full-mission trainers) as used by the military and
airlines has much higher transfer rates into skill development (often
one for one), but the operating costs of full mission simulators can
be as much as ten times the operating cost of a basic flight training
aircraft. ‘There’s a certain amount that has to be experienced in an
aeroplane during ab-initio flight training,’ he says.
Not all skill transfer goes from simulation to the aeroplane, Loretan
says. ‘It is a two-way street, many activities; particularly threedimensional activities and emotional experiences transfer from the
aeroplane to the simulator where the skill is further developed and
transferred back to the aeroplane at a higher standard, and the cycle
goes on and on. Every activity must be evaluated and the combination
of aeroplane and part task training or
full mission simulation must be carefully
designed, considering safety and positive or
negative transfer as well as efficiency and
cost effectiveness.’
‘The issue becomes how much can you
transfer and at what cost. As a pilot gets
more experience in the atmosphere, you
get more transfer from the simulator. As
you gain competence in the simulator, it
transfers to the aircraft. There are plenty of
experienced pilots who can do an entire type
endorsement in a full mission simulator.’
At the other extreme of complexity, Hignett
says the benefits of basic procedures trainers
are often overlooked in discussions about
flight modelling and fidelity. ‘The other one
that’s great for learning procedures is the old
Beech 1900 paper tiger. You can sit there and
go through all the checklists - and it really
works - you know where everything is.’
‘You explain how
you’re flying the
aeroplane by
attitude and set it
up for them - their
eyes aren’t even
outside - they’re
flying by artificial
horizon, because
that’s what you do
on flight sim.
You can pick it
straight away.’
‘I taught a girl on a T-38s in an all-singing,
all-dancing, six-axis, terrain-modelling, full
mission simulator. The T-38 at 160 knots on
finals with a simulated engine failure was
behind the drag curve, and too slow to go
around, or even maintain a three degree
approach path. To imprint this danger into
her perception I put the simulator on finals
too slow and too low and we could not
maintain the approach path in afterburner, so
we crashed short of the runway. We did this
three times.’
it get to the point of crashing you can cause a negative transfer into
the perception of the pilot.’
‘A student
should come out
of a simulator
relieved and
confident that
they can safely
handle a realistic
One airline insider told
Flight Safety Australia, ‘If you
are setting up an aircraft
for start-up and taxi, the
question has to be “does this
really need to be done on a
full flight simulator?”’
‘If you’re training to CAR 217,
it’s important to remember
you have a choice between aircraft, flight
training devices and full flight simulators.
Each one has its place, but it’s important to
develop an appropriate lesson plan for each.’
Instructor and retired Boeing 737-300 captain,
John Laming, says the instructor is often the
forgotten factor in simulator training.
He remembers his first simulator instructor
without affection or respect.
‘He was an irritable pedant who had risen to
the God-like status of check captain purely
through seniority in the airline rather than
any ability to instruct; the simulator he ran
was called the horror box.’
Another retired airline captain has a similar
story: ‘This is a philosophy that’s plagued
the industry for years,’ he says, ‘that it’s
acceptable to break people in the simulator.
It’s archaic but prevalent, the Machiavellian
simulator instructor who piles failure upon
failure. I was once literally stabbed in the back
with a pen while flying a simulator exercise
and didn’t notice it - what benefit did that
have except to a sadistic instructor?’
Laming says simulator sessions have the ‘greatest benefit when they
are relatively short, and structured to teach, rather than deliberately
overload the pilot.’
‘Any schoolteacher knows that forty-five minutes of lecture time is
about the maximum that students can absorb without losing interest:
beyond that the learning curve flattens and clock-watching sets in. Yet
I have been to simulator sessions where two hours of briefings precede
four hours in the simulator, followed often by a one hour de-brief.’
Laming strongly believes that pilots’ manual flying skills need to be
maintained and says the simulator is an ideal environment for this.
If pushed to choose, he would regard hand-flying training as more
important than line-oriented flight training (LOFT), or even crew
resource management (CRM) exercises. Citing the cluster of loss-ofcontrol accidents of the past decade and the alarming lack of basic
skills he has seen in some students and licensed pilots, he gives special
emphasis to using the simulator to train for recovery from unusual
‘I believe more accent should be on pure flying skills - meaning manual
handling - especially on take-off and landing in strong crosswinds on
wet runways.’
A commercial full-mission simulator instructor says instruction has
to be topical and relate to actual problems and situations. ‘A few
years ago, the biggest killer was controlled flight into terrain, now the
problem seems to be runway overruns. A training organisation has
to be progressive, to keep up with trends. For example, I know some
organisations are looking at training for volcanic ash.’
‘Unfortunately you can’t train for everything. The problem is there’s
limited time. We’d love to have every airline pilot in our simulators
once a month, but the biggest issue for airlines is taking crews out of
the line. They want pilots in aeroplanes, not pilots in simulators.’
*7*<)1<¼; )>1)<176<0-7:A;+0774
Hanger N Wirraway Drive, Redcliffe Airport. QLD 4021
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All CPL subjects plus IREX
Courses available full-time or by home study
Ideal weather conditions recently in south-eastern Australia
have led to high-density hatchings of locusts. And when
these insects hatch, there is plenty of their preferred foods –
grasses and cereal crops - because of the strong spring rain
much of the southeast has enjoyed. Billions of the insects are
expected to hatch and swarm across South Australia, New
South Wales and Victoria by mid-December. Accordingly, a
NOTAM warns pilots of the possible threat to aviation these
pest insects can cause.
The hatchings began in parts of northern NSW in early
September and in the central west in the second week of
September. This has been followed by hatchings near Broken
Hill, in farming areas around the Flinders Ranges in South
Australia, and near Mildura in northwestern Victoria in midSeptember. Locust swarms were expected to have formed
by late October and are predicted to continue forming in
NSW, South Australia and northern Victoria from October
until mid December.
Queensland appears to have been spared plague locust
infestation with the Australian Plague Locust Commission
reporting : Population densities in western Queensland are
low and no significant spring nymph population has been
detected.’ However, there is concern about the number of
the spur-throated locust in Queensland if the recent heavy
rains persist.
Aerial spraying has treated almost 60,000 hectares of locust- Department of Agriculture, Fisheries and Forestry
affected land in NSW, while aircraft have surveyed a vast
area (five million hectares) of that state on locust watch.
If you are flying in affected areas, you’re advised to visit the
Department of Agriculture, Fisheries and Forestry (DAFF)
and state government agencies websites for updates on the
current, and forecast, locust situation, as well as potential
areas of infestation. You can also assist DAFF by reporting
any infestations of locusts you see from the air, or by
reporting sightings to the local state agency.
Swarms of adult locusts can pose a direct threat
to aviation.
In sufficient numbers, and especially the numbers
being talked about this year, locusts can mask ground
features so you can’t see the ground reliably. Locusts
can accumulate to about 100 per square metre, and
possibly range over tens or even hundreds of square
kilometres in an individual swam.
Ingestion of locusts into engine intakes and pitot
tubes of aircraft can present cooling problems and
unreliable airspeed indications. It’s commonsense, and
good airmanship, to fit pitot covers and engine intake
blanking to prevent locust ingestion while the aircraft is
in a hangar or secured in the open.
Locusts on windscreens and goggles cause reduced
Current locust situation and news
Australian Plague Locust Commission (APLC)
Report locust sightings to Bio-security Queensland on 13 25 23
Report locust sightings to DPI Locust Hotline on 1300 135 559
Western Australia
Report locust sightings to AgLine on 1300 725 572
New South Wales
Report Locust sightings: Telephone contacts are found at:
South Australia
Report Locust Sightings Local Control Centres:
Orroroo 8658 1456 - Loxton 1800 833 451
Locust bodies can also mark paintwork.
Exercise caution when flying in areas of known locust
activity. Locusts have been observed at altitudes up to
3000ft AGL and can be in swarms of up to 50 million.
Locusts can be active 24 hours a day, with adults’ day
flights ranging up to 30km, and night flights of up to
several hundred kilometres if conditions are suitable.
Locust infestations [nymph, the non-flying immature
form and/or adult] can also attract birds. This raises the
increased potential for bird strikes – particularly near
waterways – waterfowl habitat.
Pilots should also take special care near aerodromes
supporting aerial operations associated with locust
control, as there may be increased aircraft traffic
(including low-flying helicopters and fixed-wing spray
aircraft). The greatest potential risk may occur during
take-off and landing associated with aerodromes
in locust-affected areas. If you are flying near such
aerodromes, you should be especially careful in
monitoring radio frequencies.
As Flight Safety Australia
rediscovered recently, almost
nothing stirs up the aviation
community like a discussion
on how to train pilots.
Training is an ongoing, evolving issue of direct
relevance to aviation safety, and if the experts in
the field agree on anything, it is that there is no
single right route to the right stuff. Flight Safety
provides some more perspectives on this vital
issue ...
‘You can be flying in a very different environment
to what you would in a big airline,’ he says.
‘The other thing is if you’re flying on your own
a lot you can get into some bloody bad habits.
Nobody’s monitoring you.’
There are many recipes, but no official
blueprint for making the perfect airline pilot.
Some say wisdom comes from basic flying
in regional charter and air work operations,
a finishing school that builds skill, character
and the mysterious composite of those two
elements called airmanship. Others contend
that university education, equipping the future
pilot with skills to outlast their career behind the
yoke, is the way to build the profession.
‘Flying night freight or
outback charter might
“make a real man of you”
but it doesn’t necessarily
make you a good pilot.’
The safety and operations editor of Flight
International, David Learmount, learned to fly
the conventional way, earning a private pilot's
licence, then in the British Royal Air Force,
building his skills to the high standard required
of a C130 Hercules pilot. But he wonders whether
this is still the best way to train for a career in
automated multi-crew flight decks.
‘If you go and fly night freight in a Caravan,
for example, you’re going to learn quite a few
things; but what you learn is going to depend on
what you encounter,’ Learmount says.
Other voices emphasise the importance of
command authority and say it is vital, regardless
of what sort of flying machine it is gained on.
‘Nothing matches time in command,’ says author
Macarthur Job, noting that the celebrated pilot of
US Air Flight 1549 which ditched in the Hudson
River in January 2009, Chesley Sullenberger, had
been an air force fast jet pilot and a glider pilot.
‘He had that basic feeling for the air.’
Job says extracurricular flying reinforces what
he sees as an important truth easily lost in the
complexity of modern aviation: an aeroplane
is not a just collection of systems, but a
flying machine still subject to all the laws of
‘I think you can draw an analogy with the old
naval training when officer cadets had to learn
how to sail a whaleboat. It’s about learning
the basic tenets of aviation: wind, weather,
aerodynamics and aerofoils – being aware of the
realities of flight.’
The training debate is becoming pointed because
of a predicted global shortage of pilots. The latest
crew assessment forecast from Boeing is that the
world’s airlines will need 466,650 pilots over the
next two decades, or an average of 23,300 new
pilots a year until 2029. The biggest growth area
would occur in the Asia-Pacific region, which
would need 186,600 pilots, Boeing found.
This is the context for a new school of thought
in pilot training. Its advocates say even if there
is nothing wrong with the traditional method of
accumulating hours in GA or military aircraft,
this stream will not be able to supply sufficient
pilots for the future.
The managing director of ab-initio training at
Oxford Aviation Academy, which runs an abinitio cadet program for Jetstar cadet pilots
in Australia, Anthony Petteford, says training
should concentrate more on the distinguishing
aspect of airline flight decks - multi-crew
... the world’s airlines will
need 466,650 pilots over
the next two decades, or
an average of 23,300 new
pilots a year until 2029.
‘While experience may have been beneficial,
there has to be an emphasis on conflict
resolution. Very rarely is the aeroplane in such a
state that it’s going to cease flying immediately.’
He is sceptical about the idea that command
time bestows unique advantages. ‘Our counter
to that is, what gives the captain monopoly on
the right command decisions?’
Petteford argues that air transport operations,
and air transport emergencies in particular,
require the skills of the entire crew. ‘I was flying a
sim trip with an old-school skipper who basically
went into single pilot mode and evacuated the
aeroplane into a running engine: there was no
review process,’ he says.
‘And when it comes to skills, all our courses
include recovery from unusual attitudes.’
Learmount says it is too early to make a definitive
judgement on the MPL model, although he
foresees no major issues with it. Instead he sees
a more fundamental problem: ‘We still train
pilots as if they were flying Super Constellations
back in the 1950s,’ he says.
Noting that engine failure at take-off has
become a staple of simulator testing among
most airlines, he asks: ‘Why? Engine failures
hardly ever happen nowadays and, what’s more,
modern aeroplanes are very much easier to
handle when you do get engine failure. There’s
plenty of rudder authority and in a lot of more
sophisticated aeroplanes the rudder goes on
even if you don’t put it there.’
(The Boeing 777 has a thrust asymmetry
compensation system [TACS] that commands
a rudder input if it detects asymmetric thrust
The solution: a short, sharp pilot training course
with structured, but minimal flight time, coupled
with a strong emphasis on teamwork from the
first hours in cockpit or classroom. This puts a
trainee into the first officer’s seat of an airliner
after 260 hours of actual and simulated flight.
Rather than what its advocates see as pointless
hours in irrelevant aircraft types, the graduate
of this multi-crew pilot licence (MPL) scheme
bring training in human factors, crew resource
management and communication to the flight
‘You can fly a small aircraft for the required
number of hours and find yourself in the righthand seat with insufficient training about
concepts such as pilot-flying and pilot-not-flying,
or the diagnostic approach. You’re there with
people in the back and you don’t know enough
about how to work together during non-normal
conditions. That is crazy,’ he says.
‘The other thing about modern jet transport
aeroplanes is there’s plenty of power to spare.
These days, maintaining a single-engine climb is
the least of your problems.’
Learmount says training needs to broaden its
scope to take on the insidious failures that have
contributed to a spate of air transport loss-ofcontrol crashes in the first decade of this century.
Training for instrument failures, anomalous
readings, unusual attitude recovery and
situational awareness is every bit as important
as practising handling skills, he says.
‘Modern pilot training should incorporate a huge
amount more of threat and error management.
We should be training pilots not just to use the
instruments and systems that are available but
to be sceptical about them, and to recognise that
they can lull you into a false sense of security.’
The chief pilot of Professional Pilot Training in
Coffs Harbour, NSW, Robert Loretan, takes an
astringent view that transcends the distinction
between what might be called the old-school
and modern approaches to training. He has
a distinguished record in both camps, having
been a flight instructor in the RAAF, and on
exchange in the USAF, where he instructed on
the T38 supersonic trainer and studied human
information processing at the Air Force Human
Resources Laboratory. On his return to Australia
he was appointed examiner of examiners in the
RAAF (and flew with the Roulettes display team).
Later, in the Civil Aviation Safety Authority he
was involved in the development of the MPL
concept. But his opinion is that most forms
of training fail to consider basic principles of
perception and information processing.
Poor instruction at ab-initio level often creates
problems that can trip up pilots years later,
he argues.
‘Information processing does matter for things
you will be doing later in a slightly different
context. Unfortunately a lot of the basic stuff
is setting up problems for the advanced stuff.
Information processing has to be set up so it goes
consistently through training in all activities,’
he says.
‘For example, on the first flight a student goes to
the training area and the instructor says “Look at
that landmark over there, we are near that”. Then
when the student goes on navigation training,
we abandon that and tell them to navigate from
the map to the ground. But for the first 30 hours
of training we teach students to orientate from
ground to map.’
‘You have to unlearn what has been taught to
you in the beginning.’
He uses final approach as an example of the
contradictions and complexity that have crept
into instruction. ‘If you’re low on finals you’ll
be told to increase power to reduce the rate of
descent; but in the flare you will be taught to pull
the nose up to flare – which is also reducing the
rate of descent.’
‘If you’ve got to do something differently in
two different places, one or both procedures
is wrong.’
This perceptual confusion has a dangerous side
effect, Loretan says.
‘The control manipulations have become very
complicated, because you have to add up so
many wrongs to get a right there’s no capacity
left in the brain to think.
So we’ve got these poor zombies flying along
who really have nothing left to think with when
things get a bit difficult, say in turbulence or
emergencies, because they are dong four or
five times more thinking than they need to. We
are overloading their basic ability to process
information because the information has been
programmed incorrectly in their brains.’
... training pilots not just
to use the instruments and
systems that are available
but to be sceptical about
them, and to recognise
that they can lull you into a
false sense of security.
Loretan’s other target is what he calls the
'Shaka Zulu' school of standardised training.
The 19th century Zulu warrior king was famous
for conquering other tribes by drilling his army
in the basic movements of fighting, a mode of
instruction Loretan says has no place in aviation.
‘The Zulu idea is that if everybody has the same
size spear, and acts in the same way, they will
prevail. It ignores the fact that hands and feet
are slabs of meat that do what they’re told by
the brain - so it is the brain we must train,’
Loretan says.
‘Training professional aircrew is too focused on
the technical skills of flying an aeroplane and
the odd list of human skills under the label of
human factors. It should be incumbent to train
the person as a functional employee and a
useful member of the aviation environment and
that means broadening a lot more than beyond
the very limited skills of a commercial pilot's
However, he is unconvinced that university
aviation courses do this, saying that the training
they provide is the same as the rest and falls
short of the education they aspire to.
Disquiet over naive faith in technology was a
common theme among training organisations
interviewed for this story.
Whether it was an instructor at a country flying
school commenting on how he could tell when
a 16-year-old on a trial flight had used Microsoft
Flight Simulator because their head was down
rather than looking out; the commercial
instructor lamenting the tendency of students
to engage with glass cockpits rather than the
aeroplane’s attitude; or the airliner simulator
instructor finding some students incapable of,
or unwilling to manually intercept a localiser,
the common theme is of a few pilots letting
technology fly them.
Safety and quality manager for the Royal Aero
Club of Western Australia, Warren Drake,
summed up the issue pithily: ‘I teach my
students that automation is the third member of
the flight crew, and should be treated as such,’
the former Royal Air Force officer and instructor
in the club’s commercial pilot course says. ‘You
have to bear in mind that it could be fallible.’
‘When things used to fail it was more obvious,
and from time to time you’d get practice dealing
with minor failures. Now you don’t get that
practice in line flying, so the practice you get
in simulator sessions is more important than
ever. But if you go back to the line having only
practised the kind of failures you’d get in a Super
Connie, what kind of training is that?’
The last word goes to Loretan, who says if
modern pilots lack airmanship, (which, on the
whole he doesn’t believe), it’s not their fault but
the fault of their teachers.
‘The student I graduate here today would step
into my shoes ten years down the track,’ he says.
‘I went to a conference and all the old guys were
complaining about how bad today’s pilots were.
I took this single book out containing all of my
CPL notes and told them: “This is what you had
to learn for your CPL. A modern CPL is seven
thick text books.”
A modern CPL is seven thick text books compared to one
book of hand-written CPL course notes from the sixties.
‘I said: “You knew nothing, you grew up by
accident and by a stroke of luck you are still
alive. When you graduated you were not at the
standard of a well-trained modern pilot. Help the
young pilots of today.”’
David Learmount adds to this, saying technology
dependence is a problem that results, ironically,
from the high reliability and performance of
modern aircraft.
A timely warning for pilots
It’s a harsh truth, but as far as firefighters are concerned, a sightseer
is a nuisance, whether on foot, in a car or in an aircraft. Sightseers
on the ground get in the way, and in the air they can make an already
crowded and dangerous situation worse.
Aerial firefighting is an intense form of low-level aviation that
becomes potentially dangerous when mixed with general aviation
or media aircraft. A large firefighting operation could involve heavy
helicopters, carrying up to 9000kg of water or retardant used for
firebombing; other helicopters used for firefighter crew transport;
and smaller helicopters flying for command and control, mapping and
aerial ignition.
Then there is the range of fixed-wing aircraft now used in firefighting:
agricultural aircraft modified for firebombing, and referred to as
single-engine air tankers (SEATs); turbine twins; and, last Australian
fire season, a DC-10 wide-bodied jet. Most of these will be operating
at altitudes of 200ft or lower. Light fixed-wing aircraft used for fire
detection, reconnaissance and command-and-control are likely to
be in the area at higher altitudes.
This is why the National Aerial Firefighting Council strongly
recommends all aircraft not involved in firefighting operations to
stay 5nm horizontally and 3000ft (AGL) vertically away from aerial
firefighting operations.
Unnotified intense aviation
activity associated with
firefighting operation may
occur within 5nm and below
3000ft AGL of observed fires.
Aircraft not coordinated
through the state fire authority
are requested to remain clear.
CASA’s Adelaide-based, rotary wing flying
operations inspector and former firefighting
pilot, Mark Crumblin, says a bushfire is no
place for airborne sightseers.
“First of all, there’s not much to see because
of smoke,’ he says.
Crumblin says airspace will also be crowded
away from the fire scene with aircraft
transiting between water pick-ups and
the flames.
‘We operate in a racetrack pattern, with
aircraft shuttling between the water pickup and the fire. It’s like a larger version of
the circuit, and can be just as crowded.
The radio’s pretty busy with the air attack
supervisor setting aircraft priorities and
pilots making their position calls,’ he says.
Due to smoke, firefighting operations
are often conducted in conditions of
reduced visibility. ‘It’s not exactly the best
environment for see-and-avoid,’ Crumblin
says. Although the racetrack pattern reduces
the chances of collision between firefighting
aircraft, any unauthorised aircraft entering
the area brings with it heightened risk of
traffic conflict or worse.
Stay clear! Stay outside 5nm and above
3000ft AGL of observed fires
NSW Rural Fire Service operations officer - aviation, Keith Mackay,
says an important point to note is that firefighting aircraft rarely
operate alone.
‘Generally they’ll be operating in twos or threes,’ Mackay says. ‘By
convention, the racetrack pattern used in firefighting is a right-hand
circuit, but local terrain sometimes requires exceptions,’ he explains.
Firefighting aircraft do not necessarily confine their operations to
where the flames are, Mackay says.
‘A situation could be where the observation aircraft sees a gully that
the fire might reach. The air-attack supervisor might send two or
three aircraft to drop fire retardant in that gully. And that could be up
to 10 nautical miles from the fire.
Mackay stresses the need for even well-intentioned pilots flying
near firefighting operations to be aware of two things: the area QNH
altimeter setting and the area frequency.
‘The other point I’d make is to have the area
QNH so you know your altitude is accurate.’
Crumblin says flying near bushfires is not
a pleasant experience for a private pilot.
‘We’re operating in hot windy conditions at
maximum load. It’s flying to the maximum
performance capacity of the aircraft.’
Many fires are in steep or mountainous
areas which bring the added hazards of lee
and rotor turbulence,’ Crumblin says.
‘I would discourage anyone from being there
without a good reason.’
The air attack supervisor’s aircraft will be assisting pilots by
notifying drop pilots of wires and other hazards and setting priorities
for drops. It generally flies at altitudes of between 500ft and 1000ft,
while the observation aircraft will be higher to take a broader view
of the incident and formulate wider strategy. It’s unlikely that any of
these will be higher than 3000ft, Mackay says, but if they are rotary
wing aircraft they are likely to make frequent climbs to, or descents
from, their operating altitude as they take various personnel aloft.
‘All our aircraft have two comms units,
one tuned to the area frequency and one
used for plane-to-plane communications
and speaking to ground-based fire units.
The point is if you are anywhere near a
firefighting operation, and if you’re in any
doubt about traffic separation, all you have
to do is announce yourself on the area
frequency and they will hear you.’ (But you
should never assume this).
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Maintenance is one of the pillars of aviation safety. Any aircraft,
whether new or with thousands of hours and cycles, needs expert
attention paid to it for every hour it flies. The Australian Transport
Safety Bureau quotes an average of 12 man-hours of maintenance
for every hour of flight. The safety implications are obvious.
Over several years, the Civil Aviation Safety Authority has consulted
extensively with the Australian aviation industry and has determined
that improvements could be made to the current regulations for
aircraft maintenance and maintenance personnel:
There is scope for new regulations that will not have to rely on the
exemptions that have been added to the current regulations over
the years. Freshly-drafted regulations will be easier to understand
and comply with. There is scope for new regulations to allow
innovation and improved efficiency to industry, while maintaining
high levels of safety.
There is an opportunity for new rules to align with international
regulations. This would allow Australian aviation to respond
to international changes in safety-related practices, and allow
Australian aviation maintenance organisations to compete for
international work.
Newly-drafted regulations would make clear the standard of
compliance expected by CASA and would allow for eventual
technological change.
New regulations would clarify differing requirements for varying
industry sectors.
CASA’s approach to developing new regulation is outcomes-based:
legislation details what safety standards need to be achieved, and then
allows businesses to determine how best to
achieve those outcomes. CASA will provide
an acceptable means of compliance which
reflect the standards. Operators can suggest
an alternative means of compliance, which
will be assessed and approved by CASA if it
achieves the standards to an equivalent or
great extent.
This does not mean a free-for-all, or imply any
relaxation of standards. In practice, stringent
enforcement of standards will dictate what
maintenance methods and techniques are
required to meet those standards. However,
under the new regulations there will be
scope for innovation within this disciplined
environment. Outcomes-based legislation
recognises that significant level of expertise in
aircraft maintenance resides in the industry.
Individual maintenance organisations can
decide what works best for their particular
circumstances, but must always meet the
required safety outcome. High standards
would be required for any alternative to
be deemed to be an ‘acceptable means of
compliance.’ CASA maintains close and
effective relationships with civil aviation
authorities around the world, including the
European and United States authorities.
There are also regulations about what these people should do to keep
aircraft in top, airworthy shape. But these regulations themselves are
in need of some maintenance - some improvements - to make a safe
industry even safer.
With the formation of the European Aviation
Safety Agency (EASA), CASA took a keen
interest in the aviation regulatory framework
being developed to cover the members of the
European Union.
EASA faced the challenge of developing a
system that would work and provide a safe and
standardised safety result in an environment
with 31 different nations, using 23 official
languages, all with differing regulation
and enforcement processes and training
systems. EASA decided on a set of safety
outcome-based legislation which directs their
aviation industry to the required result of the
legislation, rather than having a prescriptive
rule set. The philosophy is predominantly
‘you will achieve …’ rather than ‘you will do’.
CASA looked at EASA’s maintenance rules
and concluded that they would make a sound
starting point for developing equivalent
Australian regulations. The EASA regulatory
model for maintenance provides a safetyfocused, pragmatic, flexible and outcomebased regulatory environment for industry to
operate in. EASA’s model embraces human
factors in search of a better safety outcome.
CASA set out to reform Australian maintenance
regulations with two goals in mind: to provide
Australia with a modern and effective set
of safety regulations covering all elements
of aviation maintenance and training; and
to implement a new form of regulatory
model. Work then began on adapting the
EASA regulations to Australian legal drafting
requirements, with as little change to the
outcomes as possible. Completion of the new
regulations is planned for November 2010.
Implementation will take place in
two stages.
Stage one, beginning in June 2011, will be for all
organisations operating or maintaining regular public
transport (RPT) aircraft and/or aeronautical products
for aircraft currently operated under CAR 206(1)(c) air
operators’ certificates (AOC), as well as LAMEs and
maintenance training organisations.
Stage two, anticipated to begin in June 2013, will
be for organisations maintaining aircraft and the
aeronautical products for all aircraft not operated
under an RPT air operator’s certificate such as
charter, aerial work and general aviation.
The new Australian regulations will be based on an existing and
effective set of European legislation.
The inherent flexibility of the regulation style allows consideration
of flexible implementation in various sectors, such as RPT and GA.
Harmonising our regulatory requirements for maintenance
organisations and maintenance training organisations with
a major overseas system, and on the basis of recognised
certification, will allow Australian maintenance organisations to
compete for business internationally.
The flexibility in the system allows industry to be more innovative
with new work methods, and appropriate regulatory approaches.
Enhanced management of safety information and systems.
The project team is adopting the European system, while ensuring that
the new system is tailored to Australian requirements. It incorporates
Australian aviation strengths, such as competency-based training, and
our acknowledged expertise in aviation safety.
Key facts
The new regulations include a revised regulatory arrangement for
the training, qualification and experience of those controlling and
performing maintenance.
The new regulations adopt a regulatory style similar to that
utilised by the European Aviation Safety Agency (EASA).
This regulatory style also allows for different methods of
achieving the outcomes for large and small aircraft and various
types of operations.
The regulations are the result of extensive consultation
with industry.
Boeing 737476 Hydraulic system contactor
faulty. SDR 510011150
Hydraulic system ‘A’ circuit breaker tripped without
pump being turned on. Investigation found faulty
contactor R317.
P/No: 106144524.
1 August 2010 –
30 September 2010
Note: occurrence figures not included in this edition.
Airbus A320212 Flight data recorder
unserviceable. SDR 510011050
Digital flight data recorder (DFDR) unserviceable.
Boeing 73733A Aircraft elevator push/pull rod
clevis broken. SDR 510011061
Left-hand elevator tab push/pull rod attachment
horn fitting clevis snapped off during installation.
Investigation found evidence of previous cracking.
Airbus A320232 Elevator hinge fitting arm
damaged. SDR 510011019
No. 4 left-hand elevator hinge fitting arm
damaged and delaminated. Arm is constructed
of composite material.
Boeing 73733A Aircraft oxygen system hose
cracked. SDR 510011057
Flexible oxygen hose cracked/broken/torn. Hose is
located at passenger service unit (PSU) 167 left.
P/No: 417N31382.
Airbus A320232 Flight augmentation computer
faulty. SDR 510011176
No.1 flight augmentation computer (FAC) faulty.
P/No: B397BAM0617.
TSN: 13,585 hours/6,023 cycles.
Boeing 73733A ELT unserviceable.
SDR 510011060
Nil output from ELT following antenna change.
P/No: 9260065.
Airbus A320232 Landing gear failed to extend
at first attempt. SDR 510011174
Landing gear failed to extend. Gear extended after
a second try. Investigation could find no definitive
cause for the defect and landing gear operated
normally on ground functional checks.
Airbus A330202 Main landing-gear wheel
brake stator failed. SDR 510011011
No. 2 main wheel brake stator failed.
Investigation continuing.
P/No: 215782.
Airbus A380842 Flight control system
computer faulty. SDR 510011146
Electrical flight control secondary computer faulty.
Investigation continuing.
BAC 146200 Windshield heating system filter
unserviceable. SDR 510011036
Windshield heating system filter 2HL20 burnt
and unserviceable.
P/No: ND00751764.
BAC 146300 Fuselage lightning strike.
SDR 510011041
Aircraft suffered a lightning strike in the nose area.
Investigation could find no entry/exit points and
no damage.
BAC Jetstream3206 Inverter unserviceable.
SDR 510011072
Essential inverter unserviceable.
P/No: 1B3501B13.
BAC Jetstream4101 Engine mount bolt
fractured. SDR 510011030
Rear engine mount bolt head separated.
P/No: NAS6706DU75.
Beech 1900D Landing gear motor failed.
SDR 510011252 (photo following)
Landing gear extend/retract electric motor
failed internally.
P/No: 571302.
Boeing 73733A Spoiler actuator eye end piston
stripped thread. SDR 510011055
No. 4 ground spoiler inboard actuator eye end piston
internal thread stripped.
P/No: 65448517.
Boeing 737376 Aircraft landing light missing.
SDR 510010948
Left-hand outboard landing light assembly missing.
P/No: 4500837. TSN: 48,067 hours.
TSO: 2,392 hours.
Boeing 737376 Crew oxygen cylinder shutoff
valve leaking. SDR 510010971
Crew oxygen cylinder leaking from shutoff
valve spindle.
TSN: 2,780 hours.
Boeing 737476 Aircraft emergency lighting
battery pack failed. SDR 510010972
Emergency lighting system battery pack not holding
sufficient charge to illuminate emergency lights for
more than approximately 15 seconds.
P/No: M1134.
Boeing 737476 Air conditioning control panel
suspect faulty. SDR 510011124
Pressurisation system problems. Suspect
faulty pressurisation control panel. Investigation
Boeing 737476 APU failed. SDR 510010937
APU failed in flight. Investigation found evidence
of fresh oil in exhaust. Suspect turbine seal failing.
Investigation continuing.
P/No: 737M49503011. TSN: 55,332 hours.
TSO: 1,473 hours.
Boeing 737476 Engine pylon strut panel
missing. SDR 510011278
No. 2 engine pylon strut access panel separated in
flight. Investigation continuing.
Boeing 737476 Flight attendant oxygen mask
panel stuck. SDR 510011155
Forward flight attendant double oxygen mask
covering panel sealed shut with Silastic. Allso found
a piece of trim fouling the latch.
Boeing 737476 Trailing edge flap system
faulty. SDR 510011258
Trailing edge flap asymmetry.
Investigation continuing.
Boeing 737476 Wing leading edge slat
arm failed. SDR 510010994
No. 2 leading edge slat outboard track guide
arm broken.
P/No: 65C266564.
Boeing 7374L7 Elevator excessive play.
SDR 510011170
Excessive movement in right-hand elevator of
approximately 8.89mm (0.350in). Maximum play
as per maintenance manual 5.33mm (0.210in).
Boeing 7374L7 Wing to pylon plug burnt.
SDR 510011171
Left-hand wing to pylon disconnect plug D05124 ‘B’
phase socket burnt and welded to pin.
P/No: D05124.
Boeing 7377BX Elevator pitot tube heater open
circuit. SDR 510010921
Right-hand elevator pitot tube heater open circuit.
P/No: 0851HT1. TSN: 19,485 hours/10,864 cycles.
Boeing 7377BX Wing fuel surge tank panel
seal split. SDR 510011248
Right-hand wing surge tank access panel seal
split, dislodged and leaking. Seal was also in very
poor condition.
P/No: 110A01141.
Boeing 7377FE Wing leading edge slat
actuator leaking. SDR 510011249
Left-hand wing No. 2 leading edge slat
actuator leaking from area of inboard swivel.
Loss of hydraulic fluid.
P/No: 3818001005.
TSN: 16,241 hours/11,387 cycles.
Boeing 73782R Wheel well bulkhead vapour
barrier cracked. SDR 510011100
Left-hand wheel well forward bulkhead (rear spar)
lower LH web vapour barrier cracked from LBL 31.83
to LBL 45.64.
Boeing 737838 Air conditioning system
pressurisation faulty. SDR 510011167
Pressurisation system problems.
Boeing 737838 Aircraft fuel tank access panel
gasket leaking. SDR 510010974
Fuel tank access panel located inboard of No. 1
engine strut leaking due to faulty gasket.
P/No: 656C330952.
Airbus A330202 Engine anti-ice valve faulty.
SDR 510011128
No. 2 engine anti-ice valve faulty. Valve was closed
with anti-ice ‘On’.
P/No: FYLB521452.
Boeing 73733A Fuselage structure corroded.
SDR 510011053
Aircraft structure corroded beyond limits in
numerous locations.
Boeing 737476 Potable water tank failed.
SDR 510011202
Right-hand potable water tank plug failed. Loss
of tank contents. Plug/snap ring shattered.
Investigation continuing.
Airbus A330202 Cockpit air conditioning
system odour. SDR 510011197
Oil fumes in cockpit. Investigation found oil
contamination of cockpit trim air valve and hot
air valve.
Boeing 737476 Hydraulic system pump failed.
SDR 510010938
System ‘A’ and System ‘B’ engine driven hydraulic
pumps failed. Metal contamination of both case
drain filters. Investigation continuing.
Boeing 737838 APU failed to start.
SDR 510011236
APU failed to start. Aircraft would not accept
ground power. Investigation continuing.
Boeing 737838 Elevator pushrod attachment
bolt nut missing. SDR 510011151
Right-hand elevator pushrod aft attachment bolt
P/No 69-44683-2 nut missing. Inner and outer bolt
nuts P/No BACN10JC10CD and P/No BACN10JC7CD
not in safety and able to be turned. Investigation
P/No: 69446832.
Boeing 737838 Engine bleed air wiring
harness faulty. SDR 510011144
No.1 engine bleed air faults. Investigation found
faulty wiring harness between bleed air regulator
(DP1102) and engine firewall (DP1104). Harness
P/No 325-029-905-0 and bleed air regulator
P/No 107492-6 changed.
P/No: 3250299050.
Boeing 737838 Hydraulic system low pressure
switch connector plug corroded.
SDR 510010973
Hydraulic ‘B’ system low-pressure switch SW 142
connector plug D0816 corroded.
P/No: 1225P62.
Boeing 737838 Integrated standby flight
display failed. SDR 510011245
Integrated standby flight display (ISFD) failed.
Investigation continuing.
Boeing 737838 Trailing edge flap actuating
bellcrank sheared. SDR 510011203
Right-hand outboard trailing edge flap actuating
bellcrank sheared off.
P/No: 113A39104.
Boeing 737838 Uncommanded ELT activate.
SDR 510011040
Uncommanded ELT activation. Investigation
P/No: 11534261M512. TSN: 2,058 hours.
TSO: 2,058 hours.
Boeing 7378FE Air cycle machine seized.
SDR 510011023
No.1 air cycle machine (ACM) seized and one fan
blade fractured.
P/No: 22064002. TSN: 73 hours/48 cycles.
Boeing 7378FE Alternate pitot probe heat
system unserviceable. SDR 510011073
Alternate pitot probe heat system unserviceable.
P/No: 0851HT1. TSN: 22,809 hours/13,350 cycles.
Boeing 7378FE Elevator pitot probe drain
blocked. SDR 510010927
Right-hand elevator pitot probe visco jet
drain blocked.
Boeing 7378FE Engine fuel supply spar valve
actuator intermittent. SDR 510011179
No.1 engine fuel supply spar valve actuator
intermittent in operation.
P/No: MA30A1001. TSN: 330 hours/219 cycles.
Boeing 747438 Aircraft fuel override jettison
pump seized. SDR 510011145
Fuel override jettison pump rotor seized due to
swarf/debris. Debris also found in pump cavity.
Boeing 747438 Crew oxygen bottle time
expired. SDR 510011240
Upper crew oxygen bottle time expired. Bottle
installed with overdue hydrostatic test date.
P/No: B423651.
Boeing 747438 Engine hydraulic pump drive
shaft sheared. SDR 510011159
No2 engine driven hydraulic pump drive shaft
sheared. Case drain filter contaminated.
P/No: 6506605.
Boeing 747438 Forward galley oven smoke/
fumes. SDR 510011130
Forward galley oven 124/2 heating element and fan
contaminated. Smoke and fumes issuing from oven.
Boeing 747438 Main landing gear tyre tread
separation. SDR 510010949
Main landing gear No. 6 rear tyre tread separated.
Tyre deflated. Damage to fairing aft of tyre and
minor damage to RH body landing gear outboard
shock strut door aft edge. Investigation continuing.
Boeing 747438 Trailing edge flap rod failed.
SDR 510011239
No. 2 trailing edge flap rod failed and damaged
canoe fairing. Investigation continuing.
P/No: 65B156513.
Bombardier DHC8202 Landing gear failed to
extend – air in hydraulic system.
SDR 510010953
Landing gear failed to extend. Gear eventually
extended and aircraft landed safely. Investigation
found air in No2 hydraulic system.
CVAC 340 Wing fuel tank boost pump failed.
SDR 510011279
LH wing fuel tank boost pump failed.
P/No: TF39002. TSO: 3,785 hours.
Embraer EMB120 Aileron shroud damaged.
SDR 510010930 (photo below)
Left-hand upper aileron shroud damaged and
partially separated. Investigation found that the
inboard 15 fasteners had not been reinstalled
at last maintenance visit. Shroud had broken at
approximately two-thirds of length. Support
bracket P/No 120-31648-001 had cracked along
trailing edge radius.
P/No: 12021945001.
TSN: 50,101 hours/58,676 cycles.
Boeing 747438 Trailing edge flap spindle loose.
SDR 510011220
Trailing edge outboard aft flap spindle not secured
to structure. One screw was loose and both
screw threads were worn. Washers also missing.
Investigation continuing.
P/No: 65B0197038.
Boeing 747438 Wing fuel surge tank drain
coupling loose. SDR 510011222
Main fuel tank fuel imbalance. Investigation found
wing surge tank forward drain tube coupling
directly inboard of tank access panel 646AB loose
and incorrectly lockwired. No.4 tank forward drain
tube rigid coupling at tank wall into No.3 main tank
missing an o-ring seal.
Boeing 767336 Elevators felt heavy during
landing. SDR 510011277
Elevators unusually heavy during landing flare.
Investigation continuing.
P/No: 32687929.
Boeing 767336 Fuselage skin cracked.
SDR 510011255
Fuselage skin cracked at location BS 1660 stringer
13L. Crack length approximately 44.4mm (1.75in) and
splits in two. Crack is located aft of the pressure
bulkhead in an unpressurised zone.
Boeing 767338ER Cargo power drive unit
inoperative - loom chafed through.
SDR 510011034
No. 3 aft cargo power drive unit (PDU) failed to
operate. Investigation found loom adjacent to
PDU chafed through and sparking. Investigation
Boeing 767338ER Spoiler rub strip separated.
SDR 510011133
Unknown piece of metal separated from RH wing
during flap extension. Investigation found the metal
was the No.10 spoiler lower aft edge rub strip.
P/No: 88PH15034B.
Bombardier DHC8202 Flaps failed to extend micro switch contaminated. SDR 510010951
Flaps failed to extend when selected. Nil other
indications and no circuit breakers popped.
Investigation found flap selector micro switch
contaminated with dust/lint and earth wire at flap
power unit plug 2752-p3 had cracked insulation.
Embraer EMB120 Electronic horizontal
situation indicator failed. SDR 510011177
No.1 electronic horizontal situation indicator
(EHSI) failed.
P/No: 6226197002. TSO: 4,994
hours/3,320cycles/53 months.
Embraer EMB120 Elevator trim tab hinge
bracket corroded. SDR 510011162
Left-hand elevator trim tab middle hinge brackets
contained exfoliation corrosion. Found during
CPCP inspection.
P/No: 12011293001.
Embraer EMB120 Main landing gear wiring
loom worn and damaged. SDR 510011178
Right-hand main landing gear wiring loom contained
severe corrosion on connectors, severe chafing and
multiple breaches of wire to the core. Wire numbers
W608-0114-24, W608-0076-22, W608-0099-22 and
P/No: W608.
Embraer ERJ170100 IRU unserviceable.
SDR 510011103
No. 2 inertial reference unit (IRU) failed.
P/No: HG2100AB02. TSN: 7,182 hours/7,282 cycles.
Embraer ERJ190100 AC electrical terminal lug
open circuit. SDR 510010928
AC essential bus terminal TB0021 lug open circuit.
P/No: MS25036103.
Embraer ERJ190100 Main landing gear
trunnion bearings moved. SDR 510011264
LH and RH main landing gear upper side stay
trunnion bearings migrated. LH main gear side
stay trunnion bearing had migrated by 4.6mm
(0.18in). RH main gear side stay trunnion bearing
had migrated by 4.5mm(0.177in).
TSN: 6,036 hours/4,031 cycles.
Embraer ERJ170100 Nose-wheel steering
disarming switch faulty. SDR 510011135
Nose-wheel steering disarming switch failed.
P/No: MS21346231. TSN: 7,214 hours/7,313 cycles.
Fokker F27MK50 Landing gear selector panel
faulty. SDR 510010939
Landing gear selector panel faulty. Investigation
P/No: D49414001. TSO: 996 hours/707 cycles.
operate during test. Investigation found intermittent
contacts in the internal micro switch. Investigation
also found high resistance in the control panel
engine fire bottle squib firing switch contacts.
P/No: 5942014.
Fokker F28MK0100 Cargo door handle in
unlocked position. SDR 510010940
Forward cargo door handle in unlocked position,
although the door was still closed and latched.
Suspect secondary lock handle was forced open
by aerodynamic loads when handle was allowed
to enter the airflow due to faulty springs. Primary
locking mechanism was unaffected.
Saab SF340B Engine intake duct anti-ice wire
burnt duct. SDR 510010964
Left-hand engine lower intake duct anti-ice wiring
caused burn damage to duct.
TSO: 5,143 hours/5,707 cycles.
Hawker-Beech 900XP Wing fuel tank boost
pump faulty. SDR 510011254 (photo below)
LH wing fuel tank boost pump failed. Investigation
found a broken power wire, which was arcing
against the body. A small amount of fuel was also
leaking through the wiring receptacle and being
ignited by the arc.
P/No: 2C402. TSN: 798 hours/549 cycles.
Beech 200 Landing-gear power pack faulty.
SDR 510011218
Landing gear relay circuit breaker tripped.
Investigation found two faults: 1. power pack
P/No 101-388005-17 internal fault 2. LH main
landing gear actuator P/No 101-388014-19 leaking
internally. P/No: 10138800517.
Beech 58 Nose landing-gear failed to extend.
SDR 510011147
Nose landing gear failed to fully extend. Nose
landing gear collapsed during landing causing
damage to nose gear and radome area.
Investigation continuing.
Lear 35A Horizontal stabiliser trim actuator
faulty. SDR 510011089
Horizontal stabiliser trim actuator faulty.
P/No: 35010203.
Raytheon 850XP Hydraulic non-valve faulty.
SDR 510011246
Hydraulic non-return valve leaking fluid into bleed
air lines. Valve is located between the bleed air
supply and hydraulic reservoir, providing reservoir
P/No: HTE4853. TSN: 790 hours.
Saab SF340B Battery thermal switch ground
wire burnt. SDR 510011161
DC battery thermal switch ground wire PA 0301
burnt. Investigation continuing.
P/No: 55T8015249.
Saab SF340B DC bus bar to circuit breaker
feeder wire burnt. SDR 510010967
Wire HD 134 found burnt in several areas. Damage
included melted and bubbled insulation as well as
cracked and missing insulation. Wire is feeder wire
from DC bus bar to circuit breaker 1HD. Several
circuit breakers exhibited weld marks on screws.
Suspect caused by circuit breaker panel being
shifted when power was ‘On’.
P/No: HD134.
Saab SF340B Engine fire shutoff valve failed
to operate during test. SDR 510011009
Right-hand engine fire shutoff valve failed to
Cessna 172M Window separated.
SDR 510010979
Right-hand window separated in flight causing
damage to hinge and minor paint damage to
underside of RH wing and flap. Window was opened
in flight by passenger wanting to take photographs.
P/No: 0711050207.
Cessna 172RG Nose landing gear safety
switch wire broken. SDR 510011182
Nose landing gear safety switch wire broken. Wire
had a total of ten joiners in 0.76m (2.5ft) length.
TSN: 5,430 hours.
Cessna 182H Landing gear brake master
cylinder bracket cracked. SDR 510011069
Right-hand brake master cylinder lower attachment
bracket cracked and master cylinder pulled out
of bracket.
P/No: 07136283. TSN: 8,997 hours.
Cessna 208B Wing fuel sump panel corroded.
SDR 510011091
Left-hand wing fuel sump panel severely corroded.
P/No: 26222634. TSN: 6,390 hours.
TSO: 6,390 hours.
Cessna 210N Main landing gear actuator bolt
incorrect part. SDR 510010985
Main landing gear actuator attachment bolts
incorrect part. Bolts were also not safety
P/No: NAS464P5LA29.
Cessna 402C Main landing gear torque link
bolt separated. SDR 510011242
Right-hand main landing gear torque link centre bolt
disconnected from torque links allowing the wheel
to rotate around the leg. Investigation found the bolt
and nut intact with the split pin still fitted. Further
investigation found incorrect washers fitted beneath
the nut and the head of the bolt.
Cessna 402C Nose landing gear wheel well
angle cracked. SDR 510011166
Nose landing gear wheel well damaged.
Investigation found buckling and cracking of
attachment angle of sidewall and top plate located
at Stn 79 left-hand side.
P/No: 521304021. TSN: 11,932 hours.
Cessna 404 Fuselage/wing root hydraulic
line leaking. SDR 510011275
Hydraulic oil line leaking from pinhole in area
where line exits fuselage to left-hand wing root.
P/No: 581710210.
Cessna 421C Main landing gear trunnion
cracked. SDR 510011033
Right-hand main landing gear trunnion cracked
vertically along casting mark for approximately
304.8mm (12in) then diagonally for approximately
63.5mm (2.5in). Crack is completely through the wall
of the tubular structure with the lower fork of the
trunnion distorted by approximately 2mm (0.078in)
at the crack.
P/No: 59411102. TSN: 6,596 hours.
Cessna 441 Nacelle hydraulic line holed.
SDR 510011083
Right-hand hydraulic pressure line located in righthand nacelle had a pinhole leak.
P/No: 572700258.
Diamond DA42 Multi-function display
unserviceable – smoke/fumes. SDR 510011025
Smoke and fumes coming from top SD card slot
on multi-function display (MFD). MFD screen
information dimmed to almost unreadable. Nil
external evidence of burning, but MFD smelt burnt.
P/No: 0110097203. TSN: 846 hours.
Grob G115C2 Engine oil cooler and filter
contaminated. SDR 510011086
Engine oil cooler and oil pressure filter contaminated
with pink abrasive granules. Suspect contaminant
was from manufacture of oil cooler, which was only
11.4 hours time since new.
P/No: 20006A. TSN: 11 hours.
Jabiru J230DL Elevator trim cable broken.
SDR 510011108
Elevator trim cable broken/separated at rear
swage. Aircraft is registered with Recreational
Aviation Australia.
TSN: 19 hours.
Beech 58 Nose landing-gear drag brace
broken. SDR 510011165
Nose landing gear aft drag brace failed on RH side.
Failure appears to be at the welding vent hole.
It was also noted that the RH side spacers located
between the brace pivot hole and the wheel well
sidewall were missing.
P/No: 4582507239. TSN: 12,514 hours.
Cessna 210N Nose landing gear actuator
spring guide damaged. SDR 510010984
Nose landing gear actuator spring guide damaged.
Inspection found that the guide was early model
P/No 1280206-1 and not the improved
P/No 9882024-1 as required by SE84-3.
P/No: 12802061.
Fokker F28MK0100 Engine oil coolers SUP.
SDR 510011136
Newly-received engine oil coolers, suspect
unapproved part (SUP). Two oil coolers had the same
serial number as each other. One of the coolers had
a data plate but the other cooler had the same part
number and serial number engraved on the body.
Investigation continuing.
P/No: JR31848A.
Saab SF340B Passenger compartment
fluorescent tube failed - odour. SDR 510011002
Passenger compartment fluorescent lighting tube
located at row 2BC failed. Flight attendant detected
an odour and heard a crackling noise but no smoke
was seen.
P/No: F8T5CW.
Cessna 210N Nose landing gear actuator bolt
seized. SDR 510010983
Nose landing gear actuator rear bolt seized
in bushing.
Kavanagh G450 Balloon burner load frame
cracked. SDR 510010990
Balloon burner load frame cracked in several places
along original welded joints.
P/No: KLF201088. TSN: 466 hours/27 months.
Pilatus PC12 Trailing edge flap PDU seized.
SDR 510010968
Trailing edge flap power drive unit (PDU) seized.
P/No: 9787320003. TSN: 450 hours/4 months.
Piper PA28161 Aileron actuator attachment
fitting cracked. SDR 510011065
Right-hand aileron actuator attachment fitting
cracked in radius. Crack length approximately
10mm (0.39in).
P/No: 3564022. TSN: 9,619 hours.
Piper PA28R201 Nose landing gear actuator
rod end broken. SDR 510011064
Nose landing gear actuator rod end broken
through threaded area.
P/No: 452729.
Piper PA30 Main landing gear oleo strut
cracked. SDR 510011070
Right-hand main landing gear oleo strut cracked
and leaking in area of web.
P/No: 2705301. TSN: 8,333 hours.
Piper PA32300 Hydraulic power systems
hydraulic line holed. SDR 510011047
Hydraulic pressure line pinhole leak due
to corrosion.
P/No: 67700116. TSN: 5,684 hours.
Piper PA44180 Main landing gear trunnion
cracked. SDR 510011225
Left-hand and RH main landing gear trunnions
P/No 67926-037 and P/No 67926-036 cracked in
area of forward lugs. Found during FPI.
P/No: 67926037.
Swearingen SA226TC Autopilot trim servo
intermittent. SDR 510011276
Autopilot pitch servo faulty causing random pitching
and controls to stick.
P/No: 6222366001.
Swearingen SA226TC Cockpit window failed.
SDR 510011026
Right-hand cockpit side window failed resulting in
explosive decompression. Investigation found that
the window had been incorrectly installed.
P/No: 2621383010. TSN: 4,695 hours.
Swearingen SA227AC Hydraulic pump failed.
SDR 510011188
Right-hand engine driven hydraulic pump failed.
Investigation found the drive shaft teeth stripped
and the drive gear damaged.
P/No: PV3044026. TSO: 2,707 hours/4,690 cycles.
Swearingen SA227DC Engine EGT harness
cannon plug unserviceable. SDR 510011048
Left-hand engine EGT short harness cannon
plug pins and sockets worn causing random EGT
P/No: MS3451L10SL4P.
Swearingen SA227DC Flap hydraulic pressure
pipe split. SDR 510011185
Flap system rigid hydraulic pressure pipe split and
leaking at outer radius of 90-degree bend. Pipe is
located in LH wheel well.
P/No: 27810321040. TSN: 20,551 hours/28,549
landings. TSN: 20,551 hours/28,549 landings
/204 months.
Swearingen SA227DC Inverter wire worn and
damaged. SDR 510011187
No.2 inverter failed. Investigation found inverter
wire chafing through insulation on RH 26VAC bus bar
causing short circuit and circuit breaker trip.
P/No: SPC38A.
Further investigation found other incorrect wiring in
the electrical system.
Bell 206L1 Fuselage frame cracked.
SDR 510011125
Rear fuselage frame (tail boom attachment) cracked
in two places at upper-LH and upper-RH sides.
P/No: 206032308003. TSN: 10,661 hours.
Bell 206L1 Tail rotor drive shaft cracked.
SDR 510011012
Tail rotor driveshaft cracked from coupling
attachment bolt hole.
P/No: 206040370003. TSN: 8,815 hours.
Bolkow BO105LSA3 Tail rotor gearbox bearing
corroded. SDR 510010976
Tail rotor gearbox bearing inner and outer races
corroded. Ball had lost chrome plating. Bearing also
exhibited approximately 0.25mm (0.010in) axial play
(nil allowed).
P/No: 4639311003.
Eurocopter AS350BA Starter-generator
unserviceable. SDR 510011142 (photo below)
Starter generator failed. Investigation found the
starter drive spline sheared. Corrosion was found
on the shaft, indicating stress corrosion cracking.
P/No: 524031.
TSO: 844 hours/1,884 landings/18 months.
Robinson R44 Main rotor blades spindle worn.
SDR 510011016
Main rotor spindle worn/damaged by dust between
the spindle and sealing boot.
P/No: C1581. TSN: 1,100 hours.
Continental GTSIO520M Engine cylinder bolt
failed. SDR 510010946
Right-hand engine No. 5 cylinder had four retaining
bolts with the bolt heads sheared off. The two
cylinder through bolts were intact. Investigation
found no obvious damage to the cylinder.
TSO: 489 hours.
Continental GTSIO520M Engine cylinder
cracked. SDR 510010945
Left-hand engine No. 5 cylinder low compression.
Initial investigation indicated leaking piston rings.
Cylinder removed and inspected. Overhaul facility
found an internal crack in the cylinder in the area of
the lower spark plug port.
P/No: 655474A9P005. TSO: 937 hours.
Continental IO520C Engine connecting rod
failed. SDR 510011081 (photo below)
Left-hand engine No. 6 cylinder connecting rod
failed. Damage caused to engine.
TSO: 1,165 hours.
Eurocopter EC135 Engine air intake screen
damaged. SDR 510011018 (photo below)
No.1 engine failed to motor during start.
Investigation found FOD in the form of solder
particles in the intake area and in the compressor.
Further investigation found the solder came from
the engine intake screen. It was found that the
aircraft had previously been parked and shut
down with the tail into the wind. The wind then
entered the exhaust and went through the
engine at a temperature high enough to cause
the solder to melt.
P/No: 319718500PRESB319712039.
TSN: 4,596 hours. TSO: 1,611 hours.
Continental IO550N Engine cylinder rocker
arm broken. SDR 510010977 (photo below)
Engine exhaust rocker arm broken. Suspect
defective manufacture with suspected casting blow
hole and/or fold inclusion.
P/No: 628530K. TSN: 90 hours. TSO: 90 hours.
- intake screen
MDHC 369E Engine starting wiring incorrect
part. SDR 510011122 (photo following)
Engine starting system wiring incorrect part.
Three 10-gauge wires running in parallel instead
of one single two-gauge wire as per manufacturer
confirmation. Following removal of incorrect wires,
it was found that the insulation in the wires was
cracked in conduit running under fuel system.
Continental TSIO550G Turbocharger inlet
pipe cracked. SDR 510011113
Right-hand turbocharger inlet pipe cracked.
P/No: 657687. TSN: 529 hours.
Lycoming IO360A1A Engine exhaust system
cracked. SDR 510011184 (photo following)
Exhaust tailpipe and muffler cracked.
P/No: 630045503630045501. TSN: 4,159 hours.
Garrett TPE33112UH Engine fuel manifold
unserviceable. SDR 510011186
Left-hand engine aft fuel manifold leaking from
‘B’ nut area where flow divider pipe joins the
manifold. Investigation found a fatigue crack in
the manifold flare.
P/No: 31024692.
Lycoming IO540E1B5 Engine camshaft worn
and damaged. SDR 510011257 (photo below)
Camshaft lobes worn/damaged and associated
lifters spalled.
P/No: 05K22721. TSN: 306 hours. TSO: 306 hours.
Garrett TPE33114HR Engine oil system tube
fractured. SDR 510011031
Right-hand engine rear bearing oil scavenge
tube fractured.
P/No: 31054521. TSN: 20,147 hours/22,362 cycles.
Lycoming IO540E1B5 Engine fuel pump
incorrect part. SDR 510010954
During pre-fitment inspection of engine-driven fuel
pump, it was found that the drive shaft was slightly
longer than normal. Further investigation found
the shaft was an incorrect part. This prevented full
mating of the drive and driven splines.
P/No: RG9080J1.
Garrett TPE3318403S Engine EGT
compensator faulty. SDR 510011035
Left-hand engine EGT compensator faulty.
Compensator sending erratic signals to the LH fuel
computer causing a high EGT reading (overtemp).
Investigation found that no actual overtemp
was experienced.
P/No: 8974768.
GE CF680C2 Engine turbine disc cracked.
SDR 510011022
Stage 2 high-pressure turbine disc contained crack
indications in aft dovetail serrations. Found during
FPI. Investigation continuing.
P/No: 936M43P02.
Lycoming IO540 Magneto housing corroded.
SDR 510011226
Magneto housing badly corroded. Magneto is
believed to be from a BN2 aircraft used on coastal
surveillance duties.
P/No: 10349394.
GE CF680E1 Engine turbine seal
unserviceable. SDR 510011028
Engine high-pressure turbine rotating seal
unserviceable. Investigation continuing.
P/No: 1778M69P04.
Lycoming O235L2C Engine bearing worn.
SDR 510011256
Engine centre main bearing worn, found following
engine oil filter check.
P/No: 18D26100. TSN: 3 hours. TSO: 3 hours
Lycoming O360A1A Cylinder spark plug loose.
SDR 510010926
No.3 cylinder top spark plug loose. Spark plug was
found hanging on lead with last two threads burnt.
Spark plug is an automotive plug fitted in an insert.
PWA R985AN14B Engine cylinder exhaust
valves seized. SDR 510011210
Investigation following partial engine failure with
loss of power found four exhaust valves almost
seized due to a large amount of carbon build up and
the other five exhaust valves with moderate carbon
build up. P/No: 3485. TSO: 667 hours.
Garrett TFE73150R Engine uncommanded
rollback. SDR 510011262
Left-hand engine uncommanded rollback
during power adjustment. Engine restarted OK.
Investigation continuing.
P/No: TFE73150R1H. TSN: 798 hours/549 cycles.
TSO: 798 hours/549 cycles.
IAE V2527A5 Engine bleed air system coupling
failed. SDR 510011251
Bleed air coupling located between ‘Y’ connector
and IP check valve failed. Duct separated from check
valve with flange seal missing. Air leak caused
further to components. HP bleed valve cannon
plug sheared and fire shield damaged. Skin and
honeycomb damaged. Wiring harness damaged.
P/No: 62992580400.
IAE V2527A5 Engine turbine disc
unserviceable. SDR 510011231
Engine second stage high-pressure turbine hub
contained linear indications in the pressure face of
the fir tree root in eleven locations. Found during
penetrant inspection.
P/No: 2A4802. TSN: 18,001 hours/9,314 cycles.
IAE V2527A5 Engine turbine disc
unserviceable. SDR 510011232
Engine first stage high-pressure turbine hub
contained linear indications in the pressure face of
the fir tree root in fifty five locations. Found during
penetrant inspection.
P/No: 2A5001. TSN: 18,709 hours/11,201 cycles.
Lycoming LTS101700D2 Engine exhaust cone
inner baffle unserviceable. SDR 510010986
Engine exhaust cone inner baffle broken apart,
and contacting rear face of power turbine wheel,
Rolls Royce RB211524G Engine turbine blade
failed. SDR 510011117
No.4 engine failure with noticeable vibrations. Initial
investigation found an uncontained failure of the
intermediate power turbine blades with associated
damage. Investigation continuing.
Hartzell BHCC2YF1 Propeller governor control
cable broken. SDR 510010943
Propeller governor control cable broken in area
forward of firewall.
P/No: B190954. TSN: 13,666 hours.
Continental S6LSC200 Distributor gear
unserviceable. SDR 510010963
Magneto distributor gear unserviceable. Gear was
not rotating true. Inspection found gear out of
true by approximately 1.524mm (0.060in). Further
inspection found four out of five gears in stock with
the same condition.
P/No: 10357586.
Continental S6RN1225 Rotor damaged.
SDR 510011223 (photo below)
Magneto rotor damaged. Rotor casting distorted due
to high temperature. Magneto failed during testing
following overhaul.
P/No: 103493512. TSO: 3 hours.
Mytton 55 Gas tank cracked and corroded.
SDR 510011121
Balloon LPG fuel tank surface corrosion. Leak test
following corrosion removal found gas leakage
due to cracks in body of tank. Crack lengths
approximately 10mm to 20mm (0.39in to 0.78in).
Lycoming IO540K1A5 Engine seized.
SDR 510011052
Engine started making knocking noises with a drop
in engine oil pressure to approximately 413.7 kPa
(60psi). Engine then seized. Investigation continuing.
Rolls Royce RB211524G Engine surged.
SDR 510010936
No.1 engine surged after takeoff. FMU, VIGV
Controller and bleed control unit changed.
Investigation continuing.
P/No: RB21542GT.
Garrett TPE33112UH Engine low oil quantity.
SDR 510011066
Right-hand engine low oil pressure. Investigation
found low oil quantity but no evidence of leakage.
Following oil top up and ground run, the engine
was found to be seized solid. After cool down,
the engine could be rotated freely but exhibited a
‘graunchiness’. The engine was removed and sent
for inspection/repair. Suspect oil was leaking from
turbine labyrinth seal. Investigation continuing.
P/No: TPE33112UHR701G.
TSN: 17,255 hours/22,926 cycles.
causing rubbing damage. See attachments for
photographs. Similar problem found on another
aircraft in the fleet. Aircraft is registered in PNG.
P/No: 350A54100502.
Australia is in the process of introducing new
generation air traffic control (ATC) systems. The
two that will probably have the greatest impact
are mode S secondary surveillance radars (SSR)
and automatic dependant surveillance–broadcast
With the introduction of the new mode S radar system a number of
older-type mode A/C transponders, based on electron tube technology
(basically valve type oscillators generating the output carrier signal),
have been identified as transmitting incorrect or spontaneously
varying data to ATC. So an amendment to AD/RAD/47, due for release
shortly, requires an additional set of tests to be conducted. Other
issues that have surfaced include:
Mode S transponders require the allocation of a unique 24-bit
address for each aircraft also known as the ‘mode S address’. The
International Civil Aviation Organization (ICAO) administers the
worldwide addressing system, allocating a number of 24-bit addresses
to each state. In Australia, CASA allocates a 24-bit address to each
VH-registered aircraft, either when it is first registered, or when
its registration mark is changed, irrespective of whether a mode S
transponder is installed. Other Australian aircraft are allocated
an address on request by a recreational aviation administration
organisation recognised by CASA.
Since Airservices introduced AMSTAR radars at Melbourne and
Coolangatta airports, many aircraft have been detected with incorrect
24-bit addresses. The most common errors detected include the
transmission of an address allocated by the former state of registration,
or the transmission of a bogus address. If you’re an aircraft owner,
operator and/or maintainer you need to ensure the 24-bit address is
checked whenever airworthiness directive AD/RAD/47 is carried out.
As an example, Airservices Australia has detected several instances
of aircraft fitted with transponders intermittently transmitting
incorrect ADS-B position reports. ADS-B position reports displayed
to controllers intermittently jump, usually exceeding 10nm, from the
aircraft’s true position. The manufacturer is aware of the problem and,
we understand, well on the way to resolving it.
Airservices, with CASA agreement, may revoke ADS-B based ATC
services for aircraft transmitting corrupt data. Airservices believes this
is necessary to ensure the integrity of ATC services.
So ... operators: be aware of the equipment installed on your
aircraft and what is being transmitted.
or contact your local CASA Airworthiness Inspector [freepost]
Service Difficulty Reports, Reply Paid 2005, CASA, Canberra, ACT 2601
Online: www.
The aircraft identification you enter in the
flight notification and the transponder
should not exceed seven characters and the
ICAO three-letter designator for the aircraft
operator followed by the flight number (i.e.
QFA511 for Qantas flight 511). You should not
add any zeros, dashes or spaces if the aircraft
identification is fewer than seven characters.
If you transmit the aircraft registration mark,
again, enter it in full without zeros, dashes
or spaces added (e.g. for a CASA-allocated
registration mark: VHABC, or RA-Ausallocated registration: 551875).
Airservices, with the commissioning of the ADS-B ground station
network, now provides five nautical mile separation standards from
coast to coast. Regulations published a few years ago, require noncompliant ADS-B transmissions to be disabled. If you’re the operator
of an aircraft installed with functional ADS-B systems then you
must not transmit misleading data (under Civil Aviation Order 20.18
paragraph 9A).
Most mode S transponders can transmit
flight identification (also known as aircraft
identification, flight ID or FLTID). The Australian
Aeronautical Information Publication (AIP
GEN 1.5 Section 6) requires that you must
transmit an aircraft identification exactly
matching the aircraft identification entered in
Item 7 of your filed flight notification (flight
plan). If you have not filed a flight notification,
is transmitted.
The most common errors detected include the transmission of
the International Air Transport Association’s two character airline
designator (AB rather than ABC); added spaces, zeros or dashes;
ICAO aircraft operator designator omitted (246 instead of ABC246);
departure/destination detail (MELBNE); truncated registration mark
(ABC instead of VHABC); or bogus data such as @@@@@@.
In February 2009, COSPAS SARSAT satellite
alerting services for 121.5/243MHz emergency
beacons ceased. These121.5/243MHz beacons
were replaced with new 406MHz beacons that
can be detected by satellites and processed by
After the aircraft’s ELT was recovered,
subsequent testing revealed no evident fault
which would cause the ELT not to function.
Further research and testing confirmed
the ELT functioned exactly as its designer
Consequently, in December 2008, CASA
amended civil aviation regulations to reflect
this change. The amended regulations mean
those aircraft that are required to be fitted
with an emergency locator transmitter (ELT)
must have replaced the old 121.5/243MHz
emergency beacon with a new 406MHz ELT.
So why didn’t it work in the aircraft if it had
been installed correctly? Unlike the earlier
121.5/243MHz model ELTs, this particular unit
requires two pins to be shorted out through
the external plug-wiring loom to ensure the
G-switch circuit is complete. Simply changing
the old plug with the new plug and installing
the ELT into the existing cradle did not ensure
that the ELT would function as intended.
There are some potential safety issues
surrounding this replacement. The design of
the mounts and the rigidity of the structure
on the aircraft for the old style ELT and the
406MHz ELT are, in most cases, the same, as
can be seen in the first photograph. As a result
of this, many manufacturers have facilitated
the change by re-using the old mounts, and
in some cases, the existing trays. This is
fine, but … it’s important to ensure that the
old mounting position and structure were
handled correctly the first time around. There
are many incidents of the earlier designs and
mounting not being sufficiently rigid, resulting
in false activation, or no activation at all, for
the ELT.
Manufacturers of 406MHz ELTs supply
sufficient documentation to operate, install
and maintain their equipment into an aircraft.
However, this is only generic information,
and not specific to any particular aircraft or
installation. [see the second photograph.]
In other words, this is not approved data for
installing the equipment into an aircraft. So
unless the new ELT is a direct one-for-one
replacement that requires no change to the
existing system, then the installation must be
designed and approved by a suitably qualified
person, and installed by an equally qualified
A recent accident in Western Australia
highlights the issues which can arise if the new
ELT is not correctly installed. In this case, the
ELT was changed from the old 121.5/243MHz
ELT to a new 406MHz ELT of the same style,
from the same manufacturer. In this accident
the ELT failed to operate, and therefore failed
to do its job in assisting in the search for
the aircraft.
So if you are the owner/operator of an aircraft
with a fixed ELT, and you have replaced the
121.5/243MHz version with the new 406MHz
ELT, CASA recommends that you check to
ensure that it has been installed correctly. This
means using approved data, that all wiring is
configured correctly, and the maintenance
schedules have been amended to reflect
any changes in the ELT’s maintenance
2–15 July 2010
Lighter than Air
Hot Air Balloons
AD/BAL/3 Amdt 5 - LP Gas Cylinders
Agusta A119 Series Helicopters
2010-0142-E - Rotors Flight Control - Pilot and
Co-pilot Control Box Assemblies - Inspection /
Above 5700 kg
Airbus Industrie A330 Series Aeroplanes
AD/A330/3 Amdt 2 - Escape Slide Girt Bar Slider
Mechanism - CANCELLED
2010-0135 - Doors - Pax/Crew and Emergency Exit
Doors - Girt Bar Slider Mechanism - Functional
Check and Lubrication
Avions de Transport Regional ATR 42
Series Aeroplanes
2010-0138 - Stabilizers - Elevator Inboard
Hinge Fitting Lower Stop Angles - Inspection /
Boeing 747 Series Aeroplanes
AD/B747/53 Amdt 4 - Longitudinal Skin Lap Joint
and Body Frame Corrosion and Cracking
AD/B747/296 Amdt 1 - Body Station 2598
Bulkhead - CANCELLED
2010-14-01 - Environmental Control System
Polyurethane Foam Installation
2010-14-07 - Body Station 2598 Bulkhead
2010-13-12 - Electrical Arcing - Fuel Pumps
2008-01-01 - Flight Deck Door
2010-14-09 - Nacelle Strut Front Spar
Chord Assembly
2010-14-10 - Fuselage Lower Lobe Longitudinal
Lap Joints
AD/B747/398 - State of Design Airworthiness
Directives - 1
AD/B747/399 - State of Design Airworthiness
Directives - 2
2010-14-17 - Cracks in Overwing Intercostal Webs
between Stations (STA) 1160 and STA 1220 - Detect
and Correct
Boeing 767 Series Aeroplanes
AD/B767/41 Amdt 1 - Leading Edge Slat Drive
2008-01-01 - Flight Deck Door
Boeing 777 Series Aeroplanes
2008-01-01 - Flight Deck Door
2010-13-03 - Keyway of Fuel Tank Access Door
Cutout of the Lower Wing Skin
Boeing 767 Series Aeroplanes
2010-15-01 - Flight Deck Window 1 Arcing
Boeing 777 Series Aeroplanes
2010-15-01 - Flight Deck Window 1 Arcing
2010-14-13 - Inboard Main Track Slat Can for
Outboard Slat Number 12 - Detect and
Correct Damage
Embraer ERJ-190 Series Aeroplanes
2010-06-05 - Ram Air Turbine Balance Screw
2010-07-03 - RH Engine Compressor Stall
AFM Amendment
Fokker F28 Series Aeroplanes
2010-0139 - Fuel - Fuelling Control Panel Cam Inspection / Replacement / Functional Check (Fuel
Tank Safety)
Piston Engines
Thielert Piston Engines
Turbine Engines
Pratt and Whitney Canada Turbine Engines PW500 Series
AD/PW500/3 - Hydro-mechanical Fuel
Control Units
CF-2010-19 - Intercompressor Bleed Valve/Servo
Valve Malfunction
Propeller Governors
2010-13-10 - Ontic Governors - Pilot Valve Plunger Inspection / Repair
Propellers - Variable Pitch - Dowty Rotol
AD/PR/40 Amdt 1 - Propeller Backplate Sealant
16–29 July 2010
Eurocopter BO 105 Series Helicopters
2010-0153 - Time Limits / Maintenance Checks Main Rotor Blades with Bolted Lead Inner Weight
- Life Limitation
Kawasaki BK 117 Series Helicopters
TCD-7558-2010 - Jettisonable Sliding Door
TCD-7705-2010 - AFM Amendment
Below 5700 kg
Cessna 208 Series Aeroplanes
AD/CESSNA 208/19 Amdt 3 - Flight and Ground
Icing Operations
De Havilland DHC-1 (Chipmunk) Series
AD/DHC-1/31 Amdt 2 - Fin Rear Spar
Piper PA-28 Series Aeroplanes
2010-15-10 - Incorrectly Assembled Control
Wheel Shafts
Piper PA-32 (Cherokee Six) Series Aeroplanes
2010-13-07 Correction - Engine - V-Band Exhaust
Coupling - Replacement
2010-15-10 - Incorrectly Assembled Control
Wheel Shafts
Piper PA-44 (Seminole) Series Aeroplanes
2010-15-10 - Incorrectly Assembled Control
Wheel Shafts
Piper PA-46 (Malibu) Series Aeroplanes
2010-13-07 Correction - Engine - V-Band Exhaust
Coupling - Replacement
Robin Aviation Series Aeroplanes
2010-0151-E - Exhaust - Exhaust Pipes - Inspection
Above 5700 kg
Airbus Industrie A319, A320 and A321
Series Aeroplanes
AD/A320/173 - DASELL Toilet Walls Corrosion CANCELLED
2010-0148 - DASSELL Lavatory Walls - Inspection/
2010-0149 - Flight Controls - Elevator Aileron
Computer (ELAC) System Power Supply Modification
Airbus Industrie A330 Series Aeroplanes
2010-0145 - Hydraulic Power - High Pressure
Manifold Check Valve - Inspection
Boeing 737 Series Aeroplanes
AD/B737/6 Amdt 2 - Rear Pressure Bulkhead
2010-15-08 - Outboard Mid-Flap Carriage Spindle
Boeing 747 Series Aeroplanes
2010-14-08 - Fuel Tank Ignition Sources
Notice - 2010-14-08 - Notice to Operators
Boeing 767 Series Aeroplanes
AD/B767/138 Amdt 3 - Nacelle Strut Midspar
AD/B767/256 - State of Design Airworthiness
2010-14-18 - Primary Strut Midspar Fitting
Tangs - Detect and Correct Fatigue Cracking
Bombardier (Canadair) CL-600 (Challenger)
Series Aeroplanes
CF-2010-20 - Horizontal Stabilizer Trim Actuator
(HSTA) - Assembly of Discrepant Load Bearing
Balls in the HSTA
Bombardier (Boeing Canada/De Havilland)
DHC-8 Series Aeroplanes
CF-2010-21 - Fuel System - Inadequate Electrical
Bonding of the Motive Flow Check Valve
CF-2010-22 - Main Landing Gear Stabilizer
Extension Spring
CF-2010-23 - Main Landing Gear - Failure to Extend
British Aerospace BAe 146 Series Aeroplanes
2010-0141-CN Correction - Placards & Markings N2 Limitations for Anti-Ice Selection - To Introduce
a Placard on the Flight Deck Overhead Panel and
Wiring to Inhibit the Airbrake Auto-retract Function
Turbine Engines
Pratt and Whitney Turbine Engines PW4000 Series
AD/PW4000/15 - 14th and 15th Stage Rubstrips
Oxygen Systems
2010-0152 - Equipment and Furnishing - Oxygen
Mask Regulator - Modification
Propellers - Variable Pitch - McCauley
2010-14-20 - Propeller Hub Inspection
Boeing 737 Series Aeroplanes
AD/B737/322 - B/E Aerospace Oxygen Masks CANCELLED
2010-14-06 - B/E Aerospace Oxygen Masks
2008-01-01 - Flight Deck Door
Embraer ERJ-170 Series Aeroplanes
2010-06-04 - Ram Air Turbine Balance Screw
2010-07-02 - RH Engine Compressor Stall
AFM Amendment
Piper PA-34 (Seneca) Series Aeroplanes
2010-15-10 - Incorrectly Assembled Control
Wheel Shafts
Bell UH-1 Series Helicopters
2010-14-12 - Low Skid Landing Gear Forward
British Aerospace BAe 146 Series Aeroplanes
AD/BAe 146/107 Amdt 3 - Forward Fuselage
2009-0070R1 - Fuselage - External Forward
Fuselage - Inspection / Repair
2010-0141-CN - Placards & Markings - N2
Limitations for Anti-Ice Selection - To Introduce
a Placard on the Flight Deck Overhead Panel and
Wiring to Inhibit the Airbrake Auto-retract Function
30 July– 12 August 2010
Lighter than Air
Hot Air Balloons
AD/BAL/13 Amdt 1 - Portable Fire Extinguisher
Eurocopter SA 360 and SA 365 (Dauphin)
Series Helicopters
2010-0100R1 - Navigation - Vertical Gyro Unit
Data Output - Operational Limitation / Operational
procedure / Reinforcement
Schweizer (Hughes) 269 Series Helicopters
2010-16-08 - Oil Cooler Impeller Blades
Below 5700 kg
Diamond DA42 Series Aeroplanes
2010-0155 - Landing Gear - Main Landing Gear
Damper-to-Trailing Arm Joints - Inspection /
Gippsland Aeronautics GA8 Series Aeroplanes
AD/GA8/3 Amdt 2 - Forward Cargo Door Slide
Pilatus Britten-Norman BN-2 Series
AD/BN-2/35 Amdt 3 - Airframe Structural Fatigue
Life Limitations
Above 5700 kg
Airbus Industrie A319, A320 and A321
Series Aeroplanes
AD/A320/232 - Rudder Side Shell Skin - CANCELLED
2010-0164 - Stabilizers - Rudder Side Shell Skin Inspection
2010-0165 - Oxygen System - Passenger Oxygen
Masks - Identification / Modification / Replacement
Boeing 737 Series Aeroplanes
AD/B737/200 Amdt 1 - Outboard Mid-Flap Carriage
2010-16-06 - Flight Crew Oxygen System - Low
Pressure Flex-hose
Boeing 747 Series Aeroplanes
2010-16-05 - Flight Crew Oxygen System - Low
Pressure Flex-hose
Boeing 767 Series Aeroplanes
2010-16-04 - Flight Crew Oxygen System - Low
Pressure Flex-hose
Bombardier (Canadair) CL-600 (Challenger)
Series Aeroplanes
CF-2010-24 - Hydraulic Accumulators - Screw Cap/
End Cap Failure
British Aerospace BAe 146 Series Aeroplanes
2010-0166 - Time Limits / Maintenance Checks Airworthiness Limitations - Implementation
British Aerospace BAe 3100 (Jetstream)
Series Aeroplanes
2010-0162 - Time Limits and Maintenance Checks
- Main Landing Gear Radius Rod Mounting Shaft
Assembly - Safe Life Limit / Replacement
Embraer ERJ-170 Series Aeroplanes
2010-06-01R1 - Inspection of the Lower Region of
the Rear Pressure Bulkhead
Embraer ERJ-190 Series Aeroplanes
2010-06-02R1 - Inspection of the Lower Region of
the Rear Pressure Bulkhead
Fokker F28 Series Aeroplanes
2010-0156 - Fuel - Outer Wing Upper Skin Panel
Reinforcement Structure - Inspection / Rework
(Fuel Tank Safety)
Fokker F50 (F27 Mk 50) Series Aeroplanes
2010-0157 - Fuel - Fuel Quantity Probe & Wiring
Installation - Inspection / Modification (Fuel
Tank Safety)
Fokker F100 (F28 Mk 100) Series Aeroplanes
2010-0158 - Fuel - Crossfeed Valve System and
Fire Shut-off Valve System - Modification
2010-0159 - Fuel - Wing Tank Overflow Valve
Sense Line & Wiring Conduit Hose Attachments Inspection / Modification (Fuel Tank Safety)
SAAB SF340 Series Aeroplanes
AD/SF340/111 - State of Design Airworthiness
Airbus Industrie A380 Series Aeroplanes
2010-0167 - Fire Protection, Nacelles / Pylons
- Wing Pylon Interface / Double-Wall Fuel Pipe
Assembly - Inspection
2010-0168 - Doors - Wing Landing Gear Door
(WLGD) Hinge and Rods - Inspection / Replacement
Airbus Industrie A330 Series Aeroplanes
2010-0173 - Fuselage - Fuselage Internal Structure
at Frame 39.1 - Inspection
2010-0174 - Time Limits and Maintenance Checks
- Damage Tolerant Airworthiness Limitation Items ALS Part 2 - Amendment
Airtractor 800 Series Aeroplanes
2010-17-18 - Wing Lower Spar Cap
Boeing 737 Series Aeroplanes
2010-17-05 - Power Control Relays in the P91
and P92 Power Distribution Panels
2010-17-19 - Aft Attach Lugs of the Elevator
Control Tab Mechanisim
Turbine Engines
Boeing 747 Series Aeroplanes
AD/B747/269 Amdt 1 - Engine Core Cowl Latch
Rolls Royce Turbine Engines - RB211 Series
2010-0008R1 - Engine - Intermediate Pressure Shaft
Coupling Splines - Inspection
Boeing 777 Series Aeroplanes
2010-16-12 - Oil Scavenge Tube on the Turbine
Rear Frame
Turbomeca Turbine Engines - Arriel Series
2010-0101R1 - Engine - Module M03 (Gas Generator)
- Post-TU347 Second Stage Turbine Disc - Reduced
Life Limit
Boeing 767 Series Aeroplanes
2010-17-03 - Chafing of the Wiring Bundle in the
Centre Auxiliary Fuel Tank
Bombardier (Canadair) CL-600 (Challenger)
Series Aeroplanes
CF-2010-25 - AC Electrical Load Distribution
Propellers - Variable Pitch - Hartzell
AD/PHZL/87 Amdt 2 - Propeller Thrust Bearings
13–26 August 2010
Bell Helicopter Textron 412 Series Helicopters
2010-0171 - Fuselage - Wire Strike Protection
System (WSPS) - Upper Cable Cutter - Inspection /
Eurocopter BK 117 Series Helicopters
2010-0154 - Optional Equipment - External Mounted
Hoist System - Visual Check / Replacement
Eurocopter EC 135 Series Helicopters
AD/EC 135/22 - External Mounted Hoist System CANCELLED
2010-0154 - Optional Equipment - External Mounted
Hoist System - Visual Check / Replacement
Eurocopter SA 360 and SA 365 (Dauphin)
Series Helicopters
2010-0100R1 Correction - Navigation - Vertical
Gyro Unit Data Output - Operational Limitation /
Operational procedure / Reinforcement
Below 5700 kg
Hawker Beechcraft (Raytheon) 390
Series Aeroplanes
2010-17-15 - Armature Insulating Materials
Above 5700 kg
Airbus Industrie A330 Series Aeroplanes
AD/A330/31 Amdt 4 - Airworthiness Limitations
Items - Time Limits/Maintenance Checks CANCELLED
Bombardier (Boeing Canada/De Havilland)
DHC-8 Series Aeroplanes
CF-2010-26 - Main Landing Gear Door Alternate
Release Cable - Turnbuckle Fouling and Cable Wear
CF-2010-27 - Flight Controls - Backlash in the Crank
Arms of Elevator Torque Tube
CF-2010-28 - Elevator Power Control Unit - Shaft
(Tailstock) Swaged Bearing Wear
Dornier 328 Series Aeroplanes
AD/DO 328/73 - Flight Compartment Door Locking
2010-0169 - Equipment & Furnishings - Flight
Compartment Door Locking Device - Replacement
Embraer ERJ-190 Series Aeroplanes
2010-08-02 - Pylon Shear Pins - Replacement
Turbine Engines
CFM International Turbine Engines CFM56 Series
2009-0088R1 Correction - Engine - High Pressure
Compressor (HPC) - Inspection / Replacement
General Electric Turbine Engines - CF6 Series
AD/CF6/51 Amdt 2 - LPT Shroud - Replacement
Rolls Royce Turbine Engines - RB211 Series
AD/RB211/39 - High Pressure Compressor Rotor
Discs and Rotor Shafts - CANCELLED
2009-0073 R1 correction - Engine - High Pressure
(HP) Compressor Stage 1 to 4 Rotor Discs and HP
Compressor Rotor Shafts – Inspection
27 August–9 September 2010
Above 5700 kg
Airbus Industrie A319, A320 and A321 Series
AD/A320/183 - Additional Centre Fuel Tanks CANCELLED
2010-0177 - Fuel System - Additional Centre Tanks
Manhole Cover Seal - Replacement
Agusta AB139 and AW139 Series Helicopters
2010-0183R1 - Equipment/Furnishings - Spectrolab
Nightsun XP Searchlight - Inspection/Removal
Bell Helicopter Textron Canada (BHTC) 222
Series Helicopters
CF-2010-29 - Servo Actuator
Bell Helicopter Textron Canada (BHTC) 430
Series Helicopters
CF-2010-29 - Servo Actuator
Eurocopter EC 135 Series Helicopters
2010-0183R1 - Equipment/Furnishings - Spectrolab
Nightsun XP Searchlight - Inspection/Removal
Kawasaki BK 117 Series Helicopters
TCD-7698-2010 - Rescue Winch System
Sikorsky S-92 Series Helicopters
2010-0183R1 - Equipment/Furnishings - Spectrolab
Nightsun XP Searchlight - Inspection/Removal
Below 5700 kg
Boeing 767 Series Aeroplanes
AD/B767/256 Amdt 1 - State of Design
Airworthiness Directives
CFM International Turbine Engines CFM56 Series
AD/CFM56/30 - Engine - High Pressure Compressor
Pratt and Whitney Turbine Engines PW4000 Series
AD/PW4000/16 - Front Pylon Mount Bolts
Radio Communication and Navigation
2010-0186 - Communication - Very High Frequency
(VHF/AM) Transceiver - Modification
Bombardier (Boeing Canada/De Havilland)
DHC-8 Series Aeroplanes
CF-2010-30 - Cracking of the Nacelle Attachment
CF-2010-31 - Fuel System Safety - Introduction of
Design Changes
British Aerospace BAe 146 Series Aeroplanes
AD/BAe 146/141 - State of Design Airworthiness
Embraer ERJ-190 Series Aeroplanes
2010-08-03 - Airworthiness Limitation Section
(ALS) - Changes
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Flight Safety talks to CASA’s unmanned
aircraft specialist, Philip Presgrave.
There’s a strong hint of things to come in CASA’s in-tray.
It contains more than 45 applications for unmanned aerial
vehicle (UAV) air operator’s certificates, in addition to the dozen
currently valid. The Australian unmanned aircraft systems
(UAS) industry certainly appears to be preparing for take-off.
UAS specialist Philip Presgrave, from CASA’s flying standards
office, says activities being applied for include pollution
monitoring, law enforcement, mining survey and related land
rehabilitation, power line survey, border protection, pipeline
monitoring and real estate photography.
The industry is establishing a distinct economic niche, and a
direct benefit to the community, Presgrave says.
‘I get calls every couple of days seeking more information from
intending entrants. One of the things I would emphasise is that
we’re talking about aeroplanes, aircraft. They’re certainly not
models, they’re doing real work.’
Unmanned aerial vehicles (UAVs) are working commercial
aircraft, Presgrave says. ‘We’re trying to move away from the
idea that they’re toys – they’re very sophisticated vehicles,
capable of performing air work tasks with unique cost and
safety advantages.’
From an operator’s point of view the industry is maturing
rapidly, Presgrave says. There’s a strong ‘anti-cowboy ethos’
among operators he says, which reflects respect for CASA’s
regulations and an understanding that the industry’s status
comes from how it is seen to comply. ‘We’re getting operators
advise us of practices they observe that they consider
potentially unsafe or a poor reflection on the industry and we
are able to act accordingly.’
The recent UAV Outback Challenge held in late September, at
Kingaroy, in Queensland, demonstrated the ability of unmanned
aerial vehicles to fly and interact safely with manned aircraft,
he said.
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For now, the dominant mode of UAS operation
is visual line-of-sight operation.
A ‘sense-and-avoid’ capability for UAS is the major hurdle
worldwide inhibiting full integration of UAS into non-segregated
airspace. An Australian UAS organisation working in the area
of sense-and-avoid technology is the Australian Research
Centre for Aerospace Automation (ARCAA). The Centre, a
joint venture between Queensland University of Technology
and the CSIRO aerospace research centre, officially opened
in September. Its headline project is ‘dynamic sense-and-act’,
which uses an onboard camera, graphics processing hardware
and image processing algorithms to detect potential mid-air
collisions. It acts much like a visual version of a commercial
aircraft’s traffic collision avoidance system (TCAS), using
cameras instead of TCAS’s radar. The system has been test
flown in an autonomous mode, and ARCAA researcher and QUT
lecturer, Luis Mejias, says it could form the basis for TCAS-like
systems on UAVs and general aviation aircraft.
The category has become diverse very quickly, he says. ‘Some
multi-rotor UAVs have up to 12 rotors; then there are singlerotor designs; fixed-wing UAVs ranging from less than a metre
wingspan to sizes approaching a 737 aircraft; and lighter-thanair UAV airships.
For now, the dominant mode of UAS operation is visual line-of
sight operation.
‘Most companies that are applying plan to fly visual line-of-sight
and in visual meteorological conditions, and therefore seek
exemption to the instrument rating examination requirement of
the regulations (CASR 101-295),’ Presgrave says.
The ability to license for higher categories of flight such as
beyond line-of-sight, semi-autonomous and all-weather
operation remains important for the growth of UAS, he says.
CASA is also examining the unique requirements of UAS
‘We’ve established an industry training development team
looking at the various types of training required for different
types of unmanned vehicles and recommending how they might
be appropriately licensed,’ Presgrave says.
He says licences would reflect the size and type of the UAV, and
its type of operation.
Images courtesy of Stefan Hrabar
‘If you were operating a fixed-wing UAV at the lower end of the
scale there could be a different range of subjects and practical
skills to cover than if you were operating a multi-rotor UAV,
for example.’
CASA is examining an industry recommendation on UAS
certification standards, and this could also reflect operational
realities more closely. We are also monitoring worldwide UAS
certification developments, especially those from ICAO, the
‘The argument is that if you’re operating a UAV in a remote area
the consequences of a failure or forced landing are far less than
in a built-up area and so there may be a case for a range of
certification standards to reflect this,’ he says.
CASA is also working with the UAS industry on possible use
of unmanned aircraft for bushfire surveillance, among other
tasks. Unmanned vehicles would provide low-cost, nighttime,
eye-in-the-sky monitoring of bushfires, giving controllers realtime information on the status of fire fronts, and helping avoid
the situation where fast-moving fires can catch firefighters or
communities by surprise.
‘We had some 10 movements of manned aircraft over the
competition period, even though the airport was closed, and
they were all conducted and co-ordinated professionally and
safely. We also saw UAVs flying under automatic control in
the competition area, and that was a minor milestone for the
Challenge, as previous attempts had failed at take-off.
Name withheld by request
I was so excited! My career-long dream of being a jet pilot had come true.
I was now a 12-month line first officer flying in a new state-of-the-art jet based in
my hometown, Melbourne.
On this Friday afternoon I was rostered to operate
four sectors: a return trip to Hobart, and then to
Sydney and back. I was with a new captain with
whom I hadn’t flown before. It was a hot and
windy day in Melbourne and a frontal system
was on its way. A line of storms was approaching
from the northwest after we arrived from Hobart.
We landed on Tullamarine runway 34 and spotted
the cumulonimbus build-ups in the distance, but
didn’t think too much of it at the time.
After 60 minutes on the ground and a change
of aircraft, we pushed back and started on our
way for Sydney. Being a Friday afternoon, we
had a full load of business people. On our taxi out
we noted the storm was now quite close, and a
Boeing 767, which taxied out ahead of us, opted
to taxi the full length of runway 34 and use the
turning bay at taxiway kilo to point north and
look with its weather radar for a heading to avoid
the weather.
The taxi out was busy, as we had to re-do the
take-off figures because it started to drizzle very
lightly (despite the sunshine!) and wet figures
would be more appropriate. This combined with
a change in standard instrument departure (SID),
to a radar one, necessitated a quick re-briefing.
The 767 took a heading right 070 degrees and
departed without incident. The storm was now
getting close to 3nm of the airport, but it still
looked safe to depart. After a look at the radar
we thought it wise to depart on a similar heading
to the 767. It was my sector and away we went!
We got distracted at 500ft as we had pre-selected the heading of 070 and
the plane turned, after autopilot engagement, as it was designed to do, but
earlier than the 1500ft the SID required.
This necessitated some heads down time on both our parts: obviously a
big no-no when the storm was so close. In what seemed like about two
seconds (I’m sure it was longer), we clipped the edge of the storm and
crunch! Lightning strike number one – there were more on the way! Then
heavy rain, and as we climbed, some light hail.
Things were getting a little frantic now, trying to speak to ATC and fly clear
of the weather. Hearing each other was very difficult because of the noise
– and then bang! Another strike.
Somewhere in here I tried to clean the plane up and find a heading that
would be good not only for us, but also for ATC – we ended up on a heading
around 110 degrees.
Because of this, we were held at 5000ft due to inbound traffic. It was at
this point we looked at each other and agreed; staying on the ground would
have been a better idea! The rain and hail slowly stopped, and we sustained
one more strike.
Tullamarine was now closed because the storm was well and truly over the
top of the field. This was when cooler heads prevailed – we asked to stop
climb at 10,000ft and be vectored away from the weather whilst we spoke
to the engineers on the ground and checked vital systems. It looked as if the
electronic engine controls (EEC) may have suffered some damage and gone
into alternate mode. We ran through the appropriate checklist.
After a discussion with a company engineer via air-to-ground radio,
we agreed unanimously to hold until the weather cleared and return to
Melbourne, where maintenance could have a good look over our bruised
and battered ship.
we clipped the edge of
the storm and crunch! Lightning strike
number one – there were more on the way! Then
heavy rain, and as we climbed, some light hail.
I conducted a VOR/DME approach into runway 34 in Melbourne – (please
tell me if they ever plan on installing an ILS!). It was uneventful when
compared to the start of the flight.
On arrival, a group of engineers quickly came out and inspected the aircraft,
and I will never forget the expression of the head engineer. When he entered
the cockpit, he told us in no uncertain terms that this plane ‘won’t be going
anywhere for a week!’ This brought mixed emotions: on the one hand,
elation that we had made the right choice in returning to Melbourne, but
on the other, professional disappointment and dejection. If we had done a
few things differently, maybe this whole mess would have never occurred.
In hindsight, perhaps we could have departed from runway 27 and turned
left for Sydney, well clear of the weather. If we had used full thrust, perhaps
we would have climbed higher, turned earlier and not touched the storm? If
we hadn’t spend as much time heads-down sorting out the autopilot issues
perhaps we would have seen the imminent danger.
What if we had simply taxied back at the gate and waited 60 minutes for the
weather to clear? Looking back it seems so obvious, but at the time when
you have a full flight, curfew considerations with the plane later in the day,
blue skies over the field and only two sectors before beer o’clock, logic
doesn’t seem so clear.
This event taught me emphatically to put airmanship first and commercial
pressures second. Again, I feel a little dumb making that statement now, in
hindsight, but it’s weird how things don’t seem as easy at the time.
On a more positive note, our crew resource
management (CRM) worked well, both between
the captain and me, but also with the cabin crew
post-event. We conducted a thorough analysis
of systems after the event and were confident
of our choice to return to Melbourne after this
analysis was completed. We decided to hold near
Avalon in case we needed to get down in a hurry:
this was good airmanship on both our parts,
I thought.
Lastly, I am forever grateful to my training
captain who prepared me thoroughly to have
little things ready for the day something happens.
These included having my frequencies set up on
back up and my landing charts for the departure
airport at arm’s reach for when we need to come
back. Thanks!
You always have a natural tendency to think ‘it
won’t happen to me.’ Heck, that 767 got away
fine, just two minutes ahead, why would we
not be OK too? I learned this day never to take
thunderstorms for granted. Don’t even try and
skim close to them, despite what weather radars
and modern technologies say. Better safe than
sorry right? I was definitely sorry after this
The captain liaised effectively with the cabin crew, and made a particularly
good announcement to the passengers explaining in detail what had
happened and why we had to return to Melbourne. He regretted that some
passengers would be getting home late to their families, but said it always
best to check the plane after such an incident. He also suggested that he
didn’t think the damage would be too bad and we would be on our way to
Sydney in no time. How wrong he was to be on that front!
December 1995 – a beautiful day at Jackson’s
International Airport, Port Moresby, Papua New
Guinea (PNG) with almost perfect flying weather
forecast. I was the base manager/pilot for one
of the larger helicopter operators in Papua New
Guinea and that morning we had a government
charter, including a local government minister, a
few officials and a police escort. This was a full
complement of six passengers for my Bell 206
Longranger. The charter was to Waitope Village,
and scheduled takeoff time was 0700, something
I failed to notice during the sequence of events
for that morning. All passengers arrived on
time, so after weighing them, and manifested,
we actually departed on time. The route took us
to the north of Pt. Moresby, into the beautiful
Waitope Valley. Waitope village is located at the
top of the valley, at the base of Mt Albert-Edward,
in the Owen Stanley Mountain Range, at about
5000ft altitude. The airstrip is suitable for small
fixed-wing aircraft, with a tourist lodge near the
end of the strip.
As I lined up my approach to the far end of the Waitope airstrip, still about
half a mile out and about 500 ft AGL, we passed a primary school on our
left, which the local government minister, the member for Goilala, told me
he attended as a child. This prompted him to ask me to land at the school,
rather than the airstrip, as he was due at the school to address a grade
six graduation. Of course I complied, and immediately commenced a
descending left turn from the eastern boundary of the school to initiate a high
overhead inspection of obstacles and terrain to select an intended landing
point. There was a large soccer field in the middle of three school buildings,
with a basketball court on the eastern side of the complex. I chose the
soccer field.
As I neared the southern boundary of the school grounds approaching from
the east, I commenced a right-hand turn surveying the layout of the school
and possible forced landing areas for the approach. I noticed three large
high-tension wires on large power poles approaching the school from the
south. My eyes followed the wires, which turned east and literally formed
a border along the soccer field's northern side. I also noticed three steel
poles: two forming a ninety degree turn from south to east on the southern
edge of the school, with another pole approximately 130 metres away on
the northern side of the soccer field. The wires appeared to terminate on
the second pole on the southeastern side of the soccer field, while the third
telephone pole on the northern side of the soccer field appeared to have no
wires attached.
Rather than levelling off at about 200ft AGL and conducting a full 360-degree
inspection of the site, I opted simply to continue the approach resulting in a
270-degree flight path, executing my approach to the east. I flew between
two buildings, commencing the approach by slowing my airspeed and
continuing a standard approach and resultant rate of descent to the field.
I kept a close watch on the heavy high-tension wires immediately to my
left, clearing them by about six metres from my rotor tips. Just as I shifted
my field of vision ahead to my intended landing point, I saw a smaller wire
literally at the end of my HF antenna (only about two metres in front of the
nose of the helicopter), perpendicular to my aircraft, and level with the
antenna itself. This indicated the wire was actually under my rotor disk,
and I still had translational lift (about 20 knots of airspeed) and a four to five
degree approach angle! At his point everything I did was by reflex.
Immediately, I hauled back on the cyclic, pointing the nose of my B-206
straight up, while holding my approach power with the collective. This
manoeuvre allowed me to drop straight down, tail first, before reaching
the wire and then level the chopper in one continuous motion. I then pulled
enough collective to try to arrest my descent, and almost succeeded.
However, the rate of descent was too rapid for such a low altitude and I
hit the flat surface of the playing field rather smartly. The skids spread out
completely flat and there we sat!
I snapped off the ELT, reached down and flipped the fuel emergency cutoff
switch, silencing both the beacon and engine in a matter of seconds, and
said to my passengers (who still had their head sets on), 'Listen to me! Do
not leave the aircraft! The rotor is low enough to knock your head off. Exit
the aircraft slowly, bend way over, and walk away. Make sure you do not
stand up until you are well clear of the rotor!'
Fortunately all of the passengers did as they were instructed. Thinking back,
I am very glad I gave the ‘boring’ pre-flight briefing to the passengers, telling
them to follow my instructions ‘in the unlikely event of an emergency’! I can
only guess that was why they didn’t dart from the helicopter immediately.
Luckily, no one was injured, as the rate of descent had been slowed
considerably, as well as the shock-absorbing affect of the skids collapsing
provided adequate protection. The rest, as they say, is history.
I must say I never made another approach to a village or field again without
doing at least one 360-degree over fly, continually searching for wires,
regardless of where I was. Sometimes I even did two or three high and low
overhead flights if I had any doubt. The mindset of ‘saving the passenger
money’ is not the right one for a safe approach.
Contributing to this accident was the fact that at
altitude, I was getting the full easterly glare from
the sun in the direction of my approach, but the
sun had not risen high enough over the mountain
range to illuminate the ground or the wires
below me. There were three wires crossing the
soccer field from the steel pole at the southeast
of the field, across the field to the northernmost
steel pole, where they actually did terminate.
The wires had been placed there years ago, and
were the result of an abandoned hydro-electric
scheme. Believe me, there are very few wires in
rural PNG, very few! When I exited the aircraft
and looked up, the wires were actually over the
mast of the helicopter. That was a close one!
You’ll never guess what the local member (my
front seat passenger) said when I finally walked
away from the scene and up to him. 'Why didn’t
you land on the basketball court?' To which I
queried, 'Did you know those wires were there?'
'Yes! Of course,' he replied! There's a moral
there somewhere.
I was surprised – I couldn’t believe I had actually ‘pancaked’ the skids! The
emergency locator transmitter (ELT) was howling so loudly in my headset
I could hardly hear myself think. The rotor was still powered and turning
at full flight RPM, and the fuselage was now about a metre closer to the
ground, with the rotor spinning at about neck height for the average person!
I asked my front seat passenger if he was all right, and he replied he had
not felt the impact, and neither had I. The surprised look on his face and his
bulging eyes told of his real state of mind! I then realised that at any moment
one of my passengers in the rear compartment could bolt from the aircraft,
probably stand up and start running with most likely terminal results!
by Nasir Rakhangi
I was very close to my housemate, Dilan
Shanmughadas, while I was at Basair. We
went on all our cross-countries together,
and used to head to the Gold Coast often for
weekends. Sometime in late December 2007,
towards the end of our 10 months in Australia,
we had run out of exciting places to visit and
still had so many hours of command building
left. Sitting in our car one day, we had a bright
idea: why not Tasmania - the southernmost
place in the world before Antarctica?
We got our approval from the school, and
booked the best bird on the fleet, a Piper
Arrow. A week later we were ready ... all packed
and pumped, with blue skies all the way to
Tasmania except for some tempo periods
over the Tasman Sea for thunderstorms. We
took off with full fuel and oil, the aircraft was
just a few hours after its 100-hourly, and we
were full of confidence. It was an uneventful
flight until halfway between Mallacoota and
West Sale. Having refuelled at Merimbula, we
planned to follow the coast as far south as
possible, to about Wilson’s Promontory, and
then head straight across to Tasmania via the
Kent Islands and Flinders Island. However,
with reports of thunderstorms in the area, we
decided to land at Bairnsdale as a precaution.
And it’s a good thing we did, because for three
hours the cumulonimbus belched out rain
and lightning. Finally the skies cleared, and
we did a quick preflight. We had enough fuel,
and the oil just needed a quick one-quart top
up. Next thing we were cruising over the Tasman Sea … my God, it
was beautiful. We were doing 185kt ground speed, and hit the coast of
Tasmania soon after. No one in our school, students or instructors, had
crossed the Tasman before.
We followed the valley down towards Launceston, and landed,
deciding to stay the night there and leave for Hobart the next morning.
The next morning we did our preflight. We hadn’t lost much oil and
the tanks were filled. We decided to follow the valley down to Hobart,
a mere one-hour’s flight. We submitted our flight plan over the radio to
Launceston tower, and for the first time in my entire stay in Australia, I
didn’t submit a SARtime. ‘Why bother? It was such a short trip … what
could possibly happen?’ I thought.
We took off from Launceston on the northerly runway, made an
overhead departure and climbed to our cruising altitude of 4,500
feet. The plane performed like an ace, climbing beautifully as we cut
through the crisp cool air. We trimmed it out and let the plane fly
itself, when suddenly, as we were enjoying the scenery; we felt a light
continuous vibration through the yoke. I asked Dilan if he felt it too.
He shrugged it off lightly. But in that time, these light vibrations had
quickly grown to a full-blown shuddering. Our headsets wouldn’t stay
on our heads, the plane went out of control, there was all this dirt, and
strange black sooty stuff was suspended in the air. I remember it going
into my mouth and eyes. We took control of the aircraft and noticed
that the needle on the tachometer had gone all the way, reading more
than 3,500 rpm. I tried to reduce the speed using the pitch lever - no
change. I noticed the oil pressure gauge reading zero, and the oil temp
being within the green arc. I knew we’d lost oil. Dilan could see oil
spraying out the side of the cowling. I declared Pan Pan Pan because
we still had partial power. The rpm would come back into the green
only if I idled the throttle, so I kept the power up to a compromise with
the rpm at 3000. We were cleared back to Launceston for landing,
but we were losing height, and about 11nm from the airport. As we
slowly descended, I picked three fields to land in just in case we lost
power completely. Sure enough, half a minute later, we lost all power
We sat there stunned for about 15 seconds. When we did exit, we
almost slipped on the wing as it was covered in oil. In fact, there
was oil all the way to the fin! We looked around … nothing … just a
few dead trees and dead grass. Dilan and I had always dreamed of
landing on a field or a beach … but never with no power. We gave
Launceston tower our coordinates and soon enough a spotter plane
came up overhead, did a few circles and went back.
We were expecting choppers or something to get us out of there, but
it wasn’t to be. The tower advised us to say put near the aircraft and
the police would rescue us. The search and rescue team called us and
assured us that since we were unhurt, there was no need for them to
rush in, and that the police would pick us up. After an hour’s wait, I
called the helpful tower controller again. When he spoke to the police,
he realised the police thought the tower controllers would arrange our
rescue. Sorting out the confusion took a while, but finally we were
asked to walk east until we hit the Midland
Highway where the police would be ready to
pick us up. We walked into the bush, following
the small shadow we were managing to make
with the midday sun. Halfway through,
the same spotter plane managed to spot us
through the trees and flew over us, close to the
tree tops, firing white smoke trails to direct
us towards the east … that was amazing. We
jumped two gates, crossed railway tracks and
finally about 45–60 minutes later, reached
the highway where we were assured the
police would pick us up. Which they did, after
another 40-minute wait.
Apparently, the oil line that connects the oil
sump to the CSU governor had developed a
hairline fracture, and since it is pressurised,
the oil spurted out, causing the propeller to
run away to full fine and hence overspeed
the engine. The engine finally blew two holes
in the walls due to pressure. The engine had
seized and caused the prop to stop wind
milling. When the maintenance engineer went
to survey the aircraft later, he said we must
have stopped the aircraft within 200 to 250
metres. I thank God that the engine seized,
because had the prop kept wind milling, we
probably wouldn’t have cleared the trees. We
flew to Tasmania at an average 4000ft and
flew back at 40,000.
The aircraft engine was replaced, the aircraft
flown straight out of that field, and it is still
used to train on today.
and the propeller stopped wind milling, which is odd for an Arrow.
We declared a Mayday. Now I could only see one field off to my 2
o’clock, as the other two were behind me. The airspeed indicator was
gone as well - it was reading 200kt at one second and zero the next.
We seemed high and I put the gear down. Flying on attitude alone,
we prayed for the best L/D. I flew the plane almost sub-consciously
- I was not in the least worried - it was like any other landing. It was
midday, so you couldn’t see terrain slopes very well, and as we closed
in towards the empty field in the middle of the surrounding bush, I
looked over to my left and saw a row of trees and I thought, ‘Well, no
clearway here.’ A few seconds later we landed, and it was a smooth
one, but as soon as we looked up, we could see a huge upslope at about
30 degrees or so ahead. That was when I got scared - the combination
of 270 litres of fuel and a failed engine … fire? Just as we closed to the
base of the upslope, I yanked on the yoke and pulled the nose wheel
off the ground to cushion its blow. We climbed up the slope with a
heave and at its top, we were airborne again, and flared off again. This
time we both braked hard, stopping about 10 metres from a fence
which we hadn’t seen earlier either.
The Australian A
Chief Commissioner’s
Earlier this year the ATSB
engaged an independent market
research agency to undertake
research with our key industry
The aim of the research was
to get feedback on where
we are going well, where we
could do better and how we could improve the way we
communicate key safety messages.
The research comprised one-on-one interviews, mini
focus groups and an online survey with more than 700
The results presented some interesting findings which
were mostly consistent across all three transport modes.
Overall I was pleased to discover that the majority of
respondents thought the ATSB is performing well. In fact
86 per cent of stakeholders who have had dealings with
the ATSB rated our performance, based on direct personal
experiences, as good or better.
However, our stakeholders also identified areas that we
need to improve. In particular, timeliness of completing
investigations and communicating the status of
investigations were the areas that rated lowest in terms of
overall performance at 49 per cent.
There was also a view, particularly outside specialised
safety areas of transport operators, that we needed to be
better at communicating the safety messages coming out
of our investigations and research.
Timeliness and communication are two areas we are
committed to improving. By setting new performance
benchmarks and undertaking greater planned
communication activity, we will better meet industry’s
The survey findings will now be used to develop an ATSB
communication and education strategy. The research
results will also form a benchmark for further stakeholder
research planned for July 2011.
I thank everyone who participated in the survey and
encourage you to continue providing feedback. Your
ideas and suggestions help us improve our business of
advancing transport safety in Australia.
Martin Dolan
Chief Commissioner
ATSB supporting aviation safety in
PNG and the region
ne of the ATSB’s core responsibilities
is helping to promote aviation
safety, not just in Australia, but
throughout the region. The benefits
are many – many countries lack the
capability to investigate anything
other than major accidents; they
simply do not have the resources
to investigate serious incidents.
In addition, encouraging a
culture of safety feeds back to
us, ensuring Australia keeps it
aviation standards at their highest.
Finally, Australians are enthusiastic
and adventurous travellers, and are likely
to be flying in neighbouring countries. It’s in
their interests to do it safely. Recently, the ATSB has
been taking major steps in working with Australia’s closest neighbour,
Papua New Guinea.
After the crash of a Twin Otter aircraft P2-MCB near Kokoda on
11 August 2009, in which nine Australians died, the Papua New
Guinea (PNG) Accident Investigation Commission (AIC) formally
requested that the ATSB assist them with their investigation. These
sorts of collaborations are specifically provided for under Annex 13 of
the Convention on International Civil Aviation. ATSB investigators
worked alongside AIC staff on site in PNG, and AIC staff have
subsequently travelled to Canberra for further discussions related to the
investigation. The ATSB has provided investigator support, information
and technical advice and facilities support. The AIC expects to release
the report by the end of the year.
Recently, a team of ATSB investigators flew to Misima Island in PNG
to assist the AIC with their investigation into an accident that took
place on 31 August, 2010. A Cessna Citation aircraft apparently overran
the runway on landing, impacting with trees. The aircraft caught fire
and burned, with four of the five people on board perishing. The AIC
investigation is continuing, and the ATSB is working closely with PNG
officials to assist where possible. The ATSB is assisting the Australian
The ATSB’s assistance to PNG is managed under a Transport Safety
Investigation Annex to the Memorandum of Understanding (MOU)
between Australia and Papua New Guinea on Cooperation in the
Transport Sector. The Annex was signed by the ATSB and AIC on
13 November 2009. Both agencies are committed to enhancing the
capabilities of their investigators, and the heads of the agencies have
recently discussed how to work together even more effectively to build
the region’s capacity for aviation safety. Q
Aviation Safety Investigator
Improve your odds
orty-four per cent of all aviation
accidents and over half of the fatal
accidents between 1999 and 2008
were attributed to private operations.
These figures are even more disturbing
when you consider that private operations
represent less than 15 per cent of the
hours flown in that decade.
The ATSB has released a Research and
Analysis Report, Improving the odds:
Trends in fatal and non-fatal accidents in
private flying operations, which identifies
some of the underlying
causes of the poor
safety performance in
this sector. The report
is available from the
ATSB website.
Problems with pilots’ judgement and
planning were identified as contributing
factors in about half of fatal accidents in
Action errors and decision errors
were both common to fatal accidents.
Violations, while less frequently found,
were mostly associated with fatal
In light of the contributing factors
associated with fatal accidents in private
operations, the report provides advice
to pilots for improving the odds of a safe
Pilots are encouraged to make decisions
before the flight, continually assess the
flight conditions (particularly weather
conditions), evaluate the effectiveness
of their plans, set personal minimums,
assess their fitness to fly, set passenger
expectations by making safety the
primary goal, and to seek local knowledge
of the route and destination as part of
their pre-flight planning. Also, becoming
familiar with the aircraft’s systems,
controls and limitations may alleviate
poor aircraft handling during non-normal
flight conditions.
Some ideas to consider when assessing
and planning your flight include:
Make decisions pre-flight
threats and errors as part of your
pre-flight planning (and don’t
forget to discuss these with
your copilot if you have one)
Seek local knowledge
local knowledge (of the
weather and terrain for
example) on the routes and
Set personal minimums
minimums for deciding if
and under what conditions
to fly or to continue flying
based on your knowledge,
skills and experience.
terrain, weather, external
pressures, the aircraft’s
performance limitations and any
limitations you may bring to the
flight (for example, stress and
Finally, pilots need to be vigilant about
following the rules and regulations that
are in place – they are there to trap errors
made before and during flight. Ignoring
these regulations only removes these
‘safety buffers’.
A checklist for establishing your personal
minimums can be found on the Civil
Aviation Safety Authority’s (CASA’s)
website. Q
ATSB investigation report AR-2008-045
The report also
identifies the factors
contributing to fatal
accidents in private
operations and
how these factors
differed from nonfatal accidents. Three
occurrence types
accounted for the
majority of fatal
accidents: collision
with terrain (90%); loss of control (44%);
and wirestrikes (12%). When all incidents
and accidents are taken into account,
the likelihood of being killed was about
36 per cent for a collision with terrain
occurrence, 30 per cent for loss of control
occurrences, and about 50 per cent for a
wirestrike. For non-fatal accidents, there
was greater variability in the common
occurrence types – forced landings, hard
landings, problems with the landing gear,
and total power loss/ engine failure were
also common.
private operations, and about a quarter
involved problems with aircraft handling.
Other contributing factors associated
with fatal accidents were visibility,
turbulence, pilot motivation and attitude,
spatial disorientation, and monitoring
and checking. Non-fatal accidents were
just as likely to involve aircraft handling
problems, but had fewer contributing
factors than fatal accidents.
Investigation briefs
Robinson helicopter training to
be reviewed
Maintenance not just by the book
Aileron servo fault rectified
ATSB Investigation AO-2009-053
ATSB Investigation AO-2009-021
ATSB Investigation AO-2009-032
The ATSB encourages operators and
maintenance personnel to consider all
available information relating to the
history and performance of aircraft
components and systems when planning
maintenance activity. Manufacturers’
service bulletins and communications
only form a part of an aircraft’s
information. They should not be used to
the exclusion of other knowledge, such
as operational history and world-wide
fleet experience. The ATSB issued a Safety
Advisory Notice, encouraging operators
of CFM56-7 and CFM56-5 engines to
review their procedures after a Boeing
737-8BK experienced issues with one of
its engines.
A manufacturer has modified its assembly
practices after an ATSB investigation
identified the source of vibrations in
an Airbus Industrie A320-232. The
investigation also found an identical fault
had occurred to the same aircraft eight
months before the incident. This had
not been reported to the ATSB despite
the requirements of the Transport Safety
Investigation Act 2003.
An ATSB investigation into a faltal
helicopter accident has prompted CASA
to review the requirements for initial pilot
training and endorsement and recurrent
training on Robinson R22 helicopters.
This includes a review of the Helicopter
Flight Instructor’s Manual to ensure
that the required competencies are being
covered by flight instructors and trained
to students.
The accident occurred on 2 July 2009
when the pilot of a Robinson Helicopter
Company R22 Beta II, was carrying out
solo circuit training at the Gold Coast
Aerodrome. Witnesses saw the helicopter
climbing, followed by a rolling motion
that progressed into an exaggerated
rolling and pitching movement. A piece of
the helicopter separated from the aircraft,
with the helicopter rotating a number of
times before descending almost vertically
into trees.
Investigators found no evidence of any
mechanical problem with the helicopter,
and the weather conditions had been
fine. The post-mortem found no evidence
of any medical condition that may have
affected the pilot’s performance. The
investigation concluded that over or
mal control by a pilot more accustomed
to aeroplanes than helicopters was the
most likely precursor to the accident. In
addition, the investigation found that one
of the pilot’s instructors had an expired
Since the accident, the helicopter operator
has made a number of changes to their
induction process, which includes the
recording of instructors’ ratings and their
respective validity periods. Q
The incident took place on 20 August
2009, during a scheduled passenger
service. The aircraft departed Launceston
for Sydney when several loud bangs were
heard from the left engine, consistent
with a compressor surge. The left engine
was reduced to flight idle and the aircraft
returned to land at Launceston.
The compressor surge and damage to
the engine was found to be the result of
advanced variable stator vane bushing/
shroud wear.
The manufacturer was aware of the
engine’s propensity for inner bushing
wear and had previously released a
number of service bulletins to eliminate
the issue. The bulletins specified
inspection requirements for detecting
bushing wear and advised of the
availability of an improved bushing.
While the operator incorporated the
service bulletins into their inspection
and maintenance program, the 20
August event occurred before the engine
had reached the recommended date for
Since the occurrence, the manufacturer
and operator have taken steps to address
the safety issue and the ATSB will
continue to monitor the issue. Q
The aircraft, departed from Mackay,
Queensland on 18 May 2009. Operating
on a regular public transport flight, and
destined for Melbourne, the aircraft had
125 passengers, four cabin crew and two
flight crew on board. It was established in
the cruise at Flight Level 350 when a light
continuous vibration manifested within
the aircraft. Cockpit indications showed
that the left aileron was oscillating.
Shortly after, the cabin manager reported
to the pilot in command that there was
‘quite a bit of shaking’ at the rear of the
aircraft. The crew diverted the aircraft to
the Gold Coast Aerodrome and landed,
with the vibrations intensifying during
part of the descent.
The source of the aileron oscillation was
found to be an internal fault in one of
the left aileron’s hydraulic servos. The
fault occurred during manufacture by an
incorrect adjustment of the servo, which
caused internal wear in a number of the
servo’s hydraulic control components.
The aileron servo manufacturer has since
incorporated a new method of adjusting
the aileron servos during assembly to
minimise the likelihood of the problem
In addition, the operator has improved
the training of its staff and the reportable
event requirements in its safety
management system manual in an effort
to address the non-reporting risk. Q
Who cares if stuff happens?
‘We get around 15,000 notifications a
year,’ says Ethan Eastman, ‘and that
includes everything.’ Ethan is the
supervisor for the ATSB’s aviation
notifications team. He and his team of
five are called upon to assess and classify
any notifications that come in. And they
do come in. Every day, dozens of faxes,
letters, phone calls and emails flow into
the Canberra office, alerting the ATSB of
incidents, accidents and general problems.
These notifications run the gamut of
seriousness, ranging from minor breaches
of protocols, somebody crushing a lizard
on a runway, to a collision with terrain
involving multiple fatalities.
Periodically, people will wonder why
a particular accident or incident is not
being investigated – particularly if
someone has died. However, the ATSB
isn’t budgeted to investigate everything.
Investigations have to be selective. The
ATSB investigates events that are likely to
yield the biggest safety benefit and provide
important safety messages.
Anyone who is ‘a
responsible person’, as
defined in the regulations,
is required to notify a
‘reportable matter‘
This is not to say, however, that a
notification is of no use if the ATSB
does not investigate it. Those thousands
of occurrences (around 243,000 since
1969) create a vivid and useful portrait of
aviation safety in Australia. Investigators
and researchers use it to identify patterns
and trends. The ATSB also receives
many requests each year from the
media and researchers (both private and
professional) for details and figures of
accidents and incidents.
So what exactly needs to be reported? And
who needs to report it?
is required to notify the ATSB of a
‘reportable matter,’” explains Ethan. The
regulations in question are the Transport
Safety Investigation Regulations 2003.
While not waiting room fare, they do
provide a definition for who constitutes
a ‘responsible person.’ If you fit the
criteria for being a ‘responsible person’,
then it may pay you to acquaint yourself
more fully with what you are obliged to
tell the ATSB about, and when. If you
know that the incident has already been
reported, it doesn’t need to be reported
again, but it is your responsibility to make
sure that the ATSB has been notified.
And it is important that the notification
reports are as accurate as you can make
them. Submitting deliberately false
or misleading information is actually
a serious criminal offence under the
Criminal Code. In fact, aiding, abetting,
counselling, procuring or urging the
submission of false or misleading
information is also a serious offence.
Some of the requirements may seem
like more trouble than they’re worth.
Some of the reportable matters on their
own may seem insignificant. But the
occurrence reports all provide important
insights into the health of the aviation
system. They could also prove vital for
our understanding of aviation safety
issues, and how to address them. They
could prove vital for our understanding of
aviation safety, and how to improve it. Q
“Anyone who is ‘a responsible person’,
as defined in the regulations (see below),
Who has to notify the ATSB? Do you?
The following persons are responsible persons in relation to reportable matters:
a crew member of the aircraft concerned
the owner or operator of the aircraft
a person performing an air traffic control service in relation to the aircraft
a person performing a dedicated aerodrome rescue or firefighting service in relation to the aircraft
a person who
a. Is licensed as an aircraft maintenance engineer under the Civil Aviation Regulations 1988 or the Civil Aviation Safety
Regulations 1998; and
b. Does any work in relation to the aircraft
f) a member of the ground handling crew in relation to the aircraft
g) a member of the staff of the Civil Aviation Safety Authority
h) the operator of an aerodrome
-Transport Safety Investigation Regulations 2003 (avaliable in full at <>)
Of the 15,000-odd notifications that come
to the ATSB, about 8,000 are classified as
safety occurrences and entered into the
database. Those that don’t make the cut
are usually duplicate-reports on the same
occurrence from different sources, or they
describe things that aren’t assessed as a
transport safety matter. The 8,000 that
actually do constitute safety matters are
reviewed, and any that warrant closer
review are forwarded to investigators.
Depending on the circumstances, about
100 will be investigated each year.
he ATSB does! We know problems
happen. In an industry like aviation,
there are always going to be
problems – mechanical problems, people
problems, problems with the weather.
When an aviation problem (or incident)
happens then, by law, it most likely needs
to be notified to the Australian Transport
Safety Bureau.
REPCON briefs
Australia’s voluntary confidential aviation reporting scheme
REPCON allows any person who has an
aviation safety concern to report it to the
ATSB confidentially. Unless permission
is provided by the person that personal
information is about (either the reporter
or any person referred to in the report)
that information will remain confidential.
The desired outcomes of the scheme are to
increase awareness of safety issues and to
encourage safety action by those who are
best placed to respond to safety concerns.
Before submitting a REPCON report take
a little time to, consider whether you have
other available and potentially suitable
options to report your safety concern. In
some cases, your own organisation may
have a confidential reporting system that
can assist you with assessing your safety
concern and taking relevant timely safety
reporting directly to the Civil Aviation
Safety Authority (CASA) if you are
concerned about deliberate breaches of
the safety regulations, particularly those
that have the potential to pose a serious
and imminent risk to life or health.
REPCON staff may be able to assist you
in making these decisions, so please don’t
hesitate to contact our staff to discuss
your options.
REPCON would like to hear from you if
you have experienced a ‘close call’ and
think others may benefit from the lessons
you have learnt. These reports can serve
as a powerful reminder that, despite
the best of intentions, well-trained and
well-meaning people are still capable of
making mistakes. The stories arising from
these reports may serve to reinforce the
message that we must remain vigilant to
ensure the ongoing safety of ourselves and
If you wish to obtain advice or further
information, please contact REPCON on
1800 020 505.
Obstacle Limitation Surface
(OLS) control
Report narrative:
The reporter expressed safety concerns
about the Obstacle Limitation Surface
(OLS) at an International Airport,
reporting that the outer horizontal
surface is infringed by the construction
of five tower buildings in the City CBD.
One is reported to penetrate the outer
horizontal surface by 54.5 meters.
The reporter believes that even higher
structures are planned for the future.
The reporter believes that there may be
jurisdiction problems with regards to
which government agency approves these
apparent departures from standards and
what safety case process is employed in
the approval process. The Airports Act
1996 vests powers with the Minister to
enforce building height limitations, but
the reporter believes that the Department
does not employ appropriate specialists.
Civil Aviation Safety Regulation (CASR)
part 139 and the associated Manual of
Standards (MOS) appears to be all about
monitoring after the event, rather than
Civil Aviation Safety Authority (CASA)
approval or disapproval of tall structures
in the OLS.
Reporter comment: OLS infringement is
a serious safety risk factor. The situation
at [the aerodrome] suggests a blind eye
or a ‘she’ll be right’ approach, rather than
traditional Safety Management. There is
an urgent need to ascertain and clarify
which Commonwealth agency approves
these OLS penetrations and on what basis.
Action taken by REPCON:
REPCON supplied the aerodrome
operator with the de-identified report.
The aerodrome operator provided the
following response:
The primary Commonwealth legislation
that regulates activities on and in some
cases around [the aerodrome] is the Airports
Act 1996.
Airports Act 1996
The Airports Act 1996 (Act) and Airports
(Protection of Airspace) Regulations 1996
(Regulations) made pursuant to that Act
provide a framework for the protection of
what is known as the ‘prescribed airspace’
around [the aerodrome]. That ‘prescribed
airspace’ is determined in accordance with
international conventions and standards.
‘Prescribed airspace’ is made up of both
the OLS [Obstacle Limitation Surface] and
PANS-OPS [Procedures for Air Navigation
Systems Operations] surfaces for the airport
as well as specified airspace declared by the
secretary of the [Department of Infrastructure and Transport (the Department)].
One of the key elements of this legislation is
to protect that airspace from unauthorised
infringements - such as buildings - that
could affect the safe efficiency or regularity
of both existing and future aviation operations at the [the aerodrome].
Any structures (permanent or temporary)
infringing the prescribed airspace are called
‘controlled activities’, as defined under s182
of the Act, and require approval under the
Regulations. Controlled Activities include:
and cranes: and
causing non-structural intrusions into
the protected airspace of artificial light,
reflected sunlight, air turbulence, smoke,
dust, steam or other gases or particulate
The Act and Regulations are administered by [the Department]. [The Department] decides whether or not to approve
a ‘controlled activity’. The Aerodrome
Operator has no approval authority for
long-term controlled activities.
Note: For short-term ‘controlled activities’
(3 months or less durations) as described
under the regulations, approval authority
is delegated by the Department to the
Aerodrome Operator, who facilitates assessment and advice from both CASA and
Airservices Australia.
REPCON supplied CASA with the deidentified report and a version of the
aerodrome operator’s response. CASA
provided the following response:
CASA has no authority to stop such developments. The existing regulatory regime for
obstacles, as set out in Civil Aviation Safety
Regulation 139, does not empower CASA
to prevent a development which creates an
obstacle nor does it make CASA responsible
for the presence of obstacles.
These matters are under consideration
in the context of the development of the
Government’s National Aviation Policy
Notwithstanding the above, CASA also
advised that:
Under CASR 139.360, the aerodrome
operator must inform CASA of details
of any proposed development near the
aerodrome that is likely to penetrate
the OLS of the aerodrome and create an
obstacle. Under CASR 139.370 CASA makes
a determination if the proposed development will be hazardous to aircraft opera-
tions because of its location, height or lack
of marking and or lighting. CASA gives
written notice of the determination to the
proponent of the building or structure and
to the relevant authorities whose approval
is required for the construction of the
building or structure.
REPCON supplied the then Department
of Infrastructure, Transport, Regional
Development and Local Government (the
Department) with the de-identified report
and a version of the aerodrome operator’s
and CASA’s response. The Department
provided the following response:
assessment and decision. Importantly, the
Government’s aviation safety agencies, the
Civil Aviation Safety Authority (CASA)
and Airservices Australia are consulted. In
making a decision on an application, the
Regulations require the Department to have
regard to the opinions provided by CASA
and Airservices on the application.
Decisions must be made in the interests of
the safety, efficiency or regularity of existing
or future air transport operations.
In summary, we can confirm that [the
Department] implements the legislative
framework protecting airspace above the
OLS based on advice from CASA and
Airservices for each application to conduct
a controlled activity.’
‘Part 12 of the Airports Act 1996 (the Act)
and the Airports (Protection of Airspace)
Regulations 1996 (the Regulations) establish
a legislative framework for the protection
of the following airspace at and around
Surface (OLS)
navigation Systems Operations (PANS-OPS)
Who is reporting to REPCON?
[Department] as airspace
Facilities maintenance
Flight crew 40%
to be protected in the
personnel/ground crew 1%
interests of future air
Unknown 3%
transport operations.
Cabin crew 3%
The Act defines any activity
Air traffic controller 3%
resulting in an intrusion
into an airport’s prescribed
Passengers 8%
airspace to be a ‘controlled
Aircraft maintenance
activity’, and requires that
personnel 20%
controlled activities cannot
be carried out without
Others b 22%
approval. This includes the
construction of buildings
that intrude into the
a. from 29 January 2007 to 31 August 2010
b. examples include residents, property owners, general public
prescribed airspace.
The Regulations provide
for [the Department] or the
airport operator to approve
REPCON reports received
applications to carry out
controlled activities around
leased federal airports, of
Total 2010 a
which [the airport] is one,
Total 2009
and to impose conditions
on an approval.
Total 2008
The Department assesses
Total 2007
long-term (longer than
3 months) proposed
controlled activities and
a. as of 31 August 2010
short-term penetrations of
the PANS-OPS. The airport
may assess short-term
controlled activities.
How can I report to REPCON?
The airport operator
On line: ATSB website at <>
coordinates long-term
Telephone: 1800 020 505
controlled activities’
by email: [email protected]
assessments and forwards
by facsimile: 02 6274 6461
by mail: Freepost 600,
these and the application
to the Department for final
PO Box 600, Civic Square ACT 2608
The approval process involves the
proponent submitting building details
including the proposed maximum structure
height (including appurtenances) and
location coordinates to [the aerodrome
operator], and [the aerodrome operator]
then facilitates assessment from Airservices
Australia, CASA and the local building
authority, before forwarding comments to
[the Department] for final assessment and
approval. The Department may approve,
approve with conditions or refuse to
approve the proposed ‘controlled activity’.
On approval, a condition of approval
required by the Department is for the
structure to not exceed the approved height
by the Department.
Under the Act, penalties apply for nonapproved ‘controlled activities’ that
penetrate the prescribed airspace surfaces.
Civil Aviation Safety Regulations 1998
Under CASR 139.365 and 139.370, notification to CASA is required of any proposed
structure (including construction cranage)
in excess of 110 m AGL [Above Ground
Level]. This may result in CASA requiring
that the structure be appropriately marked
and lit. CASA is also able to make a determination under r 139.370 if a proposed
development would be hazardous to aircraft
operations including a gaseous efflux having
a velocity of greater than 4.3m/s.
Recent Building applications approved by
the Department in the [City] CBD include:
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Defence operates almost exclusively using the
restricted area system for its airspace requirements.
Whilst this has been successful in the past, giving
Defence the necessary flexibility to achieve what it has
to do, what happens within this restricted airspace, and
the services provided in it, differ widely. Consequently,
the audit and flexible usage of airspace working groups
have identified ways in which it can improve greatly for
all participants.
There have been a significant
number of changes to restricted
areas recently and there are
more to come in 2010. Some
areas have disappeared, and
undoubtedly, there are further
rumours of more changes. This
article is designed to keep you
in the picture and give a user's
guide to the changes happening
on 18 November.
One of the goals of last December's aviation white
paper was to improve aviation safety by means of a
more effective, efficient and responsive flexible use
of airspace. 'Flexible airspace' means maximising the So ... what
use of available airspace volumes while providing the what do you
required segregation for non-compatible activities.
Aircraft operations can then take place in a less restricted, more
efficient and often more environmentally friendly manner, while
meeting safety standards at all times. Flexible use of airspace optimises
civil access to military airspace and vice versa, whenever safety and
operational imperatives permit, and when the overall benefits of such
flexibility to civil and military airspace users outweigh the costs.
Over the last two years, there has been considerable work on auditing
defence usage of airspace. Through this work, CASA's Office of
Airspace Regulation (OAR) has identified key areas of airspace which
could be used more efficiently. Better guidelines on restricted area
activation and the type of control have identified the need to increase
transparency for all stakeholders, thus achieving greater usage
of airspace with gains in efficiencies and environmental benefits.
The changes will be in place for the November 2010 publications.
are the facts, and
need to know?
Reforming airspace usage
Defence, Airservices and industry will continue to work through the
OAR and with other agencies to improve the flexibility of both civil
and defence-administered airspace consistent with the increased
commonality and interoperability of our future air traffic management
Clarifying airspace management
A joint working group involving Defence, CASA, Airservices Australia,
departmental and industry representatives has been looking at how
we can manage airspace better to give more civilian access to defence
airspace, and more defence access to civilian airspace.
First is the airspace managed like controlled airspace – typically
the areas around major airfields such as Williamtown, Pearce or
Amberley. When active, RAAF air traffic controllers manage the
airspace. You can plan to go through, and request a clearance
through, this airspace and will get a clearance if the traffic
situation permits.
Second are those restricted areas that allow defence to have
priority for the area, without necessarily having ATC management.
These areas might be used for air-to-air practice, or naval gunnery,
where the risks would be higher to non-participants, and the
cost to defence would be significant if it have to give priority to
non-participants. Many of these areas adjoin the airspace around
major airfields - the areas to the east of Williamtown being a
prime example. Importantly, there may be times when such an
area is activated by Defence but is not necessarily being used
right at that moment. In these circumstances, a clearance may be
available to transit the area.
Third are the other areas designed for the protection of nonparticipants, such as radar sites and firing areas. The risks are too
high to allow over-flight of these areas. Typically, range controllers,
who are not qualified to provide air traffic services to civilian
aircraft, manage them. When active you will not be able to get a
clearance through these areas.
Fewer 'active H24' areas
The Defence/OAR audit identified some
restricted areas that could be modified, or
removed, such as some areas had not been
used in years, and were just cluttering maps.
As these areas were not being activated, they
were not actually stopping aircraft over-flight,
so there was no point retaining them. Other
areas have been identified as having strict
operating hours; for example, a local range
may have curfew hours, which prevent it
from operating at night. So the promulgated
restricted area hours now reflect this,
although often with the caveat that they may
be active outside these times by NOTAM.
Defence has also moved from having many
areas as 'active H24', but de-activating
them by NOTAM, to 'active by NOTAM'. In
effect there will be no real change to the
airspace activation hours, but the method of
notification will change. While there will still
be some H24 areas (for transmitters, storage
areas and the like), generally now you only
have to look for what is being activated.
This also provides benefits to airlines where
automated flight planning systems have not
been able to see areas that are de-activated
One of the group’s recommendations is to be clearer about how
airspace is being used. So, in 2010, there will be a noticeable change
to the way restricted areas are portrayed. This will give a better
idea of who is managing the area, and thus the likelihood of getting
a clearance through it. A bit of background as to how defence uses
airspace will help explain, and will show how usage can be broken
down in to three types:
Unfortunately, the current arrangements
do not delineate between these types of
management. All that pilots see is a red line
on a map, and a NOTAM telling them whether
it is active. While experience and local
knowledge may let the pilot know if they are
likely to get a clearance or not, to many pilots
this is not clear. However, in November, 2010,
all restricted areas will be identified as fitting
in to one of the three types listed later in
this article.
Read the NOTAM conditional status carefully,
and plan accordingly. If you cannot determine
the area's conditional status, then treat it as if
it is an RA3 and avoid the area.
This move will not substantially increase the
number of NOTAMs being released. Instead
of airspace being de-activated by a NOTAM as
before, it will now be activated by a NOTAM,
giving a more dynamic picture of what really
is being activated. At times, Defence will still
have the option of short-notice activation,
but this will be the exception rather than
the norm.
And as always, the rules of airmanship apply
– read and digest the NOTAMs before flight.
If you're not sure about activated areas, then
ask, or ultimately avoid.
November reform – changes to restricted area
Existing restricted areas will have further reclassification to conditional
status (CS) to show accessibility. Each CS is based on volume for that
given area of airspace. This will allow certain routes to be accessible.
Conditional status RA 1—you can plan through/expect
clearances when area is active – NOTAM/message will advise if
this is not the case (for areas such as MIL ATC terminal airspace
and flying training areas managed by ATC).
Conditional status RA 2—you cannot plan/should not expect a
clearance through when active, although tracking may be offered
on a tactical basis by ATC – NOTAM/message will advise if this is
not the case (R574 and some other areas where ATC and AIRDEF
work together).
Conditional status RA 3—clearance is never available when
active, except in emergency (most firing areas, laser, bomb dump,
high powered transmitter sites and non-ATC supported flying
You should also note that the conditional status is for general planning
purposes and does not override any specific existing agreements. There
is still the option to tactically provide clearances between ATC units,
as happens now. Generally, ATC will have a controlling component to
most restricted airspace. Each restricted area will be clearly identified,
and if ATC is operating, they will advise you if transit is available or not.
Read the NOTAM conditional status carefully, and plan accordingly. If
you cannot determine the area's conditional status, then treat it as if it
is an RA3 and avoid the area.
Temporary restricted areas and airspace
The above proposal works equally well for temporary restricted areas
(TRAs) as it does for standard restricted areas. You would find any
additional information regarding TRAs in the body of the NOTAM, or
in the AIPSUP.
Flexibility comes at a price
Defence is concerned about an increased risk of airspace infringements
following these changes, and so is working with CASA on implementing
a wide communication campaign on the changes. CASA's network of
safety advisors will assist industry during the course of their ongoing
AvSafety seminar program.
Be responsible and be informed, so that you can take advantage of
the changes on offer. Ultimately this comes down (again) to reading
your NOTAMs. The reform design has made the transparency of
restricted air space more user friendly and thus building the situational
awareness of all airspace users. Again, if you have any doubt, stay out!
These reforms provide more transparency of when airspace can be
shared use, or exclusive use, and also provide a degree of certainty
to enable civil aviation to plan more effectively. They are part of an
attempt to be more realistic about Defence’s ability to take advantage
of airspace at short notice, and place certain responsibilities on
Defence in the event of unplanned, short notice activation. The
options proposed do not change Defence’s current airspace usage or
limit its options. The proposal is also not solely for Defence-managed
restricted airspace; it is applicable to any volume of restricted airspace,
regardless of who manages it.
If you would like further information about these changes, please
contact the Office of Airspace Regulation at CASA.
Look and learn: eye surgery
The eye has two components that
focus, or refract, light onto the retina.
They are the cornea and lens.
About two thirds of this refraction
is done by the cornea and one third
by the lens.
(short-sightedness) occurs when light
rays are focused in front of the retina.
Traditionally these conditions have been managed by
visual correction with spectacles or contact lenses.
(far-sightedness) occurs when light
rays are focused on a point behind
the retina.
Several laser and non-laser refractive surgical procedures
have been developed to modify the shape of the cornea and
correct myopia, hyperopia, astigmatism and presbyopia,
with the aim of dispensing with the requirement for the
use of visual correction via spectacles or contacts.
Astigmatism is when there is a differential focusing
of light passing through different part
of the cornea.
is the inability to focus accurately on
near objects.
The main ones are:
photorefractive keratectomy (PRK);
laser-assisted, in-situ keratomileusis (LASIK); and
laser-assisted sub-epithelial keratomileusis (LASEK).
In these procedures, an excimer laser, which disrupts the
surface bonds of organic material, rather than cutting
or burning it, ablates or removes the front part of the
cornea’s stroma (framework) connective tissue.
The main difference between PRK and LASIK is that
LASIK creates a corneal flap before the excimer laser
reshapes the cornea.
In PRK, the central portion of the thin outer layer of the
cornea (the epithelium) is removed from the eye, usually
after being loosened with a dilute alcohol solution.
The excimer laser treatment is then applied to the
underlying corneal tissue (the stroma) to reshape the eye.
After the laser treatment, the cornea is covered with a
bandage contact lens. Within days, new epithelial cells
grow back and the bandage contact is removed.
Another technique falls between PRK and LASIK: laserassisted sub-epithelial keratomileusis (LASEK) also
known as Epi-LASEK. It cuts a fine flap of 50 microns
thickness (as opposed to 100-180 microns in LASIK) and
the patient’s original epithelial sheet is repositioned onto
the stromal bed after laser ablation.
The main difference between LASIK and LASEK is the
thickness of the flap, which includes corneal stroma
tissue in LASIK, and epithelial tissue only, in LASEK.
In LASIK, the excimer laser ablation is done under a
partial-thickness lamellar corneal flap. A microkeratome
(a precision surgical instrument with an oscillating blade)
creates the flap, or a femtosecond laser (that uses pulses
of a tenth of a billionth of a second, or shorter) can create
a much more uniform flap giving better quality of vision.
A hinge is left at one end of the flap, and the flap is folded
back, allowing access to the corneal stroma. The excimer
laser is then used to re-model the stroma. Once the
ablation is completed, the corneal flap is repositioned.
There are possible risks of flap-related complications such
as wrinkles, epithelial in-growth under the flap, debris,
folds, buttonhole and diffuse lamellar keratitis. LASIK is
also more likely to produce higher-order aberrations such
as starbursts, ghosting, halos, night vision disturbance
and double vision. This is no longer the case in the
latest versions of LASIK using a femtosecond laser and
a wavefront-guided ablation laser that ablates the cornea
more accurately.
And what does all this mean for
the pilot?
For more information
These guides to laser surgery from Australian
providers discuss suitability, expectations and possible
complications for people considering the procedure.
Is LASIK Suitable For Me?
A detailed guide on the risks of lasik surgery.
CHOICE survey of members’ experience with
eye surgery.
Risks and complications of laser eye surgery.
An online guide from an Australia laser surgery
This leads to a wound-healing response that might
result in greater stromal haze and scarring then in
LASIK. Recovery is slower and more painful than LASIK,
and because of this, PRK is now largely an historical
Compared with PRK and LASEK, LASIK results in
earlier and faster improvement of vision with minimal
postoperative discomfort, improved stability and
Refractive Eye Surgery
and the Aviator
Dr David Fitzgerald from CASA Aviation
Medicine takes a close look at trends in eye
surgery, and their implications for pilots.
For almost as long as there have been aircraft
it’s been accepted that the pilots who fly them
must have sharp distance vision. An Australian
Flying Corps recruiting advertisement from
1916 called for volunteers with ‘a sound heart
and good eyesight’1.
Vision standards for pilots are still high,
but the good news is that, in the words of
the Designated Aviation Medical Examiner's
Handbook, ‘CASA has not placed restrictions
on applicants who require high levels of
correction in order to meet the required visual
standards. CASA considers the ability to meet
the standard is all that is required, regardless
of the power of corrective lenses necessary to
achieve this outcome.’
But not every pilot wants to fly with
spectacles, which can be dropped, or broken,
and bring unavoidable visual distortions; or
contact lenses, which can be uncomfortable,
particularly in the dry air of a pressurised flight
deck at high altitude. Refractive eye surgery is
a recent way of achieving acute vision without
the need for corrective lenses of any type.
Since the first vision correction operations
in the late 1980s, refractive eye surgery has
become hugely popular, so much so that
DAMEs are encountering many existing and
prospective pilots who have either undergone
the surgery, or are considering it.
CASA recently conducted a review of the aviation implications of
refractive surgery with the help of aviation ophthalmologists and the
Australian College of Optometry.
For some years, the certification management of aircrew who have had
refractive surgery has been fairly liberal. Reports have generally been
sought from treating ophthalmologists; however, specific examination
of aviation-specific visual function has not generally been a focus.
When CASA reviewed overseas regulators’ practices we found that, in
general, most do not allow certification until three months after the
The particularly significant consequences for flight safety regarding
night flight and flight in low contrast situations have led CASA to
require testing of contrast sensitivity function before certification.
Ongoing impairment of low contrast acuity in some applicants may
bar them from flying at night or in instrument conditions.
Following CASA’s review, the following guidelines for certification were
The main aeromedical issues surrounding refractive
surgery include:
1. Post-operative recovery time
2. Complications of surgery
3. Effect on glare and contrast sensitivity, and therefore night
visual function
4. Ongoing gradual myopic deterioration and long-term effects.
CASA recommends a minimum four weeks’ grounding after the
operation, although up to three months would not be excessive.
(Ophthalmologists say most recreational activities are not
recommended for at least four weeks).
... loss of sharpness at certain times of day or night
In terms of post-operative screening for complications – a report from
the treating ophthalmologist is suggested before being cleared back to
flight, detailing:
If it’s less than 12 weeks after surgery, diurnal variation of
refraction (loss of sharpness at certain times of day or night) over
two weeks needs to be tested and reports provided
Pre-operative visual acuity and dioptres
Size of the pupil and ablation zone
Post-operative visual acuity and dioptres
Results of an objective test of mesopic contrast sensitivity, which
relates to vision in outdoor night-time or street-lit settings. (Results
and methods for this are to be provided). No particular test or
method is preferred – there are a number of different tests to
measure contrast sensitivity.
Ophthalmological examination for haze or other abnormalities
Noting any other issues.
If abnormalities of mesopic contrast sensitivity, haze or halos are
noted, the medical certificate will be restricted as not valid for night
flying until such issues have resolved.
In follow-up, the aviation medical should be able to screen for myopic
deterioration in the case of good results, but detailed ophthalmological
review may be required for difficult cases after one or two years, and
an ophthalmological review will be required for all applicants a year
after surgery.
Postoperative issues
Stability of visual acuity
It takes up to three months post surgery for the visual acuity to
stabilise2. Acutely, there is some evidence that the effect of hypoxia may
lead to some corneal expansion and flattening, leading to hyperopic
shift 3. There is also evidence that in the 12 months after surgery, there
is some continuing regression of visual acuity back towards the
original myopia.
Dry eye
Dry eye is the most common issue post refractive surgery (in up to
48 per cent of patients4) due to the disruption of corneal nerves and
resulting decreased tear production. It is usually rectified by the use
of artificial tears, or in more severe cases by surgically blocking the
lachrymal punctum duct that drains tears from the eye. In the low
humidity at high altitude, dry eye is already a problem for even the
normal eye – and further impairment of tear production due to eye
surgery is potentially especially problematic for pilots.
Flap displacement
The flap created in the cornea in Lasik surgery heals by normal wound
healing processes such as collagen deposition, and this can be quite
slow to reach its full strength. As a result, the flap is subject to slippage
in the first few days or weeks, after surgery. This can happen several
months after surgery and could be caused by such minimal trauma
as eye rubbing. It is generally suggested, therefore, that patients avoid
contact sports or trauma for at least four weeks after surgery.
Glare and halos – night vision disturbance
Glare disability and halos may be produced
after refractive surgery. Glare disability,
image degradation and loss of contrast
sensitivity are problems that may occur in
individuals who have otherwise excellent
vision during the day5. These symptoms are
most noticeable at night, or in low ambient
light, when the pupil dilates and more light
rays enter the eye through the untreated
peripheral cornea, particularly if the area of
treatment is small or the pupils large. One
reason why these changes may not be as
apparent in daylight is that in daylight, the
pupils are very small. Corneal scars or haze
can also cause intraocular light scattering.
This has significant ramifications for aircrew
flying at night or in conditions of low ambient
visibility such as in IMC. Where flight in VFR
day conditions may not be associated with
notable visual dysfunction, flight at night or
in poor light may result in unacceptable loss
of visual acuity or image degradation in the
form of halos or starbursts from runway lights
and beacons.
To sum up: refractive surgery is becoming an
increasingly common and effective way of
correcting for myopia and avoiding the use of
spectacles or contact lenses. However, there
are some possible significant ramifications
for pilots who undergo such surgery. Any
decision to have refractive surgery should be
one made in conjunction with the treating
ophthalmologist and should be made after
weighing up the benefits and risks of such a
procedure. Return to flying after surgery may
take up to three months, or even longer, and
unimpaired contrast sensitivity is required
before flying at night or in low ambient light
conditions. It may be prudent to determine
which ophthalmologist or optometrist can
conduct the contrast sensitivity test in your
area before surgery, as not all practitioners
routinely test this.
‘Unconscious of any distinction?’ Social and
vocational quality in the Australian Flying Corps,
1914–1918 Michael Molkentin Journal of the
Australian War Memorial No 40 January 2007
Clinical Ophthalmology 2010:4 455–458
Ophthalmic Research; 2000: 32, (1); 32-40
American Journal of Ophthalmology 2006:
Surv Ophthalmol 2002: 47 (6) 2002
For monovision-corrected refractive surgery, (where one eye is
corrected for near vision and the other eye is corrected for distance
vision) visual correction should still be worn to meet the distance
visual standards.
Pilots would be wise to avoid aerobatics or
high G manoeuvres in the postoperative
The ‘leans’ is a condition encountered in instrument flying
which is initiated where
(a) strong northerly winds over southern Australia.
(a) a rate of roll is below the threshold of detection by the
vestibular system.
(b) strong south westerly winds over southern Australia.
(b) a low rate of yaw is not detected by the vestibular system.
(c) strong westerly winds over southern Australia.
(c) an inexperienced pilot attempts to keep the head vertical
during a turn.
(d) a col resulting in light and variable winds between the
two systems.
When a low-pressure system is present over the Tasman Sea
and a there is a high pressure system over the Bight the two
systems combine to produce:
When a pilot discovers a defect in an aircraft, details of the
defect should be noted in the column of the maintenance
release document headed:
(d) longitudinal acceleration is mistaken for a descent.
When tracking north in a westerly wind the balance ball
(a) will be slightly to the left and left drift will be experienced.
(a) ‘Maintenance Required’.
(b) will be slightly to the left and right drift will be
(b) ‘Endorsements’.
(c) should be centred and right drift will be experienced.
(c) ‘Daily Inspection’.
(d) should be centred and left drift will be experienced.
(d) ‘Permitted Unserviceability’.
As the water vapour in the atmosphere increases, the density
of the air
(a) either on the ground or airborne and will result in yaw to
the right.
(a) decreases.
(b) either on the ground or airborne and will result in yaw to
the left.
(b) increases.
(c) remains the same.
(c) only when on the ground and will result in turn to the right.
(d) increases until precipitation occurs.
A possible cause of relatively sudden incapacitation of a
flight crew is
(a) chronic fatigue.
(b) heatstroke.
(c) dehydration.
(d) food poisoning.
During a landing with a right crosswind, ‘weathercocking’
can occur
(d) only on the ground and will result in turn to the left.
You wish to steer a heading of 120(m) and notice on the
compass deviation card ‘FOR 120 STEER 124’. To correct for
the compass deviation you should set the directional gyro to
(a) 124 (m) when the magnetic compass indicates 120 (c).
(b) 124 (c) when the magnetic compass indicates 120 (m).
(c) 120 (c) when the magnetic compass indicates 124 (m).
(d) 120 (m) when the magnetic compass indicates 124 (c).
Unstable atmospheres are associated with
(a) cumuliform clouds and large temperature lapse rates.
(b) cumuliform clouds and small temperature lapse rates.
(c) stratiform clouds and large temperature lapse rates.
(d) stratiform clouds and small temperature lapse rates.
10. If the aerodrome elevation was 300ft and with 1013 HPA set on
an altimeter subscale, the altimeter reading was zero when
the aircraft was on the ground, the QNH would be
(a) 1023 and the pressure height would be zero feet.
(b) 1023 and the pressure height would be 300ft.
(c) 1013 and the pressure height would be zero feet.
(d) 1003 and the airfield pressure height would be 300ft.
(d) is not influenced by outside magnetic fields.
‘Washout’ refers to a design feature where the angle of
incidence of the wing
(a) AN834-4.
(b) increases towards the tips and is adjustable on
some aircraft.
(b) AN834-4D.
(c) reduces towards the tips and is not adjustable.
(d) AN837-4D.
(a) is not regarded as a suspected unapproved part, but
should be reported via the defect reporting program.
(c) 50 per cent to useful work.
(b) 75 per cent to useful work.
(a) coarser pitch, which would have a tendency to
increase RPM.
(b) coarser pitch, which would have a tendency to
decrease RPM.
When an airworthiness directive from a foreign state requires
information to be sent back to the Nation Airworthiness
Authority (NAA) of that state, the required information
(c) finer pitch, which would have a tendency to
increase RPM.
(d) finer pitch, which would have a tendency to
decrease RPM.
(a) should be submitted via CASA only.
(b) should be submitted only to the NAA.
(c) should be submitted to the NAA and copied to CASA.
(d) need not be submitted to either airworthiness
authority since the foreign NAA only controls aircraft
in its own state.
A starter-generator on a turboprop engine acts as a
(a) series motor during engine start, and a shunt or compound
generator during running.
(b) series motor during engine start, and a series generator
during normal engine running.
(c) shunt motor during engine start, and a shunt or compound
generator during normal running.
(d) shunt motor during engine start, and a shunt generator
during normal running.
On a propeller, the centrifugal twisting moment tries to
change the blades to
A constant displacement oil pump delivers
(a) a constant volume per revolution, and therefore requires a
pressure relief valve on the suction side.
(b) a constant volume per revolution, and therefore requires a
pressure relief valve on the delivery side.
(c) a constant pressure, and therefore does not require a
pressure relief valve on the delivery side.
(d) a constant pressure, and therefore requires a pressure
relief valve on the delivery side.
(d) 30 per cent to useful work.
(d) is regarded as a suspected unapproved part and should be
the subject of a suspected unapproved part (SUP) report.
Of the energy released from fuel, a typical piston aircraft
engine converts approximately
(a) 80 per cent to useful work.
(c) is regarded as a suspected unapproved part and should be
reported via the defect reporting program.
(c) AN837-4.
A particular part, manufactured by an approved source, which
has been determined to depart from the type design
(b) is not regarded as a suspected unapproved part and is not
necessarily required to be reported.
A standard hardware designation for a ¼in elbow, 45 degree,
flared tube, steel is
(a) increases towards the tips and is not adjustable.
(d) reduces towards the tips and is adjustable on
some aircraft.
Filters are some times rated in microns. A micron is
(a) 0.003,937 in.
(b) 0.000,393 in.
(c) 0.000,039 in.
(d) 0.000,003 in.
10. An active clearance control in a jet engine increases the
efficiency by directing cooling air
(a) to the turbine stator vanes to reduce tip clearance.
(b) to the outside of the turbine casing to reduce tip
(c) into the labyrinth seal to reduce leakage.
(d) into the turbine blades to maintain stable operating
temperatures at the tips.
GPS arrival and GNSS RNAV
You are inbound to Shepparton (YSHT) Victoria in a category B
aircraft tracking along W477 (refer TAC -3), currently passing
6500 on descent and in cloud. You have copied the current AWIS,
part of which reads ‘... wind 360/05, QNH 1005, cloud BKN 009,
visibility 4000m.’ Your aircraft is equipped with a TSO 129
approach approved GNSS, current database and you are qualified
and current.
At 3 GPS to run in cloud you lose the Morse identifier of the SHT
NDB, and the ADF needle wanders.
What action must you now take?
(a) Continue descent to MDA using GPS alone to provide
tracking data.
(b) Execute the missed approach, tracking 008 and climbing to
1900ft, the 25nm M.S.A.
The following questions relate to the instrument approaches
available into YSHT, dated 28th Aug 2008 and 28 Aug 2010.
(c) Continue at the present altitude when the NDB failed,
using the GPS to provide tracking data.
(d) Execute the missed approach, tracking 243 and climbing to
3800ft, the 25nm MSA.
Based on the current AWIS, you elect to conduct the GPS
arrival (RAIM available). Passing 25 GPS SHT, what altitude
may you descend to?
(a) 3800ft.
(b) 1900ft.
You have conducted the missed approach, currently at 5 GPS
north, north east of YSHT on a heading of 010m, and levelling
at 3800ft. You now elect to conduct the GNSS RNAV approach
runway 18.
(c) 2800ft.
(d) 3000ft.
Passing 9 GPS what altitude may you now descend to, and
what is the speed range applicable at this distance?
Which of the following IAFs would be the most expedient to
track to, and how would this be expressed in the radio call to
advise Melbourne Centre.
(a) 1600ft, 120 to 180kt.
(a) SHT ND, expressed as ‘Sierra Hotel Tango November
(b) 2000ft, 120 to 180kt.
(b) SHT ND, expressed as ‘November Delta’.
(c) 1600ft, 85 to 130kt.
(c) SHT NI expressed as ‘Shepparton November India’.
(d) 2800ft, 120 to 180kt.
(d) SHT ND, expressed as ‘Shepparton November Delta’.
When may you descend to MDA, and what is this minima?
(a) After passing 5 GPS, MDA is 930ft on QNH/2.4km
(b) After passing 4 GPS, MDA is 930ft on QNH/2.4km
You load and activate the appropriate GNSS RNAV approach.
Having then done a RAIM prediction, you find there are
no outages.
What scaling ‘mode’ will the GPS unit be in, and what is the
scale if this is the navigation presentation:
(c) After passing 4 GPS, MDA is 1030ft on QNH/2.4km
(d) After passing 5 GPS, MDA is 1030ft on QNH/2.4km
(a) ‘Terminal’ mode. 1 ‘Dot’ equals 1nm.
(b) ‘Terminal’ mode. 1 ‘Dot’ equals 0.3nm.
(c) ‘Terminal’ mode. 1 ‘Dot’ equals 0.2nm.
(d) ‘Approach Active’ mode. 1 ‘Dot’ equals 0.06nm.
Your heading is now 020m, altitude 3800, approaching the
Which of the following is correct concerning the ‘capture
region’ to be able to go in to the approach?
What will be this MDA for the approach?
(a) The aircraft is within the 70° capture region and thus can
go straight into the approach on a track of 249.
(a) 1030ft/2.4km.
(b) The aircraft is not within 30° of the initial approach track
of 249 and thus cannot go straight in to the approach.
Manoeuvring is necessary.
(c) 880ft/2.8km.
(c) The aircraft is not within the 180° capture region and thus
cannot go straight into the approach on a track of 249.
Manoeuvring is necessary.
(d) Because the aircraft is not within the capture region at
‘SHTND’, you should track to ‘SHTNC’ where a published
sector entry can be flown to position for the approach.
Inbound on the approach, having passed ‘SHTNI’ using the turn
anticipation and established on a track of 179 you descend
toward ‘SHTNF’.
You consider the MDA for circling having regard to no AWIS for
the last 20 minutes when the SHT NDB failed. You set the YSHT
In order for the GPS to achieve its final scaling (approach
active) what parameters must be met, and what is the
(a) The aircraft must simply be positioned at ‘SHTNF’ and the
scaling automatically becomes ±0.3nm.
(b) 930ft/2.4km.
(d) 780ft/2.8km.
(e) 1080ft/2.4km.
The MAPT is at 0.2nm from the threshold.
10. Which of the following is correct concerning the missed
approach procedure?
(a) Priority one is establish the climb, then turn right, tracking
to ‘SHTNH’, climbing to 1900ft.
(b) Select ‘SHTNT’ for track guidance then initiate climb to
1900ft. At ‘SHTNT’ turn right, tracking to ‘SHTNH’.
(c) Priority one is establish the climb, then resequence
the GPS to track 179 to ‘SHTNT’, climbing to 1900ft.
At ‘SHTNT’, turn right and track to ‘SHTNH’.
(d) Priority one is establish the climb, and continue tracking
179 to ‘SHTNT’ since the GPS has automatically
sequenced to this waypoint, climbing to 1900ft.
(b) The aircraft is positioned at ‘SHTNF’. The scaling remains
at ±1.0nm.
(c) The aircraft is at ‘SHTNF’, in sequencing mode, RAIM is
available and the scaling becomes ±0.3nm.
(d) The aircraft is within 2nm of ‘SHTNF’ in sequencing mode,
the HDG is toward the FAF, RAIM is available and the
scaling becomes ±0.3nm.
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1 2
3 4 5 6
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21 22 23 24 25 26 27
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z Flight Safety Foundation International
Air Safety Seminar 2010
7-12 zCivil Air Navigation Services Organisation
Global Safety Seminar
„ Regional Airspace and Procedures
Advisory Committee
10-11 z Business Aviation Safety Seminar-Asia
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& opening of new photographic display
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Error in Complex Systems
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Crowne Plaza, Darling
Harbour, Sydney
„ CASA offices close for Christmas/
New Year break
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Ph: 02 9791 9099 Email: [email protected]
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Flying Ops
IFR Operations
1. (d)
2. (a) unapproved parts CAAP
3. (a) AC 39-01 and CASA
4. (a)
5. (c)
6. (d)
7. (c)
8. (b)
9. (c) one millionth of a metre.
10. (b)
(d) the DG should indicate
the magnetic heading.
When this is 220 (m) this
particular compass will
indicate 224 (c).
9. (a)
10. (a)
10 (c)
YSHT GPS arrival plate.
YSHT GPS arrival plate.
AIP ENR 1.5-11 Para 1.15.1.
YSHT GPS arrival plate.
AIP ENR 1.5-30 Para 5.3.2.
YSHT GPS arrival plate.
AIP ENR 1.5-43 Para 13.2.2. D.
YSHT RNAV RWY 18 approach plate.
This is typical terminology.
Check the handbook for the GPS
equipment concerned.
AIP ENR 1.5-15 Para 2.4.1 C.
These are the typical criteria.
Check the handbook for the GPS
equipment concerned.
YSHT RNAV RWY 18 approach plate.
AIP ENR 1.5-30 Para 5.3.2.
Note: add 50ft only if using area QNH.
YSHT RNAV RWY 18 approach plate.
The Guild of Air Pilots
& Air Navigators (GAPAN)
Griffith University
Applications are invited for the 2011 scholarship, established
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2011 Aviation
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One scholarship will be awarded. This will cover tuition
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Applications close 28 January 2011.
… essent
t ial aviation reading
Maintenance special:
Ageing aircraft update
The new maintenance regulations
The 2005 Grumman Mallard crash
And … more close calls
Lau irns,
nce Cam
s to
n c ridge
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