`Safety is no accident` `Wake in fright`

`Safety is no accident` `Wake in fright`
‘Safety is no accident’
Accident investigation and aviation safety
Jul-Aug 2010
Issue 75
i A matter of degree
Aviation & universities
i After all these years
Ageing aircraft
i Close calls
And ... more
‘Wake in fright’
Wake turbulence 101
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B h
be sa
be safe
Be heard, be seen, be safe
ISSUE NO. 75, JUL-AUG 2010
John McCormick
Gail Sambidge-Mitchell
Robert Wilson
Fiona Scheidel
P: 131 757 or E: [email protected]
Flight Safety Australia
GPO Box 2005 Canberra ACT 2601
P: 131 757 F: 02 6217 1950
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Bi-monthly to 87,000 aviation licence
holders, cabin crew and industry personnel
in Australia and internationally.
‘Safety is no accident’
The painstaking work of air crash investigators.
Margo Marchbank
20 ‘Wake in Fright’
Wake turbulence is your invisible enemy.
‘A matter of degree’
The academic approach to flight training.
29 ‘After all these years’
The implications of our ageing general aviation fleet.
40 ‘When it all comes unstuck’
What can go wrong with aircraft bonding.
44 ‘AOC survey report’
Information from the AOC Holders Safety Questionnaire.
58 ‘Repercussions of the Concorde disaster’
A tragedy that marked the beginning of the end for supersonic transport.
64 ‘A new road for diabetics’
Protocols for pilots with Type 1 diabetes.
Stories and photos are welcome. Please
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Australia does not imply endorsement by
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Warning: This educational publication
does not replace ERSA, AIP, airworthiness
regulatory documents, manufacturers’
advice, or NOTAMs. Operational
information in Flight Safety Australia should
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operational documents.
Information contained herein is subject
to change. The views expressed in this
publication are those of the authors, and do
not necessarily represent the views of the
Civil Aviation Safety Authority.
33. SDRs
38. Directives
46 Close Calls
© Copyright 2010, Civil Aviation Safety
Authority Australia.
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these supplements are written, edited and
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COVER: Fiona Scheidel
Flight Bytes–aviation safety news
ATC Notes–news from Airservices
Accident reports–International
Accident reports–Australian
Airworthiness pull-out section
46 ’Thunderstorms in area’
48 ‘Red means danger’
51 ‘Fail safe’
ATSB supplement
Av Quiz
Quiz answers
First some housekeeping - all mail for CASA should
be addressed to our central address: GPO Box 2005
Canberra ACT 2601.
Using the correct address will ensure your letter reaches
the right person in CASA, which is a large organisation
with constantly mobile staff. Some regional offices
are reporting considerable problems with incorrectly
addressed mail.
This is the last edition of Flight Safety Australia that
Airservices Australia employees will receive without
directly subscribing to the magazine.
To continue receiving FSA from the September–October
edition, Airservices employees will need to email their
address and contact details to [email protected] before
31 July.
The change will not affect Airservices employees who
already subscribe through CASA using their aviation
reference number (ARN), or personal details.
To assist industry to meet the requirements for safety
management systems (SMS), and make a successful
transition to the new Civil Aviation Safety Regulations,
CASA has developed a web-based manual authoring &
assessment tool, or MAAT.
Writing manuals, and the associated document control,
require high-level technical knowledge, skill in technical
writing and a commitment to good administrative
practices. For large organisations with a dedicated
staff—and a budget to match—that’s an achievable goal.
However, for medium and small operators, particularly
those in regional and rural areas without access to a
dedicated technical librarian and skilled technical writers,
delivering manuals to CASA’s required standard is not
as easy.
CASA recognises this, and so to support such operators,
CASA trialled an SMS builder tool, in a CD format.
This gave step-by-step guidance in preparing an AOC
application, and a structure and content for writing the
required manuals.
However, there were disadvantages with this format.
To use the CD, a separate program had to be loaded on to
each computer using it. It also required regular updates
in the form of patches with the latest legislation update
details. The 2008 ICAO Australian audit showed the
timing was right to build on the step-by-step guidance in
the CD, and to deliver this material online. Enter MAAT.
The manual authoring & assessment tool supports
industry in developing their manuals so that they are
ready for the new regulations: to have manuals which
then require CASA assessment. This applies especially to
developing the documents required by CASRs for flight
operations, existing charter operators, low- and highcapacity regular public transport operations; as well as
the new maintenance regulations under CASR Parts to
come into effect over the next couple of years.
The good news for operators who have prepared manuals
using the previously developed CD is that they can load
these manuals into MAAT for future use.
Operators can still write manuals and submit them to
CASA using existing processes.
However, there are distinct advantages with using MAAT.
Commercial Pilot – CPL-A
Multi Engine Command
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) Proudly owned and managed
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The standardised format and content streamlines
approval of the large number of manuals CASA receives
from industry. Using the supplied guidance material
and sample texts – pre-approved by CASA – allows for
a speedy approval process by CASA inspectors, because
they can concentrate on technical assessment, rather
than formatting errors, as these are minimised. If the
sample texts are used without addition or subtraction,
there is no requirement for extra approval by CASA,
resulting in a reduction of up to 75 per cent in approval
time and associated costs. The manual also aligns with
the most up-to-date legislative requirements, as MAAT
automatically updates when new legislation becomes
An additional benefit of manuals created online is that the
system is fully auditable; and it is easy to report on the
status of any manual in the system regardless of its level
of completion.
CASA has also developed a tutorial so you can become
familiar with how MAAT works. If you would like to view
this tutorial, please contact the MAAT team at [email protected]
casa.gov.au who will set up a user name and password so
that you can access it.
CPL Theory
28 June, 16 August,
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5 July, 2 August
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ph: (07) 3715 4000 email: [email protected]
) Queensland’s largest flight
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) Proudly owned and managed
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CRICOS Provider code: 01208J RTO 32009
The US National Transportation Safety Board (NTSB) has
backed pilot Chesley ‘Sully’ Sullenberger’s decision to
ditch US Airways flight 1549 on the Hudson River, in New
York, in January 2009, after it hit a flock of Canada geese
while at 2700ft. Sullenberger, (and first officer Jeffrey
Skiles), became an international hero after everyone on
the flight survived the potentially fatal accident.
Simulations of the Airbus A320’s flight at Airbus
headquarters in Toulouse by experienced pilots, including
an Airbus test pilot, bore out Sullenberger’s decision.
In eight of fifteen attempts, the fully-briefed simulator
pilots managed to return to New York La Guardia airport
– but only if they reacted immediately to the emergency.
The one attempt made to simulate returning to La Guardia
after a 35-second delay ‘was not successful’.
Sullenberger told the NTSB that, based on the aircraft’s
position, altitude, airspeed, and heading away from the
airport, and the time it took to stabilise the aircraft and
analyse the situation, he had determined that returning
to La Guardia was not possible. The inquiry endorsed
this decision: ‘Therefore, the NTSB concludes that the
captain’s decision to ditch on the Hudson River, rather
than attempting to land at an airport, provided the highest
probability that the accident would be survivable,’ it said.
Another finding was that Sullenberger had the Airbus’s
sidestick pulled back to the rear stop for the last 50
vertical feet of the flight.
The inquiry found four factors contributed to the
outcome: They were: (1) the decision-making of the flight
crewmembers and their crew resource management;
(2) the fortuitous use of an aircraft equipped for an
extended overwater flight, including the availability of
the forward slide/rafts, even though it was not required
to be so equipped; (3) the performance of the cabin crew
in the evacuation of the airplane; and (4) the proximity
of seven ferries, a fire department boat and two coast
guard vessels to the accident site and their immediate and
appropriate response.
Some sport aircraft pilots have asked questions
concerning the application of the civil aviation regulations
to ‘transition training’ and familiarisation flights for pilots
taking delivery of an unfamiliar experimental aircraft
from its current owner. CASA is examining these issues
and will provide some guidance in the next edition of
Flight Safety Australia (the September-October issue).
Helicopter pilot training is a serious and sometimes risky
business, particularly in its first hours. A German helicopter
operator hopes to make it a little safer with concept study
for a full-motion simulator to teach low-hour students the
fundamentals of rotary wing flight.
Heli Aviation GmbH presented its Heli Trainer at the ILA
air show in Berlin in June. The project, co-developed
with the Max Planck Institute for Biological Cybernetics
aims to develop a realistic flight trainer for ‘safe, effective
and cost-efficient’ pilot training. Heli says the advantage
of its trainer is that: ‘critical flight
manoeuvres can be repeated as
often as required and simulated
right up to a safe forced landing,
whereas in practical flight training,
the flight instructor has to intervene
immediately when incorrect flight
control actions are made.’
The trainer cabin is attached to a
six-axis, heavy-duty robot with a
carrying capacity of up to 500kg. It is
the only industrial robot in the entire
world certified to carry passengers. A
linear traversing axis can be added
as an option to simulate run-on
landings and take-offs.
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Details at www.libertyaircraft.com
Business aviation’s safety weaknesses are landings and
‘level busts’, safety experts told the 10th annual European
Business Aviation Convention and Exhibition in Geneva.
Overrunning runways - even long ones - and flying
through cleared flight levels were both mistakes made
disproportionately by business aircraft pilots, the UK Civil
Aviation Authority’s Simon Williams said.
Williams revealed that although business aviation
represents only eight per cent of traffic in European
Union skies, it was responsible for 20 per cent of flight
level busts, and 20 per cent of altimeter setting errors.
Safety analyst, Bob Breiling, of Breiling Associates, said
landing mishaps accounted for more than 50 per cent of
all business aircraft accidents, a higher proportion than in
other aviation sectors.
According to the Museum’s website, ‘The new building will
allow wider public access and ensure that the Museum’s
unique collection of Battle of Britain aircraft, memorabilia
and archives is preserved for the education of future
The aim of the building is to act: as a gateway to London
and an iconic landmark; a lasting tribute to the sacrifice
and bravery of an international force of men and women;
an education resource in the lessons of the Second
World War, for generations to come; an inspirational
new interpretation for 21st Century of the world’s finest
collection of aircraft and artefacts of the period; and a
salute to the city of London and the enduring legacy of
freedom and democracy.’
The shimmering 116m aluminium structure will dominate
the local skyline and be visible from central London. (Does
that mean we justify mentioning it as a NOTAM?)
We’re diverging from our safety flight plan on this one,
but we hope you’ll forgive us on the basis that any excuse
to mention a Spitfire is a good one. The British Royal Air
Force Museum in Hendon, north London has announced
plans for the Battle of Britain beacon, to be completed by
the 75th anniversary of the battle in 2015.
The beacon will be a sculpted aluminium tower that will
house an exhibition devoted to the battle in which about
3000 Allied pilots (including 32 Australians) between July
and October 1940, halted the advance of the German
Luftwaffe and postponed Nazi Germany’s plans to invade
The preliminary report into the crash of an Embraer
120ER Brasilia at Darwin airport has confirmed the two
pilots were performing a simulated engine failure when
the accident occurred. Greg Seymon, 40 and Shane
Whitbread, 49 were killed when the aircraft crashed into
bushland on the nearby RAAF base during a training
A call to the
aviation industry
CASA’s Safety Promotion seeks interested industry
members willing to take part in research to assist
in developing our aviation safety promotion products
and campaigns.
Please email [email protected] to register
your interest, providing your contact details and area of
expertise (e.g. airworthiness, human factors, flying training,
safety management). This will enable us to enlist your help in
developing safety promotion products that will contribute to
safe skies for all.
*CASA’s Safety Promotion branch develops a variety of campaign materials
and products, communicating regulatory reform & safety initiatives to industry.
Recent products include the Look out! DVD on situational awareness; the SMS
toolkit; and the campaign surrounding the transition from GAAP to Class D.
Witnesses reported that the take-off appeared ‘normal’
until a few moments after becoming airborne, ‘when the
aircraft rolled and diverged left from its take-off path’, the
Australian Transport Safety Bureau report said.
The report said the simulated left engine failure, known
as a V1-cut manoeuvre, was made about one second after
the aircraft became airborne. ‘Asymmetric flight, whether
from a simulated or actual engine failure, involves an
element of risk,’ the report said. Examination of the
aircraft’s engines, propeller hubs, aircraft rudder power
control unit and hydraulic actuators, as well as the cockpit
voice recorder (CVR) and flight data recorder (FDR),
is continuing. The ATSB said it found no safety issues
relating to Air North’s fleet.
An Australian aviation company is about to mark a minor
but significant milestone. Sometime during the currency
of this issue the first commercially-operated Whitney
Boomerang will mark its first 1000 hours of operation
– not bad going for just over two years of service. Dean
Wilson Aviation managing director, Gary Dean, says the
aircraft has performed impeccably for the first 1000
hours of its 22,000 hour design life. ‘All we’ve had to do is
recalibrate a fuel sender reader: there have been no issues
with airframe, avionics or engine,’ he said.
The aircraft uses tried and true aviation technology.
Airframe construction is conventional stressed skin
aluminium, primary instruments are mechanical, and
power comes from the venerable Lycoming IO-235 engine
that has been around in one form or another since 1949.
Dean Wilson Aviation plans to build a more powerful IO320- engined model with a constant speed propeller for
use as an IFR and navigation trainer.
During the aircraft’s first two years in service with a West
Australian flying school maximum take-off weight for the
type was able to be increased from 825 to 850kg.
The Boomerang is designed as a primary flight trainer,
similar in many respects to the respected, but ageing Piper
Tomahawk, but with innovations including a steel tube
safety cage for the side-by-side cockpit. This was tested
for a 12g impact at the NSW Roads and Traffic Authority’s
Rosebery crash laboratory in Sydney.
Following the signing of a memorandum of
understanding between CASA and the ATSB,
Flight Safety writer, Robert Wilson, looks at the
role of accident investigation in aviation safety.
The story that begins when an aircraft crashes, (or has a major inflight incident) often ends in a small room in central Canberra. The
Australian Transport Safety Bureau’s (ATSB) audio analysis room
is a slightly sombre place, fittingly, because the sounds and words
analysed there can be from the last moments of pilots’ lives. It’s a
small black room, padded and silent, despite the racks of high-end
stereo amplifiers and loudspeakers that give it a strangely domestic
feel. They contrast with its other contents: test equipment and brightly
coloured metal boxes, some scorched and some crushed. They are
flight data recorders and cockpit voice recorders.
Investigators listen to cockpit voice recordings many times, alert for
nuances in sometimes desperate conversations, and other audible
clues: engine and propeller speeds can be deduced from the pitch of
background noise; the click of a switch being moved can be isolated to
a certain control or system; and warning tones can be compared with
the repertoire of flight deck horns, voices and alerts every certified
aircraft type must leave on file with the Civil Aviation Safety Authority
In a nearby engineering room pieces of
metal, rubber and plastic, some of them
recognisable as aircraft parts only after close
examination, speak silently but eloquently
about fire, failure and scarcely conceivable
impact forces. A closer look at the scorched
relics confirms relatively few of them are
from crashes involving private pilots.
Assembling truth
from wreckage is
one of the ways
the ATSB tries
to make aviation safer. The other half of the
puzzle is talking to people, for even in a crash
with no survivors there will be people to talk
to; witnesses, maintenance staff, the aircraft’s
previous crew, and family and colleagues of
the crew, who are often vital in painting a
picture of the 72 hours before the crash. To
get answers rather than evasions requires
an innovation every bit as important as the
digital flight recorder: the no-blame approach.
Our role is to find out what
happened, not to blame or punish.
ATSB director of aviation safety investigation,
Ian Sangston, says taking a no-blame, noliability approach to safety investigation is
more useful than affixing blame, because
it reveals the truth and allows safety
improvements to be built on that foundation.
‘If you want to get people to talk to you and
work with you, you pretty much have to adopt
that approach,’ he says.
‘Our role is to find out what happened, not to
blame or punish. If we took that role nobody
would talk to us and transport would be less
safe because the opportunity to learn from
accidents and incidents would be lost.’
The no-blame approach to safety investigation,
while well established in Australian aviation,
is under threat in other skies. The aviation
industry worldwide is expressing concern at
the trend for litigation to bring punishment
and blame to bear in the aftermath of
Delegates to this year’s Royal Aeronautical
Society conference in London on the
criminalisation of air accidents heard it
was becoming more common for criminal
prosecutions to follow accidents.
The conference heard recent and current
proceedings had arisen following the Helios
and Concorde crashes, and the mid-air
collisions over Uberlingen in Switzerland and
over the Amazon in Brazil in 2006.
Aviation barrister, Charles Haddon-Cave, told
Flight International that as a consequence the
industry was tending to engage in ‘defensive
engineering, not just technical, but personal
and administrative’. Procedures were now
being designed as ‘a bulwark against criticism’,
rather than an improved way of doing things,
he said.
Flight data recorders are opened and their
secrets, whether on tape or computer chip,
are revealed, by download in the case of a
modern solid-state recorder, and by playing
back the tape on a similar undamaged unit in
the case of older tape recorders.
The International Society of Air Safety Investigators in a stronglyworded resolution this year said among other things: ‘Criminal
investigations and prosecutions in the wake of aviation accidents can
interfere with the efficient and effective investigation of accidents and
prevent the timely and accurate determination of probable cause and
issuance of recommendations to prevent recurrence.’
‘Increasing safety in the aviation industry is a greater benefit to society
than seeking criminal punishment for those “guilty” of human error
or tragic mistakes.’
In Australia, pilots can be, and have been, sued for their alleged role
in crashes, but the ATSB does not cooperate in adversarial legal cases.
‘ATSB investigations and data are never used in litigation proceedings
or any other attempt to establish liability,’ Sangston says.
‘We’re not into that. It specifically says in the act that the aim of
investigations is not to apportion blame or liability, or to be seen to
be doing that.’
This approach is one factor that contributes to the ATSB receiving
about 15,000 notifications of accidents and incidents a year. ATSB
director safety data research and technical, Julian Walsh, says, ‘We
enjoy a very healthy reporting culture in Australia.’
Of those 15,000 notifications, about 8000 equate to accidents or
incidents, and the remainder are duplicates or other matters, he says.
‘We still store and log them in our system,’ Walsh says. ‘Our message
to the industry is “we don’t mind, we prefer to make the assessment”.
If in doubt, it’s better to report.’
About 80 incidents and accidents are
investigated every year – one in a hundred of
all actual occurrences reported to the bureau.
The decision to investigate is based on the
significance of the accident in terms of
deaths and injuries, and the probability of its
revealing significant lessons.
This focus on finding significant lessons
reflects a subtle change in focus the ATSB
is taking in choosing its investigations, the
Bureau’s commissioner, Martin Dolan, says.
As an illustration, he points out that while
(VH-registered) private aviation accounts
for about one-seventh of aviation activity in
Australia; private flying represents over half
of the fatalities in Australian aviation.
‘There’s about a 40-times more likelihood
per hour that you will die as a private pilot,
compared to the equivalent exposure on the
roads. This is about the same exposure that
motorcyclists have,’ Dolan says.
The comparison is valid, Dolan says, not
only because of the broadly-similar mortality
rates, but because of philosophical similarities
between private pilots and motorcycling. ‘I
think both are about an ethos of freedom and
mobility, and both embrace a certain level of
risk,’ Dolan says.
He says there comes a point when continuing
with detailed investigation of private aircraft
crashes makes little or no further contribution
to safety, given the repetitive and predictable
nature of many of these crashes:
‘Over the last 10 years, the majority of
contributing factors relate to things pilots did
or did not do, and accidents and fatalities are
driven in the same proportion and the same
set of factors as they were ten years ago,’
Dolan says.
Safety is better served by the ATSB using engaging means to educate
and inform pilots. ‘There’s a need to go beyond reports, to produce
clear, simple and compelling safety messages,’ he says.
‘We see cooperation with CASA as an important part of this,’ Dolan
adds. ‘Our two organisations have a common interest in effective
safety education.’
In a further shift in its investigation focus, the ATSB has recently added
a new level of investigation, Level 5. These investigations are less
involved than level 1-4 investigations, but by conducting additional
investigations, even brief ones, the aim is to add to the safety database
of Australian aviation.
The aim of these is just to gather some facts and circumstances around
an occurrence, perhaps by interviewing the pilots or getting a copy of
the operator’s internal report,’ Walsh says.
‘It’s a very short report, without any analysis, but we make comments
to point people in the direction of research. The idea is that those
will be put into a quarterly bulletin and will add to the database of
‘As has already happened, when we make a few enquiries, gather
evidence, all of a sudden there can be alarm bells ringing, and a short
report can turn into a more significant investigation,’ he says.
‘Likewise, it also happens in reverse when investigations are
downgraded from Level 4 to Level 5.’
The result, eventually, will be to fill in the gaps in the air safety
picture. ‘When you have enough snippets in the database, you may
be able to begin a safety issues’ investigation. That’s where there’s no
major incident, but the data appears to be pointing towards an issue,’
Sangston says. ‘One we have at the moment is a number of incidents
of pilots taking off and knocking over runway lights.’
The ATSB routinely shares data with CASA, but does so strictly for
the purpose of improving safety. Every business day, CASA receives
factual information from the ATSB on air safety occurrences. CASA
reviews the information to decide if further investigation is needed.
The data can also be analysed to uncover air safety trends.
CASA also conducts its own air safety investigations, but has a slightly
different focus to the ATSB. The manager of CASA’s accident liaison
and investigation unit, Richard White, says its investigations can be
more difficult than ATSB investigations, as there is no compulsion for
industry to talk to CASA. The investigation focus is specifically on what
happened; whether regulatory contraventions may have occurred;
and whether intervention of some kind, in the interests of safety, may
be necessary or appropriate.
(images above) Flight data
recorders have evolved from using
metal foil as a recording medium
(bottom), to magnetic tape
(middle), and most recently solidstate computer memory (top).
The recently-commenced Level 5 program aims to conduct 120
investigations, which would bring the ATSB to about 200 investigations
a year. Sangston says the Level 5 program is already adding to the air
safety picture.
‘The ATSB investigations are extremely
thorough and may take some time to
complete. Often CASA needs to know in
advance of the formal report what the issues
are so it can take corrective action,’ White
says. Liaison with the ATSB is an important
part of the process.
CASA has a number of methods it applies for
enhancing aviation safety, White says. Most
of its safety investigation actions are carried
out through safety promotion and educational
activities, and through the advice it gives on
operational and technical matters to pilots,
engineers and operators.
CASA also encourages pilots, engineers and
operators to comply with legislation and
to conduct their activities at a high level of
safety through a counselling process and by
recommending remedial training.
Administrative enforcement actions, such
as retesting, suspension or cancellation of
licences can follow a CASA investigation. ‘A
CASA investigation may involve ensuring a
person who is demonstrably unable and/
or unwilling to comply with legislative
requirements, is prevented from continuing
with the aviation-related activities they would
otherwise be authorised to do,’ White says.
clues usually rests with local police. ‘A crash scene is not a
crime scene, but when we ask police to treat it like a crime
scene they know exactly what we mean,’ Sangston says.
White, who investigated crashes for the New Zealand Civil
Aviation Authority before joining CASA, emphasises the
importance of preserving the crash scene. ‘An old adage
for accident investigators is “keep your hands in your
pockets during the first walk through the wreckage”,’ he
He says the need to keep the accident scene untouched
until investigators arrive is very important, second only
to safety considerations. ‘The clues can be very subtle:
marks on the ground; or in one case I attended, scrapes
in the road where a propeller made contact, revealing
information on speed and direction.
The third investigator of civilian air crashes in Australia,
Detective Inspector John Hurley of the NSW Police Force’s
Air Wing, is often the first among agencies to arrive at a
crash scene. The Air Wing’s fleet of five helicopters and a
Cessna 206 means he can usually be at a crash site within
two hours of the impact. It is not unusual for him to call
the ATSB to notify them of a crash before they hear of
it through other channels. That’s part of the close and
courteous relationship between all crash investigation
agencies, he says.
He says being the first on the scene of a fatal crash is
always a little unsettling, even to an officer hardened by
almost three decades of police work.
‘We don’t suspend somebody’s licence to
punish them; if we suspend, it’s because
of a safety issue.’
‘Myself and a crewman walking through the silence of the
forest approaching a crash site; it’s an eerie sensation.’
White’s role in accident investigation is delicate.
He lacks the freedom to offer indemnity in the
same way as the ATSB. ‘I tell people before an
interview that a formal conversation with me
can never be a no-jeopardy situation,’ he says.
‘Usually people cooperate and are willing to
provide information about the occurrence,
and it is rare for people to deliberately breach
the legislation when involved in accidents
and incidents.’
Hurley is a 29-year veteran of the NSW police force – with
26 years spent as a detective. ‘I was a country detective
on the far South Coast, then I was chief of detectives at
Kogarah [in Sydney].’ He went on to stints in special crime
investigation on drug and organised crime cases. For
relaxation he learned to fly, then to fly aerobatics.
The first stage in a major investigation is to
examine the scene. Until ATSB investigators
arrive, the responsibility for preserving the
‘But you have to move on and put your investigator’s hat
on, so to speak.’
His combination of aviation and investigation experience
led to him being selected as the Air Wing’s first aviation
fatality investigator in 2006. To his long experience,
he has added training and qualifications from the
ATSB, the International Aviation Safety Network, the
Directorate of Defence Aviation and Air Force Safety and
Cranfield University.
He is also the Safety Manager for the Police Air Wing.
He manages investigations conducted by the NSW Police
Force into fatal accidents involving anything that flies
in the state of NSW, including general aviation, airlines,
charter, helicopters, base jumpers, parachutists, hang
gliders, gliders and recreational aircraft.
Typically, there will be about 20 investigations open and
at varying stages of enquiry. The record, since he began in
2006, was 38 investigations on the go.
‘The ATSB will run an investigation and we’ll run a parallel
investigation,’ Hurley says. ‘Legislation prevents them
from sharing information with us until it’s released in a
final report. Then it becomes a public document and that
report is usually included in our final brief of evidence that
goes before the coroner.’
‘Should a matter have elements of criminality involved
then another course of action needs to be adopted. Should
this occur then the matter would usually be referred by the
Coroner to the office of the Director of Public Prosecutions
for legal direction.’
His police career has taught him to avoid jumping to
conclusions about the cause of the crash.
‘It’s a discipline, to keep an open mind. As a criminal
investigator I approach every accident as an evidencebased, fact-gathering process. I need to satisfy myself;
“Has this accident occurred as a result of a criminal
act? Yes or no? Is this a suicide? Yes or no? What caused
the accident?”’
Hurley has found re-creating the crashed aircraft’s
flight profile, using recording equipment on the
Police Air Wing’s helicopters, to be a key investigative
tool. ‘What you see on the ground and what
you see from the air are usually very different,’
he says.
Recreation Aviation Australia has been
investigating crashes involving sport aircraft for
26 years.
‘We investigate accidents involving everything
from powered parachute onwards, including
weight-shift trikes, three axis and highperformance sport aircraft,’ says RA-Aus
operations manager, Lee Ungermann.
RA-Aus, and its predecessor the Australian
Ultralight Federation, investigate sport aircraft
crashes which rarely meet the ATSB’s criteria for
an investigation, and work closely with the ATSB
on the relatively few Bureau investigations which
do involve sport aircraft.
‘The catchcry is that we do investigation to
prevent similar accidents from happening again,’
Ungermann says. ‘We go on site with the police,
and act as subject matter experts to produce
reports for the coroner.’
Ungermann says GPS units make ‘very good’ defacto flight data recorders. ‘We can obtain data
on altitude, heading, ground speed, latitude and
longitude from an intact GPS, and can overlay
flight routes on Google Earth.
If the GPS is damaged, we can
take it to the ATSB who will
have a look for us.’
Ungermann says RA-Aus and its
trained voluntary investigators
were able to share information
and procedures for dealing with
issues such as safe disarming
of ballistic parachutes. ‘That
was an area our organisation
had experience in, because a
lot of aircraft in our category
use them,’ he says.
‘Myself and
a crewman
through the
silence of
the forest
a crash site;
it ’s an
‘Where we differ from an ATSB investigation is that we
have to satisfy coronial requirements in regard to identity,
date, place, manner and cause of death and as such the
apportionment of blame or responsibility sometimes
occurs in that process.’
Investigating sport aircraft accidents
Yet he often drives back to a crash scene
for another look, sometimes within hours of
returning to Bankstown. He agrees it makes
for some very long days, but he stresses
professionalism, experience and dedication
as qualities an investigator must have.
‘While here are no new accidents in aviation,
every investigation we do is unique,’ he says.
However, Sangston emphasises that air safety
investigation is, in the main, a desk job.
‘There’s a bit of a misnomer that air safety
investigation is about being out there kicking
tin in the field. You’re probably in the field for
15 per cent of the time, maximum. The rest of
the time you’re in the office,’ he says.
Investigators come from varied backgrounds.
The ATSB’s staff includes LAMEs, pilots, air
traffic controllers, human factors experts,
technical and recording analysts, and
materials, avionics and electrical engineering
The bureau has several investigators devoted
to instrument analysis, ranging from needle
impact to data recovery, to analysis and
interrogation of EFIS systems and electronic
recording media. Information can also be
recovered from GPS systems and FADEC
engine management computers. The bureau
is developing equipment and standards to
maximise access to this information. This
involves liaison with equipment and chip
makers about what information is available
and the best way to read it.
Sangston says the complexity of modern aircraft, particularly air
transport aircraft, is
requiring more computing and electronics
specialists for investigations.
‘We found the QF72 investigations very technically intense,’ he says.
The ATSB draws on expertise from manufacturers and overseas
safety agencies. ‘We recognise we have limitations, but we have plans
in place to call for assistance.’
Technological advance is also affecting investigations into sport
and general aviation aircraft. They are not required to carry flight
recorders, although low-cost versions are now available for them. But
Walsh says the work of crash investigators is being made easier by the
amount of solid-state electronics in modern small aircraft, particularly
in sports aircraft. ‘We’re surprised and happy at the amount of
data that modern aircraft electronic systems record and can make
available,’ Walsh says.
According to Ian Sangston, ‘We’ve already had a case where we brought
an electronic system, not a dedicated recorder to the distributor, who
said “you won’t get anything off that”, but our guys kept on playing
with it and they did.’
However, technology can create new hazards. ‘In some aircraft there’s
now an explosive capsule that comes out to deploy a parachute. We
have to be aware of it, so that our people on the site can work safely,’
Sangston says.
Other hazards are quieter, but debilitating in their own way. ‘We have
had incidences of investigators suffering critical incident stress. You’d
think that would be from the broken bodies and broken aeroplanes,
but it’s not necessarily so. It can come from dealing with next-of-kin
and going through that process.’
One of the first things ATSB investigators do is establish contact with
next-of-kin, Sangston says.
‘They’re involved in the draft report, involved
in finalising the report. Generally the guys will
sit in with them at the inquest and that can be
quite traumatic.’
Some investigators take on too much
emotional burden Sangston says. ‘That can
lead to stress and strain. It can be insidious, or
they can see something once that just knocks
them over. It could happen if they see a child,
and it reminds them of their own children.
Some of it is cumulative, and some of it is
flashback, but we have systems in place,
and we’re always looking to improve them.
We have a [counselling] service provider.
We can’t force people to use it, but it’s
always there.’
Next-of-kin are a vital source of information in building the crash
picture, Sangston says. ‘One of the main things we need to obtain
early from the next-of-kin is the person’s 72-hour history. We need to
understand “had they been sick, had they been prescribed medicine,
was there an emotional or relationship problem, or were they having
trouble sleeping? Was it good sleep?”’
‘What next-of-kin want after accidents is for no-one else to go through
what they’ve had to go through. That’s our agenda too.’
A common theme among all the investigators is dedication to their
work. All three speak of the satisfaction of being able to make aviation
incrementally safer.
‘I love it. It’s a privilege to be able to contribute, in a small way to
improving safety,’ Sangston says.
Hurley says, ‘I’ll be doing this until they ask me to go elsewhere.’ Asked
what he most likes, he responds: ‘Getting to the truth of the matter
for the benefit of the relatives of those who have tragically lost their
lives. This is unfortunately never quick or easy, but getting the correct
answers to the hard questions is what makes it all worthwhile.’
For more information
Australian Transport Safety Bureau: www.atsb.gov.au
International Society of Air Safety Investigators: www.isasi.org
The Evolution of Flight Data Analysis: http://asasi.org/papers/2007/
Aviation Safety Network: www.aviation-safety.net
Air Crash, Macarthur Job, Aerospace Publications, Volume 1,
1991 & Volume 2, 1992.
Air Disaster: Volume 1 (1995), Volume 2 (1996), Volume 3 (1999),
Volume 4 (2001) Macarthur Job, Aerospace Publications.
Beyond the Black Box: The Forensics of Airplane Crashes,
George Bibel, Johns Hopkins University Press, 2007.
Hurley is aware that his closeness to the
industry comes at a cost. ‘Some investigations
I go to are those where I know the pilots,’ he
says. ‘One was the crash that killed [champion
aerobatic pilot] Tom Moon. Tom waved to me
as he taxied past our hangar at Bankstown
Airport a couple of days before it happened.’
‘I subsequently found myself at the scene of
his accident, managing the investigation.’
Despite its costs, Sangston says involvement with relatives is a vital
part of the ATSB’s work. ‘Stakeholder management is well worth
investing in. We see advantages in it all the time.’
$7& Notes
Twenty point oh: good to go?
You check your GPS: the distance from Anywhere is 20.0nm.
‘Great’, you think, ‘I’m at the step and I’m good to go!’ Without
further visually confirming your position, you commence climb to
the next step limit of four thousand five hundred.
Shortly afterwards, you hear ATC calling an aircraft in your area.
You answer and ATC tells you that you have infringed the C LL 3500
step on your climb-out. What went wrong?
There are two main problems in this relatively common scenario.
First is an inappropriate reliance on GPS when visual reference
(pilotage) is the required primary means of navigation for VFR
aircraft. Second is a failure to apply the required navigation
tolerances to make sure controlled airspace is not infringed.
Fixing position clear of CTA using visual fixes
ou are nearing the 20 DME Class C step heading north out
of Anywhere. It’s a great VFR flying day and you are cruising
at three thousand five hundred, right on the Control Area
(CTA) step lower limit.
Be cautious using a single visual ‘abeam’ fix as it does not always
guarantee clearance from CTA steps.
Use an on-track fix or a line of position between two visual fixes to
establish definite clearance of a CTA step. Make sure you have correctly
identified the fixes you use.
To land or not to land:
that is the question
Airservices incident investigations have revealed a worrying
trend at some towered airports.
While GPS is a great tool for the VFR pilot, it must be used
within the navigation requirements of AIP.
For a VFR flight you must be able to navigate by visual
reference to the ground or water, or by using any of the
methods specified for IFR flights that you are qualified
for - except below 2000ft, when you must be able to
navigate visually.
AIP also requires that, when operating in Class E or
G airspace, appropriate tolerances must be applied to
your flight path, depending on the navigation method
you are using. For visual navigation by day this is +1nm
for operations between 0- 2000ft AGL and +2nm for
operations between 2,001-5,000ft AGL.
In our example above, the pilot should have allowed at
least 1 or 2nm (depending on terrain height) beyond the
step before commencing climb. The pilot should also have
cross-checked their GPS with a positive visual fix clear of
the step. This is particularly important if using a GPS with
a map display, as the map indication of the CTA steps may
not be completely accurate.
So, when VFR, use GPS for what it is - a great secondary
reference for visual navigation. When operating around
controlled airspace don’t rely on GPS alone: apply a
suitable buffer from CTA and take a good look out
the window.
One of the primary functions of the control tower is to
provide runway separation. Runways are potentially
dangerous places and movements need to be strictly
controlled to ensure everybody’s safety. Because clearances
for runway movements, for example runway crossings, do
not always occur on the tower frequency, pilots on final may
not have full situational awareness of what is happening
on the runway. Lack of a landing clearance may be due
to an aircraft or obstacle entering or on the runway, and
frequency congestion or workload may prevent ATC issuing
instructions to go around.
GO’, or ‘CLEARED FOR THE OPTION’ (touch and go, full
stop, stop and go, or go around), pilots must go around if
they do not receive a landing clearance. The only exception
to this is in the event of an emergency.
It is therefore critically important that you have a decision
point in mind for a time, or place, at which you will go
around if you cannot obtain a clearance to land.
Remember: no clearance, no land!
Avalon airspace changes
Remember: Avalon airspace changed to a Class D Control
Zone with Class E airspace surrounding on 3 June 2010. A
broadcast area is in place for VFR flights entering the Class E
airspace. Pilots must contact Avalon Tower on frequency 120.1
before entry. Check NOTAMs and the Airservices Australia
website for further details.
One IFR navigation method is the use of a self-contained
navigation system. This can only be used as the primary
means of navigation if the system installed has been
approved by CASA and the pilot operates the system
in compliance with this approval. If you don’t meet
these requirements, your GPS can only be a secondary
navigation reference.
It appears a culture is developing in which some pilots are
landing without a clearance from air traffic control. This
clearly has the potential to present a serious risk to other
airport users.
International Accidents/Incidents 30 March - 22 May 2010
Fatalities Damage Description
30 Mar
Antonov 74
Ivanovo, Russia
Aircraft overran runway after take-off was aborted due to engine failure.
10 Apr
Tupolev 154M
Smolensk, Russia
Polish Air Force VIP transport struck trees and crashed on approach to former
military airfield in fog. President of Poland and other senior Polish leaders
among dead.
12 Apr
Rockwell T-39N
near Blue Ridge,
Georgia, USA
US Navy training aircraft crashed in dense woods on cross-country exercise,
igniting a 6ha forest fire.Three bodies recovered.
13 Apr
Boeing 737-322
ManokwariRendani Airport,
Written off Merpati Nusantara Airlines flight was landing when it overshot runway 35 by
200m before coming to a stop in a river bed. It struck a bridge, breaking the
fuselage. Ministry of Transport said runway was wet from drizzle.
13 Apr
Airbus A300B4203F
near Monterrey
Airport, Mexico
19 Apr
de Havilland
Canada DHC-6
Twin Otter 300
Kangel Danda
Airfield, Nepal
Substantial Aircraft diverted by weather to remote mountainous airstrip where it was
damaged in forced landing.
21 Apr
Antonov 12BP
Barangay Laput,
25 Apr
Bell UH-1H
Near Wellington
New Zealand
Written off Three crew were killed and a fourth seriously injured when helicopter crashed in
heavy fog, about 40km north of Wellington.
1 May
Blériot XI replica Plasy airfield,
near Plzen, Czech
Substantial Replica of first aircraft in Bohemia made hard landing during an airshow
celebrating 100 hundred years of flying in Czech republic
4 May
Antonov 2
Near Marianivka,
Written off Engine stopped at 500ft after take-off, prompting immediate forced landing.
Aircraft damaged in post-landing fire
12 May
Airbus A330
Near Tripoli, Libya 103
Airliner operated by Afriqiyah Airways destroyed when it crashed while on
approach to Tripoli International Airport, Libya. An 11-year-old boy survived.
15 May
Antonov 28
near Poeketi,
Aircraft departed from cruise flight and crashed in a wooded area of eastern
16 May
De Havilland
Canada DHC-3
Turbine Otter
Biscarrosse, France 0
Substantial Seaplane nosed over during a water landing, and came to rest upside down.
17 May
Antonov 24B
Salang Pass,
19 May
Embraer EMB110 Bandeirante
near Cascavel
Airport, Brazil
Substantial Cargo aircraft attempted to land in foggy, overcast weather and touched down
in soy bean field 500m from runway threshold.
22 May
Boeing 737-800
Airport, India
Written off Aircraft overran runway and slid down a wooded valley, bursting into flames.
AIP India says 'Aerodrome located on hilltop.Valleys 200ft to 250ft immediately
beyond paved surface of runway.'
On final approach, aircraft crashed on to a motorway, about 2km short of
runway threshold. It hit a car, killing the driver. Another person was found dead
later. Aircraft broke up and caught fire.
Cargo aircraft crashed in rice paddy near the town of Mexico, Philippines.
Media reports mentioned in-flight fire.Three of six crew killed.
Aircliner crashed in a mountain pass at 13,000ft. People in area reported heavy
Notes: compiled from information supplied by the Aviation Safety Network (see www. aviation-safety.net/database/) 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 27 March - 30 May 2010
A/C Damage Description
27 Mar
North American
Aviation AT-6D
Piper PA-30 Twin
Perth Aerodrome, Fatal
E M 43Km, WA
31 Mar
Robinson R44
near Roper Bar
1 Apr
Piper PA-28-161
Aerodrome, VIC
28 Mar
On touchdown, the aircraft encountered a wind gust. The pilot could not maintain
directional control. The aircraft ran off the runway, struck a fence and came to rest
in a drain.
It was reported that the aircraft collided with terrain. Both occupants were fatally
injured. The investigation is continuing.
During takeoff when the helicopter was about 15 ft AGL, it encountered a wind
gust causing a loss of lift. The pilot ran the helicopter onto the ground, but lost
control when the skid caught under the fence and the helicopter hit the ground on
its side.
The pilot misjudged the approach and the aircraft was too low to avoid colliding
with dense vegetation.
Australian Accidents/Incidents 27 March - 30 May 2010 cont.
2 Apr
Jabiru J400
Aerodrome, WA
4 Apr
Victa Airtourer
5 Apr
Beech C24R
Aerodrome, 255°
M 17Km, TAS
Tyabb (ALA), VIC Nil
7 Apr
Cessna 172N
near Epic Energy
Five (ALA), SA
10 Apr
Cessna A188B/
A1 AgTruck
Cessna 152
During the initial climb, the engine lost power. The pilot turned the aircraft and
conducted a glide approach and landed on runway 03. During the landing roll, the
brakes failed and the left brake was reported to be on fire. The aircraft ran off the
runway and subsequently hit a small ditch before rolling into a fence.
During the flight, the engine failed. The pilot conducted a forced landing on a
nearby road. On landing, the aircraft's left wing collided with a tree and the aircraft
spun into an embankment. The investigation is continuing.
On landing, the aircraft bounced before landing nose down. The nose landing gear
detached from the aircraft, the propeller struck the ground, and the aircraft left the
runway, coming to a stop in the grass.
While landing crosswind, the pilot encountered strong wind gusts that pushed the
aircraft off the side of the landing strip. The pilot decided to go around, but was
unable to gain altitude due to a tailwind and the aircraft configuration. The pilot
attempted to land in low scrub next to the runway, but the aircraft bounced and
nosed over. Both occupants were uninjured.
The aircraft was reported to have impacted terrain. The investigation is continuing.
The aircraft landed heavily damaging the nose landing gear.
Aerodrome, S M
185Km, QLD
Rolleston (ALA), S Nil
M 25Km, QLD
11 Apr
13 Apr
Ayr (ALA), W M
9Km, QLD
Aerodrome, NSW
Cessna 180K
Aerodrome, NW
M 22Km, NSW
Cessna 337H
Goolwa (ALA),
Super Skymaster 118° M 12Km, SA
The aircraft landed with the landing gear retracted.
11 May
Air Tractor
Hillston (ALA),
057° M 16Km,
12 May
Eagle Aircraft
Australia Eagle
X-TS 150
Bell 206B
Aerodrome, WA
During cruise, the engine lost power and subsequently failed. During the forced
landing approach onto a nearby paddock, the left wing and nose dropped and
the aircraft impacted the ground. The aircraft was seriously damaged. It was
suspected that the engine failed due to carburettor icing.
While conducting agricultural spraying, the aircraft struck a powerline that
impacted the right wing and a section of the leading edge detached from the wing.
The pilot conducted a forced landing but the right wing impacted the ground and
the aircraft was seriously damaged.
During approach, the aircraft collided with terrain. The aircraft sustained serious
damage and the two occupants were seriously injured. The investigation is
During agricultural spraying operations, the helicopter struck a powerline and hit
the ground.
18 Apr
19 Apr
22 Apr
Cessna 180A
22 Apr
Robinson R22
28 Apr
10 May
11 May
14 May
20 May
Bell 206L-3
21 May
Piper PA-31-350
Bell 206B (III)
27 May
30 May
Robinson R22
Aerodrome, 260°
M 30Km, QLD
Latrobe Valley
Aerodrome, 206°
M 37Km, VIC
Marree (ALA), SA Nil
Port Pirie
Aerodrome, 016°
M 19Km, SA
Aerodrome, S M
22Km, QLD
During forestry spraying operations, the helicopter struck a powerline and
subsequently collided with terrain. The pilot, the sole occupant, sustained fatal
injuries and the helicopter was destroyed. The investigation is continuing.
On final approach, the pilot did not use a checklist, and the aircraft was landed with
the landing gear retracted.
During the power line inspection, the pilot heard a loud bang. When the forward
speed of the helicopter decreased, it entered a spin. The pilot reduced power to
correct the spin, but the helicopter hit the ground resulting in substantial damage.
Inspection revealed that the tail rotor blade had separated in flight.
While conducting mustering operations, the helicopter tail rotor struck a tree and
the helicopter then collided with terrain. The helicopter was seriously damaged and
the pilot suffered serious injuries.
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.
Station (ALA),
148° M 62Km, NT
Aerodrome, ENE
M 19Km, NSW
Piper PA-44-180 Ballarat
Aerodrome, VIC
near Goolwa
Super Pulsar 100 (ALA), SA
During the landing flare, the aircraft encountered a wind gust, which caused the
aircraft to land hard, bounce, and swing to the right. The left landing gear collapsed.
The aircraft sustained serious damage.
During takeoff the aircraft did not accelerate normally. The pilot rejected the
takeoff, but the aircraft overran the strip and came to rest after striking a fence,
trees and a dry creek bed. An engineering inspection revealed that the right main
landing-gear wheel bearings were not moving freely.
During initial climb, the engine failed. The pilot conducted an autorotation on
to rocky terrain, where the helicopter overturned, resulting in serious damage.
Inspection revealed water in the fuel lines.
At 500ft on final approach, the engine failed and the pilot conducted a forced
landing in a heavily grassed, rough paddock. The subsequent engineering
inspection revealed a broken fuel cable.
During cruise, the engine sustained a partial engine failure, and the pilot conducted
a forced landing. The helicopter landed heavily and rolled onto its side. During the
subsequent engineering inspection, no fault could be found with the engine.
During cruise, the windscreen caved in, and the pilot conducted a forced landing.
Under the new class D procedures,
the responsibility for wake turbulence
avoidance now rests on VFR pilots’
shoulders. So, Flight Safety does a
refresher course—‘wake turbulence 101’.
Plane spotters know wake turbulence. From their
viewpoint near the airport fence it manifests itself
on still days as a sudden wind, rushing with a
strange, Pentecostal intensity about 90 seconds
after a heavy aircraft has passed overhead.
Pilots who have encountered wake turbulence take
a less poetic view. For them, it makes itself known
by sudden uncommanded roll - sometimes to
inverted, with alarming yaw, also uncommanded,
and often accompanied by merciless loss of
altitude – typically from low level. Any wing that
produces lift produces wake turbulence. This
means all winged aircraft (including rotary-winged
ones) produce wake turbulence.
Small aircraft should land well past the
touchdown point of large aircraft
Wake turbulence vortices fall
below the path of the aircraft
Vortices stop at touchdown
Illustration: Juanita Franzi, Aero Illustrations
Remember your basic aeronautical knowledge
(BAK) course about how a wing produces lift
through generation of low pressure – suction
– over its upper surface? Wake turbulence,
more correctly called wingtip or wake
vortices, happens when the higher pressure
air underneath the wing follows the laws of
physics and attempts to flow into the lowpressure zone above it. The path it follows
is to move outwards under the wing towards
the wingtip and curl up and over the wing’s
upper surface.
Minor contributors to the vortex are the
pressure differential, also causing air to move
inwards over the wing. There are also small
trailing-edge vortices, formed by outward and
inward-moving streams of air meeting at the
trailing edge. These move outwards to the
wingtip and join the main wingtip vortex. It
grows larger as it departs the wingtip. Jet blast
and propeller wash add to a dangerous recipe
for following aircraft.
The core is surrounded by an outer swirl
which can be up to 30m in diameter. Its
rotation speed decreases as the distance from
the core increases.
The strongest vortices are produced by heavy
aircraft, flying slowly, with flaps retracted,
or clean. Flying clean and slow requires
increased angle of attack, which increases
vortex production.
Wake vortices generally persist for about three minutes, or longer
in still air. Wake vortices near the ground are most persistent in
light winds of three to 10kt. A point to note is that light crosswinds
in an otherwise stable atmosphere can make vortices drift. A three
to five knot crosswind will tend to keep the upwind vortex near the
runway, and may cause the downwind vortex to drift toward another
runway. Turbulent or variable winds usually cause vortices to break up
more rapidly.
The greatest hazard from wake turbulence is induced roll and yaw.
This is especially dangerous during takeoff and landing, when there
is little altitude for recovery. Aircraft with short wingspans are most
affected by wake turbulence because they tend to roll faster than
aircraft with longer wingspans.
The effect of wake turbulence on an aircraft depends on many factors,
including the weight and the wingspan of the following aircraft, and
relative positions of the following aircraft and wake vortices. In the
mildest form there may be only rocking of the wings, similar to that of
flying through ordinary mechanical turbulence.
In the most severe form, a complete loss of control of the aircraft may
occur. The potential to recover from severe forms of wake turbulence
will depend on altitude, manoeuvrability and power of your aircraft.
Small aircraft following larger aircraft can be subjected to rolls of more
than 30 degrees. Most commonly, the trailing aircraft encounters both
vortices and is rolled in both directions.
The most dangerous situation is for a small aircraft to fly directly into
the wake of a larger aircraft. This usually happens when the smaller
aircraft flies beneath the flight path of the larger aircraft. Flight tests
in this situation have encountered sudden and severe roll, usually with
loss of control. If the aircraft is flown between the vortices, sink rates
of more than 1000 feet per minute can be added to the situation.
Small aircraft should rotate well before
the large aircraft and stay away from
the large aircraft's course
Vortices start at rotation and drop
below the path of the aircraft
Viewed from behind, the left vortex rotates
clockwise, and the right vortex rotates
anticlockwise. Like a cyclone, the vortices
have a core and an outer circle. The core can
vary in size from only a few centimetres in
diameter, to a metre or more, depending
on the type of aircraft. A heavy aircraft can
generate a circular wind near the core moving
at up to 100 metres per second (194 knots).
Wake turbulence is generally thought of as a problem that large
aircraft leave behind them for smaller ones to encounter. This is true,
but aircraft of any size can produce, and fall victim to, dangerous
wake turbulence. There are documented cases of wake turbulence
accidents between single-engine general aviation aircraft and wake
turbulence-induced ‘pitch excursions’ (a horrid euphemism) between
wide-bodied airliners. And there is at least one accident report on the
public record of an agricultural aircraft crashing after flying into its
own vortices.
Flight tests conducted by pilots attempting to fly
into the vortex at a slightly skewed angle produced a
combination of pitching and rolling, which typically
deflected the aircraft away from the wake. Research
shows the greatest potential for a wake turbulence
incident occurs when a light aircraft is turning from
base to final behind a heavy aircraft flying a straight-in
The light aircraft crosses the wake vortices at right
angles, resulting in sudden pitching that can cause
structural damage to the aircraft.
Avoiding wake turbulence
Your best defence against wake turbulence is to stay
away from it. To do this, you need to recognise where
it occurs.
Do not get too close to the aircraft in front.
Do not get below the aircraft in front’s flight path.
Be particularly wary in still air or light winds.
The onus to avoid wake turbulence has recently shifted
towards pilots. Under the class D airspace procedures
introduced on 3 June, if you’re flying VFR, you are
entirely responsible for avoiding the wake turbulence
from heavier aircraft ahead, including when you are
landing. The same applies if you’re flying IFR and
you accept responsibility to follow or maintain own
separation with a heavier aircraft ahead. In these
circumstances, air traffic control (ATC) assistance will
be limited to issuing a wake turbulence caution.
Climb angles and tail winds are a couple of wild cards
in this game of survival. Remember that large aircraft
will often make their climb-out at an angle few general
aviation aircraft can match. The result: even if you
rotate before a jet, to avoid its wake, you could still fly
through it, perhaps at an uncomfortably low altitude.
And with low airspeed and high angle-of-attack in the
heavy aircraft, this wake turbulence is likely to be as
bad as it gets.
Tail winds are another sneaky game-changer: they blow
vortices along the runway so that even if you touch
down after a heavy aircraft’s landing point, you might
still encounter them.
Helicopters and wake turbulence
Then there’s helicopter wake turbulence.
Because of the high-power nature of helicopter
flight it’s usually significantly stronger than for
that of a fixed-wing aircraft of similar weight.
A helicopter’s rotating wings produce spiral
wake turbulence similar to an aeroplane’s
stationary ones, and add its own unique
effects, such as downwash.
Just as aeroplanes produce their greatest
wake turbulence in low airspeed and high
angle-of-attack situations, the strongest wake
turbulence from a helicopter also occurs at
lower airspeeds (20–50 knots), as this is usually when the most power
is going through the rotors, putting their blades at high angle of attack.
The action to take when piloting a small aircraft near helicopters is to
avoid taxiing within three wingspans of a helicopter that is hovering,
or hover taxiing. Avoid flying beneath the flight paths of helicopters.
Wake turbulence is an invisible but avoidable hazard. It’s particularly
dangerous when it occurs near the ground, and is also often stronger
there because aircraft in take-off or landing configurations produce
more turbulence. But the cure is simple. All you have to do is avoid
where it is likely to be. If in doubt, increase your separation from other
aircraft. In other words, wait and the problem will go away.
Illustrations: Juanita Franzi, Aero Illustrations
Hangar N Wirraway Drive, Redcliffe Airport. QLD 4021
Check out our web page at www.bobtait.com.au
All CPL subjects plus IREX
Courses available full-time or by home study
Aviation as a university
subject is taking off in
Australia. Flight Safety
Australia’s Robert Wilson
examines the issues
driving the academic
trend in aviation.
Would you go to a dentist who had learned the
art of pulling teeth by working in the outback,
or perhaps in Papua New Guinea? Professor
Patrick Murray doesn’t think so, and he
wonders why we treat pilots differently.
‘A hundred years ago if you wanted to be a
dentist, you would just become one’, the
associate professor in Griffith University’s
aviation department says. ‘All you had to
do was put up a sign. The trade progressed
through a “master and apprentice” phase, but
as knowledge and technology advanced, the
technical skills needed to be supplemented
with broader non-technical skills, and
eventually it became the norm for dentists to
learn their profession at university. Now, you
wouldn’t consider going to a dentist who was
effectively self-taught.’
Head of Griffith’s Aviation department, Paul
Bates, takes it further. ‘If you look at a dentist,
100 years ago their role was mainly drilling
and pulling teeth. But my daughter is unlikely
to have a filling in her entire life.
‘The role of the dentist
has changed, with
becoming key, and we
would say the role of the
airline, pilot has also evolved
Griffith University, in suburban Brisbane,
is one of 10 Australian universities teaching
degrees in aviation. As a practical vocation with a
strong requirement for theoretical understanding,
it is a fitting subject for university teaching,
Bates says.
But university aviators are quick to say that they
have not retreated to the supposed ivory tower
of academia. ‘The perception of a university
as an ivory tower is out of date,’ Bates says.
‘Universities are very much these days driven
by public policy and industry relationships, and
respond very rapidly to those needs. If you don’t
respond you’re left behind. The reality is that
universities are changing rapidly like the rest
of society.’
Aviation department staff at Griffith are drawn
from the industry, and maintain close links
with it, Murray, a former Cathay Pacific check
captain and Civil Aviation Safety Authority
executive says. ‘The majority of lecturing staff
are professional pilots. We try and keep a blend
of full-time staff and a significant number of
part-time adjunct staff, all of whom are aviation
industry professionals’, he says.
Caps and gowns are new to aviation, but flight training has long had
an academic component. It began with the work of Royal Flying
Corps Major Robert Smith-Barry, who, in response to a training
crash rate that rivalled the RFC’s combat losses, pioneered the
combination of classroom theory instruction and dual flight training
at Gosport, England in 1917. His technical innovation, in those days
before intercom, was a rubber speaking tube – the Gosport tube –
that connected instructor’s and student’s cockpits on the Avro 504J
training aircraft.
And university flyers also concede that the skills and knowledge
required to fly a large aircraft to a commercial standard of competence
have long been, at least the equivalent in intellectual intensity and
effort to earning an undergraduate degree, a comparison borne
out by the choice of long-standing and
reputable flying schools as the partners
of many university aviation departments.
‘The basic flying skills haven’t changed all
For most of
that much.
They’re mostly laid out in Smith-Barry’s
syllabus from Gosport,’ Murray says. But
he argues that it’s what happens next that
makes university education superior.
‘The traditional system is one of
experiential learning, he says. ‘People
undergoing a conventional training course
are taught pretty much the minimum
they need to know to hold a commercial
pilot’s licence.
They are then effectively told: “Whatever
it is you need to learn we can’t really
teach you, but go off for a couple of years
and if you come back you’ll have it.”’
The problem with experiential learning
is that it can be a brutal teacher, Bates
and Murray argue. ‘Cast your mind back
to riding a bicycle: it’s the way we learn
things, but unfortunately in aviation we
don’t have the option of falling off and
us, th
choice to do
a degree is
about doing
that separates
us from the
While aeronautical engineering has been taught
at universities for decades, flying aircraft as an
academic subject is relatively new in Australia.
Griffith has been teaching Aviation for about 20
years and has well established undergraduate,
postgraduate and PhD research programs.
However, it has been on the curriculum in
other countries for many more years. The US
University Aviation Association was founded in
1947 to promote college-level aviation education.
Embry-Riddle Aeronautical University in the US
can trace its antecedents back to 1925, and as
a flying school, was training pilots before World
War II. It became a university in 1970. About 25
per cent of airline pilots in the US are EmbryRiddle graduates.
The University of NSW Aviation Department argues strongly for
academic flight training on its website, and says it gives the graduate
an advantage that will extend beyond their career in the cockpit or
on the flight deck. ‘For most of us, the choice to do a degree is about
doing something that separates us from the competition. Around the
world, more pilots are getting a degree as well as their flying licences,
and airlines look favourably upon such well-rounded individuals. It
makes a lot of sense to have a wider understanding of the industry
you intend to be part of, and in later life it will help particularly when
going for command or management positions.’
... the advantages
of university education
... a rounded individual,
who can not only fly, but
communicate effectively
with engineers and
management, and have a
thorough understanding
of non-technical as well
as technical flying skills.
getting back on,’ Murray says. And
he argues there are many better
ways of progressing towards the
flight deck of an airliner than
piloting old-technology, singlepilot aircraft from remote outback
‘The bulk of flying in GA (general
aviation) is geared towards singlepilot operations, whereas the airlines
are looking for other skill sets,’ Bates
says. ‘A university course is a change
in the way you do things, so that
you can concentrate specifically on
producing an airline pilot.’ A newlyqualified doctor can practise under
supervision in a major hospital,
as can an accountant in a big city
practice. There’s no going bush
for these professions, Bates says,
and Griffith’s aim is to produce
junior airline pilots who are equally
employable straight out of the box,
so to speak.
‘The Rudd Government has recently
said that universities should be turning out people with qualifications
for industry. That happens to align with our own view that we should
be turning out graduates, not with qualifications where they can go
out and learn by themselves for a couple of years, but people who are
fit-for-purpose with their degree,’ Bates says.
The head of aviation at the University of South Australia, (UniSA)
Stephen Phillips, says the academic benefit of learning to fly at a
university is more to do with the theoretical side than the practical. ‘All
unis would be of the view that we provide a greater depth and require
a better level of understanding than that required by a flying school.
In addition, the non-core study and the academic rigour are aspects
which work to produce a “better” pilot,’ he says.
Phillips notes that several airlines around the world require their
pilots to have tertiary qualifications, and having a degree has long
been a requirement for pilots in the US Air Force and the majority of
North American airlines. In Australia, he says the benefit of a degree
is not seen or supported by all in the industry. Phillips sees distinct
advantages in combining flying training with the academic discipline
of university.
‘The difference I see is that the degree-qualified instructor would seem
to be better at addressing the issues and providing likely resolutions,
not just the problem,’ he says. ‘The rigour of study tends to create
someone who assesses the issue from more than just the obvious.’
Phillips also sees a safety benefit from
academic pilot training because the university
format allows for more time to be spent in
areas that do not get a strong focus elsewhere.
UniSA includes human factors, human
performance & limitations, threat & error
management, risk & safety management and
crew resource management in its degree, he
says. ‘In the average flying school there would
in all likelihood be only two of these, or at
best perhaps three.’
Murray says university pilot education is here
to stay. ‘Regardless of who you talk to we’re
moving into a pilot shortage. It had arrived
in 2007, but in the last couple of years, the
global financial crisis (GFC) created a pause.
That’s now ending. And the projections are for
a massive pilot shortage,’ he says.
‘Even if the existing way was considered quite
good, there isn’t going to be the luxury of
doing it in future. There are a couple of drivers.
The quality driver, and also the imperative
that in times of expansion there have to be
new ways of improving training effectiveness.
He stresses the advantages of university
education in producing a rounded individual,
who can not only fly, but communicate
effectively with engineers and management,
and have a thorough understanding of nontechnical as well as technical flying skills.
He believes that sound stick-and-rudder skills
will always be essential, but with 70 per cent
of accidents being caused by human factors,
it is vital that future pilots have solid skills in
this area.
‘A school leaver who wants to be a pilot is
around 18 years-of-age, and while there are
some mature 18-year-olds, maturity tends to
come with time.
One way of doing that at the moment is to give
someone a commercial pilot’s licence and get
them to go out and mature in an environment
such as PNG or the bush. Alternatively, you
can mature them in a more controlled
environment. One of those has traditionally
been the military, who do it extremely well university is becoming another pathway.’
Griffith’s course places strong emphasis on
leadership, management and communication
skills, which are developed, among other ways,
by students having significant involvement in
the running of the Wide Bay Air Show.
‘Our students learn broad management
skills so that they can integrate with other
aviation disciplines. Traditionally, aviation
professionals have tended to grow up in their
own narrow professional silos. We believe
that all aviation professionals need broader
industry understanding. This will allow
graduates to be better equipped to take on
command and management roles at an earlier
age,’ Murray says. Teamwork is another
emphasis in Griffith’s aviation syllabus.
Phillips says the more likely scenario is for a growing number of
tertiary-qualified pilots, which will then further drive demand as
airlines recognise that they get more than just a pilot with a degree.
‘There will however, still be a place for the non-degree CPL; there may
just not be as many of them around,’ he says. He also predicts more
degrees among ex-military airline pilots.
A recent innovation in pilot training was the introduction of the multicrew pilot licence, (MPL), a competency-based licence which allows
newly-trained pilots to fly as first officer on a two-pilot turbine or jet
aircraft. For the moment, universities are sticking to the ab-initio
model and training their graduates to a commercial pilot licence in a
fixed-wing piston aircraft. Graduates emerge with about 200 hours of
flight time from university aviation courses.
MPL licensing raises the issue of pilot competency, with supporters of
the traditional approach – self-education in a variety of types to build
command hours - claiming there is no substitute for the reality of being
in charge of an aircraft. Phillips expects universities will continue to
follow the CPL licensing model.
‘The constraints of the MPL regarding the airline/trainer relationship
are likely to militate against a uni going with the MPL,’ he says. Instead,
he foresees an evolution of CPL licensing: ‘something between the total
crew approach of the MPL and the strictly single-pilot focus of the CPL.’
Murray and Bates agree that basic piloting skills are on the agenda
internationally, after a spate of airliner loss-of-control crashes.
‘Obviously it’s important to achieve the correct blend of flight
management and '"hands-and-feet skills",' Murray says. While making
no judgement on the merits of MPL versus CPL licensing, he offers the
observation that ongoing evidence-based simulator testing and check
flights are as important to maintaining piloting skills as sound basic
Education, he argues, adds to safety and proficiency; it provides both
a philosophical and practical foundation on which graduate pilots
can build their understanding of flying skills, teamwork, knowledge,
compliance and the myriad other attributes required to fly safely.
‘With the internationalisation of the profession, the technology
and the equipment, we believe there is, more and more, a case
for future pilots being educated as well as trained.’
'Working as a team is essential,
and from day one at the university
the students are focused on
teamwork, concentrating
on such areas as developing
communication, assertiveness,
self confidence, leadership and
However, Griffith’s aviation department recognises not all student
pilots will take the tertiary pathway. Bates says: ‘we believe that for
many years to come there will be parallel pathways into professional
aviation. Traditionally, in Australia, graduates are under-represented in
aviation compared with other countries, that’s both aviation graduates
and graduates in general.’
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Reach new heights with a degree
in aviation management.
An ageing aircraft can be defined as an operational aircraft that is
approaching the end of its design life. In Australia, the percentage of
multi-engined piston aircraft more than 40 years old is approaching
10 per cent. Who would have thought, when these aircraft first came
on the register in the 1960s, they would still be flying in the second
decade of the 21st century?
Older aircraft are not necessarily a risk to safety, but an ageing fleet
has safety implications for the industry and the regulator. There are
two distinct issues at work. One is the effect of time and use on the
aircraft, and the other is the appropriateness of continuing to use
technology designed generations ago.
A useful analogy is to compare the ageing aircraft situation with the
automotive sector. If the equivalent proportion of ageing automobiles
was still in circulation as is the case with ageing aircraft, we could
expect to still see large numbers of Volkswagen Kombis, EH Holdens
and Bedford vans on our roads, with many engaged in commercial
old is
old ?
‘The innocent and the beautiful, Have no enemy but time,’ said the
poet William Butler Yeats. There’s no reason why it shouldn’t be the
same for a well-flown and well-maintained aircraft. But all good things
have to end sometime and with the average age of Australian general
aviation aeroplanes now more than 30 years, the question ‘how old is
too old?’ is starting to be asked. The answer is yet to be discovered,
because the impact of ageing aircraft fleets, particularly in relation to
commercial operations, is not yet fully understood.
Even in as-new condition, a 1960’s vehicle would be no match for its
newer equivalent in safety terms. Newer vehicles have safety systems
that were science fiction in the 60s, including airbags, anti-lock brakes
and electronic stability control,making them dramatically safer than
old ones. A study by Monash University estimated that if all young
drivers involved in crashes were driving the safest car available, rather
than the cars they usually drove; their road fatality and serious injury
rate could be reduced by more than 80 per cent.
The analogy with general aviation is not exact; many new systems
such as solid-state instruments can be fitted to existing aircraft. And
a pessimist might say cabin safety improvements are a moot point
because many aircraft crashes are, by their nature, non-survivable. But
safety improvements such as solid state instrumentation, autopilots
and ballistic recovery parachutes are undeniably more common on
newer aircraft than older ones.
Those vehicles were leading-edge designs in their day and complied
fully with the roadworthiness standards of their time. But there is no
way they would be considered suitable for daily commercial activities
today - particularly if passengers were involved. No business would
accept their levels of safety, reliability and economy.
The effects of age are subtly different on aircraft than on cars.
Corrosion or rust is a factor that takes many older motor vehicles off
the road, because it reduces structural strength dramatically. But most
aircraft are made up of a large percentage of aluminium - less subject
to corrosion. However, structural integrity in aircraft is arguably even
more important than in a land vehicle; there is no coming to a stop
at the side of the road in the event of a wing-spar failure. And with a
large number of aircraft now operating long after their manufacturers
anticipated, the Australian fleet is moving into uncharted territory
when it comes to the effects of ageing.
Factors on the side of older aircraft are that many of their systems have
been designed to be replaceable, and the cost of new aircraft makes
maintenance of old ones a viable alternative – even when it involves
substantial repair and refurbishment work done to a high standard.
The automotive arena has better news when it comes to the use of
old vehicles in a non-commercial context, for instance their private
weekend use by enthusiasts. The risk exposure to both the travelling
public and the drivers and passengers involved is significantly reduced
under such circumstances. Both government authorities and the
insurance industry acknowledge this reality by offering concessional
registrations and discounted premiums to classic car owners in
recognition of their low-risk profile.
The situation in aviation is likely to be similar (although there are no
promises of discounts) and CASA fully appreciates that there is no onesize-fits-all approach to the ageing aircraft issue.
The effects
of age
are subtly
on aircraft
than on
CASA has taken the first steps in appraising and addressing the
ageing aircraft situation in Australia. On the 25 February 2010, the
CASA Strategic Priorities Committee approved the ageing aircraft
management plan (AAMP) in response to the Government aviation
white paper – Flight Plan to the Future – released in December 2009. In
the white paper, the Government called for CASA to continue its focus
on the safety of ageing aircraft, particularly in relation to the regional
airline sector.
The first stage of the plan will quantify the magnitude of the ageing
aircraft issue in Australia and will recommend strategies to address
any issues raised. Stage 2 will involve the implementation of the stage
1 strategies considered most necessary. Finally, stage 3 of the plan
will involve the annual review of the implementation measures that
may have been put in place in the earlier stage as well as any new
The adequacy of the regional airline’s sector’s ageing fleet
airworthiness programs;
The fly-in/fly-out sector’s use of older jet transport aircraft;
Charter operations that utilise ageing aircraft;
The overall health of private-use ageing aircraft;
The appropriateness of existing systems of maintenance for
supporting ageing aircraft;
The development or implementation of structural inspection
documents (SIDs) and supplemental inspection programs (SIPs);
Reviewing appropriate categories of operation for certain
aircraft types;
The requirement for additional maintenance activities;
The development or cancellation of relevant airworthiness
The AAMP project is sponsored by Peter Boyd, Executive Director
Standards Development and Future Technology. The project manager
for the AAMP is Continuing Airworthiness Engineer: Pieter van Dijk,
who will work in conjunction with Mike Higgins, Lance Thorogood,
Darren Morris, Larry Russell and external consultants to deliver the
Stage 1 AAMP report.
The Stage 1 report, due in December 2010, will provide CASA with a
co-ordinated overview of the status of ageing aircraft in Australia, the
priorities for addressing any issues that may have been uncovered, as
well as provide recommended strategies for the future to ensure the
ongoing safety of the Australian travelling public. Areas of particular
interest for the AAMP project team are likely to include:
The ageing aircraft management plan, intended to run over three
stages, will involve significant industry liaison and consultation.
In addition, risk management techniques will be applied in order
to quantify potential threats to ongoing safety in Australia’s ageing
aircraft fleet. In particular, CASA will focus on issues such as structural
fatigue, corrosion, wiring systems, power plants and mechanical
The project team will consult with both CASA and industry experts
for inputs into the AAMP. This will include CASA hosting several
Ageing Aircraft Advisory Group (AAAG) meetings in either Canberra
or Brisbane, which will formally draw upon the advice from industry
representative organisations and groups including Aircraft Owners
and Pilots Association (AOPA), Regional Airlines Association of
Australia (RAAA) and the Australian Transport Safety Bureau (ATSB)
among others.
In addition to the AAAG meetings, members of the project team will
also make targeted visits to selected CASA regional offices to meet
CASA airworthiness inspectors, as well as industry representatives,
aircraft owners and operators in that region. The aim of this exercise is
to workshop the issue with airworthiness inspectors in order to gather
as much information as possible on ageing aircraft issues from around
Australia, as well as harness the collective experience of both CASA
and industry to assist with the study. Members of the public will be
invited to contribute via a CASA website.
Running in parallel with the AAMP, and in conjunction with the Royal
Australian Air Force (RAAF), CASA is co-sponsoring the Australian
Aircraft Airworthiness & Sustainment Conference to be held at the
Brisbane Convention and Exhibition Centre (BCEC) from 17–19 August
2010. The conference will bring together representatives from military
and commercial aviation to share their knowledge and experience,
ideas and technologies relating to platform sustainment. An update
on the status and findings to date of Stage 1 of the AAMP will also be
presented at this forum. For more information on the conference,
contact the event co-ordinator on (07) 3299 4488.
If you have any further questions relating to the AAMP or wish to make
an individual submission or contribution to the study, please contact
AAMP Project Manager: Pieter van Dijk on (02) 6217 1417 or via email
on: [email protected]
Australian Aircraft
& Sustainment
Conference to be
held at the Brisbane
Convention and
Exhibition Centre
(BCEC) from 17–19
August 2010.
1 Apr 2010 – 14 May 2010
Note: Occurrence figures not included in this
Airbus A319115 Aircraft stair/door proximity
switch sticking. Ref 510010464
Air stair/door indicating system faulty. Intermittent
indication allowed aircraft to taxi with stairs
extended while cockpit indications showed stairs
Airbus A320232 Windshield anti-ice system
unserviceable. Ref 510010344
RH windshield unserviceable. Popping sounds
followed by burning odour and ‘ANTI ICE: R
WINDSHIELD’ message.
P/No: STA320271. TSN: 6,990 hours/3,776 cycles.
TSO: 6,990 hours/3,776 cycles.
Airbus A330202 Angle of attack sensor
suspect faulty. Ref 510010328
Angle of attack sensor suspect faulty.
Airbus A380842 Air conditioning odour in
cockpit and cabin. Ref 510010266
Fumes in cockpit and cabin. Investigation could
find no cause for the smell. No3 engine had been
recently changed.
Airbus A380842 Floor panels delaminated.
Ref 510010466
Numerous floor panels delaminating. Suspect
manufacturing error. Investigation continuing.
Airbus A380842 Landing gear systems tyres
blew out. Ref 510010275
Main landing gear No5 and No6 tyres blew out on
landing. Wheels and brake assemblies damaged.
Suspect brakes locked up on landing. Investigation
Airbus A380842 Seat belt loosens after
tension is removed. Ref 510010314
Seat belt loosens after tension is removed.
Investigation found a mixture of knurled pinch
rollers with different friction settings. Investigation
Boeing 7378Q8 Cockpit window frame
cracked. Ref 510010402
L1 cockpit window frame cracked through C-D post
in area parallel to A-C sill.
P/No: 141A880053.
Boeing 7378Q8 Ground spoiler interlock cable
broken. Ref 510010272
RH ground spoiler interlock cable broken.
P/No: 580250451.
Boeing 737476 Engine EGT indicator
unserviceable. Ref 510010476
No2 engine EGT indicator unserviceable. Display
blank and pointer incorrect reading.
P/No: WL202EED6. TSN: 57,150 hours.
TSO: 57,150 hours.
Boeing 747438 Galley oven fumes and white
smoke. Ref 510010420
Fumes and white smoke from upper deck galley
oven. Investigation found oven to be contaminated
with spilled food.
Boeing 737476 Engine fuel shutoff valve
failed. Ref 510010484
No1 engine fuel shutoff valve failed in the ‘open’
position causing tailpipe fire. Exhaust and turbine
inspected with nil damage found.
P/No: 737M28500011. TSN: 42,778 hours.
TSO: 14,594 hours.
Boeing 747438 Pylon brace forward
attachment fitting damaged. Ref 510010277
No4 pylon diagonal brace forward attachment
fitting damaged. Fretting evident and 17 of 18
fasteners P/No BACB30FM14AU were loose
and holes were found to be worn. Investigation
P/No: 65B89616.
Boeing 737476 IRU failed. Ref 510010414
LH inertial reference unit (IRU) failed.
P/No: HG1050AD05. TSN: 49,345 hours.
TSO: 30,842 hours.
Boeing 7377Q8 Air conditioning aircycle
machine plenum cracked. Ref 510010300
LH aircycle machine plenum cracked.
P/No: 22064002. TSN: 27,737 hours/20,085 cycles.
Boeing 737838 Air conditioning odour in
cockpit and forward galley. Ref 510010396
Mild odour in cockpit and forward galley area during
takeoff. Odour was described as ‘stale/mouldy’.
Odour disappeared 3-4 minutes after takeoff.
Investigation could find no definite cause for the
Boeing 737838 Captain’s windshield cracked.
Ref 510010416
Captain’s L1 windshield cracked.
P/No: 5893543135.
Boeing 737838 Landing gear manual
extension switch failed test. Ref 510010490
Landing gear manual extension switch S1060 failed
test. Switch was found to be open circuit at all
P/No: MS250112.
BAC 146200A Cabin rows 2 and 3 oily fumes.
Ref 510010327
Oily fume-type odour in cabin area around rows 2
and 3. Investigation iaw BAE SB 21-150 and AD/
BAE146/86 could find no source for the fumes.
Boeing 737838 Trailing edge flap ‘up’ switch
faulty. Ref 510010415
Trailing edge flap ‘up’ switch S1051 faulty
preventing automatic start of the standby hydraulic
P/No: 426EN108.
Boeing 717200 Air conditioning duct
disconnected. Ref 510010271
RH air conditioning duct disconnected. Duct is
located in rear compartment.
P/No: 59718801.
Boeing 737838 Wing fuel tank panel leaking.
Ref 510010386
RH wing fuel tank access panel 632CB cracked and
leaking. Crack length approximately 38.1mm (1.5in).
P/No: 112N61014.
Boeing 747438 Upper-deck near crew rest
area burning smell. Ref 510010421
Electrical smell evident near upper-deck crew rest
area. Investigation could find no cause for the smell
and no electrical burning.
Boeing 767336 Cabin lighting wiring loom
worn/burnt. Ref 510010325
Cabin lighting system wiring loom W1236 worn and
burnt. Loom is located above LH mid-cabin toilet.
Investigation continuing.
Boeing 767336 Engine service panel missing.
Ref 510010315
LH engine RH inner service panel separated from
aircraft during takeoff. Panel was found on runway.
Investigation continuing.
P/No: UL25208.
Boeing 767338ER In-flight entertainment
cooling filter blocked. Ref 510010320
Plastic burning smell in cabin followed by failure
of in-flight entertainment (IFE) and cabin reading
and call lights behaving erratically. Investigation
found the area equipment cooling filter completely
Boeing 767338ER Passenger seat separated.
Ref 510010379
Passenger seat 57DEF adrift from seat track.
Investigation continuing.
Boeing 767338ER Wing trailing edge flap
fairing loose and bolts missing. Ref 510010296
No2 trailing edge flap aft fairing loose and two
attachment bolts missing. Inspection found nil
Boeing 7773ZGER Galley oven dirty –
overheated and smoking. Ref 510010441
Mid galley No2 oven overheated and smoking due
Airbus A330303 Aft galley circuit breakers
covered by galley ceiling panel. Ref
Aft galley circuit breakers (2off) covered by aft
centre galley ceiling panel preventing the circuit
breakers from being tripped if needed.
Boeing 737376 Spoiler actuator faulty. Ref
No7 flight spoiler actuator faulty. Vibration
experienced when right turn aileron applied.
Actuator rod-end bolt also replaced during actuator
P/No: 654456115. TSN: 62,749 hours.
TSO: 62,749 hours.
Boeing 7378FE Fuselage and engine bird
strike. Ref 510010282
Two bird strikes on takeoff. One strike on fuselage
and one on RH engine. Fuselage inspection and
borescope inspection of engine found nil damage.
Aircraft returned to service.
Airbus A320212 Passenger oxygen container
faulty. Ref 510010368
Passenger oxygen system container had no oxygen
generator fitted.
P/No: AH5L3760.
Boeing 717200 Aux hydraulic pump and case
hoses chafed/leaking. Ref 510010346
Auxiliary hydraulic pump pressure and case drain
hoses chafed and leaking. Pressure hose P/No
AS116-08-0352 and case drain hose P/No AS11706-0285. Loss of hydraulic fluid.
P/No: AS117060285.
to build-up of oil on oven base under oven insert.
Overheat switch found tripped.
P/No: 820216000001. TSN: 5,195 hours/439 cycles.
Boeing 7773ZGER Thrust reverser cowl
bracket broken. Ref 510010316
LH thrust reverser cowl bracket broken.
P/No: 311W16705. TSN: 4,709 hours/416 cycles.
Bombardier DHC8102 Pitot head anti-ice
faulty. Ref 510010280
RH pitot head anti-ice faulty. Investigation found
high resistance causing circuit breaker to trip.
P/No: PH11001DH.
Bombardier DHC8315 Nose landing gear
cable guide distorted. Ref 510010463
Nose landing gear cable guide damaged (twisted).
Support bracket bushes P/No M81934/2-05A008
worn. Line at transducer support bracket P/
No 8961-1 mounting lug broken. Investigation
P/No: 83220087001.
Fokker F28MK0100 Forward floor panel
collapsed. Ref 510010366
Forward entry floor panel collapsed. Panel is
located between front coat locker and galley
cupboards. Investigation continuing.
Beech 58 Engine nacelle wiring chafed.
Ref 510010372
LH and RH engine nacelle wiring chaffing on top
forward sections of main spar. Wiring is used for
alternator and starter motor.
Fokker F28MK0100 Lift dumper manifold
suspect faulty. Ref 510010305
Lift dumper manifold suspect faulty. Investigation
P/No: 1095123.
Cessna 152 Alternator brushes worn.
Ref 510010321
Alternator brushes worn out. Alternator failed in
P/No: ES4118. TSN: 1,018 hours.
Saab SF340B Aircraft lightning strike.
Ref 510010293 (photo below)
Aircraft suffered a lightning strike on the captain’s
side. Double DC generator failure. Lightning strike
inspection revealed numerous areas of damage
including the fin tip and wings.
Cessna 152 Seat tracks worn. Ref 510010295
Seat tracks P/No MC0410235-1 and P/No
MC0410235-6 worn and cracked.
P/No: MC04102351.
Cessna 172N ELT remote switch missing.
Ref 510010491
ELT installed with no remote switch fitted. No ‘G’
switch loop installed.
Bombardier DHC8402 Cargo door incorrectly
secured. Ref 510010404
Forward baggage door incorrectly secured. Door
lock was not fully engaged in the locked position
causing the door warning light to illuminate.
Bombardier DHC8402 Engine oil cooler
bypass door nut loose. Ref 510010269
RH engine oil cooler bypass door upper attachment
nut loose on bolt. Investigation found that the
cotter pin had not been installed at factory during
aircraft build.
Saab SF340B Aircraft oxygen system fitting
sparking. Ref 510010355
Orange sparks coming from No2 oxygen bottle
outlet port fitting during reconnection. Aircraft was
earthed and power was off. See SDR5100009880
for similar occurrence.
Bombardier DHC8402 Engine startergenerator failed. Ref 510010389
No2 engine starter-generator failed.
P/No: 11521063.
Saab SF340B Tail pipe fire detector low
resistance. Ref 510010352
LH tailpipe fire detector 27WG low resistance.
Resistance was approximately 100K ohms.
P/No: 1734362450F.
Embraer ERJ170100 Engine anti-ice valve
unserviceable. Ref 510010398
No2 engine anti-ice valve unserviceable.
P/No: 32157903. TSN: 4,004 hours/4,040 cycles.
Embraer ERJ170100 Galley burning smell.
Ref 510010323
Burning smell from rear galley area. Investigation
could find no definitive cause for the burning smell.
Investigation found strong odour in galley bin and
RH trolley compartment due to old food and fluids. It
was also noted that the exterior of the aircraft and
engines were covered with dead locusts which may
have caused the smell.
Cessna 172M Rudder attachment bracket
cracked. Ref 510010337
Top rudder attachment bracket worn and cracked.
P/No: 05310186. TSN: 9,264 hours.
Cessna 208 Engine rear oil pressure tube to
boss elbow unserviceable. Ref 510010383
Engine rear oil pressure tube to boss elbow leaking.
Investigation found wear inside elbow due to oil
transfer tube rubbing. Investigation found o-ring
seal damaged during fitment.
P/No: 3007389. TSN: 8,885 hours/9,321 cycles.
TSO: 1,044 hours/1,459 cycles.
Cessna 210L Control column tube worm/
damaged – support bearings failed. Ref
(photo below)
Control column tube worn and damaged due to
failure of support bearings.
P/No: 12601408. TSN: 4,698 hours.
Beech 200 Pilot’s rudder pedal failed.
Ref 510010347 (photo below)
Pilot’s LH rudder pedal failed at LH attachment
bolt hole. Investigation found the bolt hole worn
unevenly followed by failure. The twisting motion
then caused the RH attachment point to fail.
P/No: 355240119.
Embraer ERJ190100 Engine IDG failed.
Ref 510010456
No2 engine integrated drive generator (IDG) failed.
TSN: 4,047 hours/2,766 cycles.
Embraer ERJ190100 Landing gear steering
control module unserviceable. Ref 510010401
Landing gear steering control module
P/No: 1855A000004.
TSN: 1,929 hours/1,313 cycles.
Fokker F28MK0100 Flap control data unit
faulty. Ref 510010479
Flap control data unit (FDCU) faulty. Investigation
TSN: 20,088 hours/18,003 cycles.
TSO: 41 hours/23 cycles.
Cessna 402C Landing gear microswitch wire
broken. Ref 510010451
LH main landing gear microswitch wire broken.
Wire connects between switch and selector valve.
Cessna 404 Aileron quadrant bearing loose.
Ref 510010361
LH aileron quadrant bearing popped out causing
aileron free play.
TSN: 15,015 hours.
Cessna 404 Engine control cable bracket
broken. Ref 510010317 (photo below)
Engine control cable support bracket broken in two.
Engine control travel compromised.
P/No: 501150829. TSN: 32,676 hours.
Cessna 441 Avionics bus circuit breaker/
switch faulty. Ref 510010462
RH avionics bus circuit breaker/switch faulty.
Switch was broken and had to be held by hand in
the ‘off’ position for remainder of flight.
P/No: W31X100050.
Cessna 501 Cabin bleed air supply duct
coupling loose. Ref 510010390
Aircraft would not maintain cabin pressure.
Investigation found cabin bleed air supply duct
coupling partially migrated from duct inlet flange.
Outflow valve sense line ‘B’ nut also found to be
Extra EA300200 Aileron control rod cracked/
corroded. Ref 510010459 (photo below)
LH aileron control rod cracked and corroded. Crack
length 35mm (1.37in).
P/No: PC43201A4. TSN: 988 hours.
Jabiru 160DLSA Main landing gear leg
delaminated. Ref 510010417 (photo below)
Main landing gear leg delaminated. Aircraft is
registered with RAA.
P/No: 6204023. TSN: 99 hours/70 landings.
TSN: 99 hours/70 landings/11 months.
Agusta Westland AW139 Windshield cracked.
Ref 510010407 (photo below)
Front RH windshield extensively cracked.
Windscreen is constructed from laminated glass.
P/No: 3G5610V00451. TSN: 562 hours/1,417 cycles.
Piper PA31350 Landing gear microswitch out
of adjustment. Ref 510010388
Landing gear microswitch out of adjustment. Could
not be duplicated on the ground and was only
evident when air loads present.
P/No: 487862.
Reims F406 Electrical static inverters failed.
Ref 510010304
Phase B and phase C static inverters failed.
P/No: 1B10001G.
Reims F406 Nose landing gear initially failed
to extend. Ref 510010458
Nose landing gear failed to extend on first attempt.
Gear operated OK on second attempt. Nose landing
gear door bellcrank spring adjusted.
Socata TB20Trinidad Nose landing gear strut
body cracked. Ref 510010374
Nose landing gear strut body cracked at drag brace
P/No: TB2042019001. TSN: 3,961 hours.
Swearingen SA227AC Engine mount truss
burnt. Ref 510010471
RH engine mount truss burnt by battery cable which
arced to the frame. Investigation found the cable
incorrectly installed, allowing the cable to rub
on the frame and short circuit. Starter/generator
changed as a precaution. RH generator current
limiter and generator control unit also damaged by
short circuit.
P/No: 2762114095.
Swearingen SA227AT Starter-generator
brushes worn. Ref 510010342
RH engine starter-generator brushes worn.
Swearingen SA227DC Horizontal stabiliser
trim actuator bracket corroded. Ref 510010301
Horizontal stabiliser trim actuator attachment
bracket lugs contained exfoliation corrosion on both
lower brackets.
P/No: 2743060011.
TSN: 16,132 hours/11,968 cycles.
Swearingen SA227DC Passenger door lock
spring retainer incorrect part. Ref 510010475
Passenger door lock assembly diaphragm spring
retainer unapproved part. Suspect part appeared
to be from a bottle cap or tin of unknown origin,
adapted to fit. A search of aircraft records could find
no evidence of the repair/modification being carried
out. Incorrect/unapproved part.
Bell 206B3 Engine/transmission drive shaft
grease boot unserviceable. Ref 510010357
Engine to transmission drive shaft forward
grease boot failed. Grease leaking from boot
and ‘teletemps’ activated. Following drive shaft
replacement, the forward boot had failed again on
the new drive shaft. Further investigation found the
cause of the failure to be a faulty isolation mount.
P/No: 206040015103.
TSN: 13,408 hours/21,952cycles/21 months.
TSO: 175 hours/184cycles/5 months.
Eurocopter AS350B2 Tail rotor control lever
inner bearing unserviceable. Ref 510010284
(photo below)
Tail rotor control lever inner bearing surfaces worn.
Suspect bushings had been working inside lever
for some time and fell out of lever when pivot bolt
P/No: 350A33105803.
TSN: 2,002 hours/2,700 cycles.
Cessna 560 Wing aileron hinge brackets
cracked. Ref 510010362
Aileron hinge brackets P/No 6624032-3 and P/
No 6624031-4 cracked. Brackets are located at LH
aileron inboard and RH aileron centre.
P/No: 66240323. TSN: 230 hours.
Pilatus PC12 Landing gear hydraulic motor
unserviceable. Ref 510010467
Landing gear power pack hydraulic motor
P/No: 9603002104.
TSN: 7,880 hours/10,497 cycles.
Correct part number 27-24127-029.
TSN: 16,243 hours/12,575 cycles.
Cessna 404 Wing panel disbonded. Ref
LH and RH wing panels disbonded. Found during NDI
iaw AD/Cessna400/108 Amdt1.
PAC CT4B Aircraft lighting power leads
incorrectly stowed. Ref 510010470
Elevator momentary restriction. Investigation of
the elevator control system could find no faults.
Internal investigation of the tail cone found the tail
navigation light earth and power leads incorrectly
stowed and possibly catching in the elevator
connecting rod bolt.
Eurocopter AS350BA Engine startergenerator drive shaft fractured. Ref
Engine starter/generator driveshaft sheared.
Further investigation found the incorrect assembly
of the Belleville washers and incorrect torque on
the retaining nut.
TSO: 618 hours/16 months.
Continental IO550N Engine crankshaft
cracked. Ref 510010465
Crankshaft cracked in radius of rear flange. Crack
length 50.8mm (2in). Found using magnetic particle
inspection (MPI) following inspection by an
automotive engine rebuilding company. Crankshaft
serial number N08GA147.
P/No: 649900.
Eurocopter EC225LP Tail boom pylon deck
cracked. Ref 510010334
Tail pylon inclined deck cracked. Broken brackets
in support structure for inclined drive shaft fixed
Continental IO550N Magneto bearings heat
damaged/corroded. Ref 510010326
Magneto bearings heat damaged and corroded
especially on the external surface of the capacitor.
Magnetos were incorrect part. Correct P/No
10-500556-1 incorrect fitted magneto P/No 10500556-101. Incorrect magnetos had pressurisation
gaskets fitted.
P/No: 10500556101. TSN: 100 hours/16 months.
Robinson R22BETA Engine oil cooler cracked.
Ref 510010287
Engine oil cooler cracked and leaking due to
corrosion pitting.
P/No: 1061LTC. TSN: 990 hours.
Robinson R22BETA Engine/transmission
drive belt faulty. Ref 510010286
Engine to transmission drive belt contained a small
bulge on outer surface.
P/No: A1902. TSN: 439 hours.
Robinson R22BETA Main rotor collective
spring rod end broken. Ref 510010350
Collective spring assembly upper rod end broken.
Investigation found rod end bearing extremely tight.
P/No: B2923. TSN: 1,378 hours.
Robinson R44 Main rotor blade skin
delaminated. Ref 510010394
Main rotor blade lower skin delaminated at blade
tip. Delamination was 3.175mm (0.125in) back from
tip and 3.175mm (0.125in) along the spar joint.
P/No: C0162. TSN: 1,922 hours. TSO: 1,922 hours.
Schweizer 269C Fuel system water
contamination. Ref 510010385
Water contamination of fuel system. Investigation
found that although the fuel system had been
drained, the design of the system allows several
areas where water can accumulate and not be
detected during fuel drain. This water can then
affect the engine during flight.
Continental GTSIO520M Engine fuel injection
fuel flow line worn. Ref 510010489
LH engine fuel injection system fuel flow line
P/No: 510010694.
Continental GTSIO520M Engine hydraulic
valve lifter worn. Ref 510010384
RH engine hydraulic valve lifter worn. Found when
changing leaking pushrod seals.
P/No: 653909. TSN: 968 hours.
Continental GTSIO520M Engine turbocharger
non-compliant. Ref 510010302
RH engine turbocharger non-compliant with FAA AD
2010-07-08. Turbocharger fitted at engine overhaul.
P/No: 4659309002. TSO: 939 hours.
Continental IO550D Engine failed – suspect
cylinder piston faulty. Ref 510010447
Engine failed. Suspect caused by piston.
Investigation continuing.
P/No: 648046A2. TSN: 120 hours.
Continental TSIO520N Engine cylinder
cracked. Ref 510010333
RH engine No5 cylinder cracked.
P/No: TIST714BCA. TSN: 392 hours/10 months.
Lycoming IO540E1B5 Engine camshaft lobes
worn. Ref 510010406
Metal found in oil filter. Investigation found two
camshaft lobes badly worn.
P/No: LW13940. TSO: 1,390 hours.
Lycoming IO540E1B5 Engine crankcase
cracked. Ref 510010364
RH crankcase cracked in area located below No3
TSO: 1,139 hours.
Lycoming IO540E1B5 Engine cylinder
cracked. Ref 510010367
Engine cylinder cracked from top spark plug hole.
TSO: 1,132 hours.
Lycoming IO540E1B5 Engine fuel pipes worn.
Ref 510010408
Engine solid fuel lines severely chafed. Found during
inspection iaw AD/Lyc/90.
Lycoming O360A4M Engine camshaft idler
gear incorrect part. Ref 510010438
Incorrect camshaft idler gear fitted during overhaul.
No drive to engine-driven fuel pump. Engine
stopped when the auxiliary pump was turned off
during aircraft ground run.
P/No: 74996.
Lycoming O360J2A Engine cylinder exhaust
valve guide incorrect part. Ref 510010482
No2 cylinder exhaust valve guide incorrect part.
As a consequence, exhaust valve rocker arm P/No
17F19357 was broken in half due to contact with
the valve guide. Personnel/maintenance error.
P/No: 75838. TSN: 435 hours. TSO: 1 hour.
Allison 250C20J Engine FCU unserviceable.
Ref 510010336
Fuel control unit (FCU) unserviceable. Bench testing
found the FCU out of limits. Further investigation
involved removing the ratio lever covers, which then
found the lock nuts on the ratio levers incorrectly
secured, allowing the ratio levers to move out of
calibration (levers were lock-wired).
P/No: 23070606.
Garrett TPE33111U611 Engine compressor
section impeller damaged. Ref 510010485
RH engine first stage impeller had a substantial
piece missing from vane.
P/No: 31081822. TSN: 10,152 cycles.
TSO: 4,360 hours/4,371 cycles.
Garrett TPE33111U Engine reduction gear
bearing failed. Ref 510010264 (photo below)
RH engine failed. Suspect fuel loss. Metal found in
gearbox chip detector. Investigation found failure
of FCU drive bearing P/No 3103035-1 located in the
accessory gear and drive idler housing assembly.
P/No: 31030351. TSN: 3,205 hours.
Lycoming IO540C4B5 Engine fuel pump drive
gear corroded. Ref 510010380
LH engine fuel pump drive gear corroded on cam
P/No: 71652. TSO: 1,447 hours/384 months.
Lycoming O360A1F6 Engine cylinder inlet
valve stem damaged. Ref 510010427
(photo below)
New cylinder found with damaged inlet valve stem
causing valve to stick in valve guide. Valves appear
to be damaged at assembly by manufacturer.
P/No: 17A23938.
GE CF3410E Engine oil system metal
contamination. Ref 510010444
No1 engine oil system magnetic chip detector metal
contamination. Following oil replacement, system
flushing and ground runs, nil further contamination
was evident. Analysis of metal found the engine
was OK for further operations.
GE CF680E1 Engine control alternator drive
adapter bearing failed. Ref 510010322
No2 engine control alternator drive adapter bearing
collapsed. Metal contamination of engine gearbox.
Engine changed. Investigation continuing.
GE CFM567B Engine accessory drive bearing
failed. Ref 510010353
No2 engine aft sump chip detector contained three
metal flakes. Analysis identified flakes as bearing
PWA PW123E Engine HBOV leaking. Ref
No2 engine handling bleed-off valve (HBOV) leaking
around dome gasket.
P/No: 311669101.
GE CFM567B Engine air inlet fan blades
damaged - bird strike. Ref 510010399
No2 engine bird-strike. Four fan blades damaged.
Nil evidence of ingestion into engine core.
P/No: 3401613030.
PWA PW125B Engine bleed valve
intermittent. Ref 510010319
LH engine handling bleed valve intermittent in
operation. Bleed valve had only been fitted prior to
this flight.
P/No: 03R311282601.
IAE V2527A5 Engine air inlet cone fairing
bolts loose. Ref 510010473
RH engine inlet cone fairing attachment bolts (3off)
loose. Anchor nuts appeared OK.
IAE V2527A5 Engine turbine air seal cracked.
Ref 510010373
Stage 2 high pressure turbine air seal cracked for
approximately 180 degrees in front fillet radius.
P/No: 2A3596. TSN: 18,321 hours/9,309 cycles.
TSO: 18,321 hours/9,309 cycles.
PWA PT6A67B Engine fuel pump leaking. Ref
Engine driven low pressure fuel pump leaking due
to internal failure.
P/No: RG9570R1. TSN: 4,726 hours.
TSO: 1,930 hours.
PWA PT6A67B Engine oil filter carbon
contamination. Ref 510010273
Carbon contamination of engine oil filter.
PWA PW123E Engine Compressor bleed
control piston ring sticking. Ref 510010434
No1 engine LH and RH P2.5/P3 switching valves
sticking due to faulty piston rings.
P/No: 3311221801.
PWA PW4168A Thrust reverser fairing
missing. Ref 510010289
No1 engine inboard thrust reverser lower
blocker door close out fairing partially missing.
Investigation continuing.
P/No: 74M312004.
Rolls Royce RB211524G Engine failed. Ref
No3 engine failed. Engine stalled and EGT overtemp. Investigation continuing.
Rolls Royce RB211524G Engine failed. Ref
No4 engine compressor stall accompanied by high
vibration, loud bang and flames. EGT peaked at
950 degrees C and vibration at 5.00 units. Engine
removed for further investigation.
P/No: RB211524GT.
Rolls Royce RB211524G Thrust reverser
blocker door separated. Ref 510010468
No1 engine thrust reverser No8 blocker door
separated. Corona P/No LJ32557 located aft of
blocker door damaged. Investigation continuing.
P/No: LJ40613.
Hamilton Standard 14SF23 Propeller PCU
faulty. Ref 510010397
No2 propeller pitch control unit (PCU) faulty.
Hartzell HDE6C3B Propeller feathered in
flight. Ref 510010486
LH propeller feathered in flight. LH propeller oil
pressure caution message. Investigation continuing.
Extinguisher contaminated. Ref 510010279
Lavatory fire extinguisher filled with contaminated
Halon 1211. Found during inspection iaw EASA AD
2010-0062 and FFE ASB 26-116 Issue A.
P/No: BA20509AA4SN037520.
Bendix 1200 Magneto unserviceable. Ref
Magneto had excessive play in gear shaft bush
causing gear to jump teeth and affect timing.
P/No: BENDIX1200. TSO: 299 hours.
Collins Radio Co SVO65 Servo incorrectly
marked. Ref 510010453
Servo unit incorrectly marked. The servo was
originally marked as P/No 622-5734-002 but
had been over stamped to P/No 622-5734-001.
Investigation found that the unit was still a P/No
622-5734-002 unit internally. The two part number
units are not compatible.
P/No: 6225734002.
Rolls Royce TAY65015 Engine slow
acceleration – N2 stagnation. Ref 510010332
No1 engine would not accelerate due to N2
stagnation. Several engine runs were carried out
with normal engine parameters and the aircraft has
flown without further problems.
or contact your local CASA Airworthiness Inspector [freepost]
Service Difficulty Reports, Reply Paid 2005, CASA, Canberra, ACT 2601
Online: www. casa.gov.au/airworth/sdr
Lycoming LTS101600A3A Engine startergenerator drive shaft fractured. Ref
Engine starter/generator driveshaft sheared.
Further investigation found the incorrect assembly
of the Belleville washers and incorrect torque on
the retaining nut.
TSO: 618 hours/16 months.
PWA PW150A Engine compressor bearing
carbon seal cracked/damaged. Ref 510010454
RH engine high oil consumption. Investigation
found the No5 bearing rear carbon seal cracked
and damaged allowing oil to leak. The compressor
bleed valve was found to be dry and free of oil
TSN: 4,668 hours/5,475 cycles.
Allison A6441FN606 Propeller solenoid valve/
regulator o-rings misaligned. Ref 510010483
LH propeller feathered and shut down engine.
Investigation found that the propeller solenoid valve
had been changed and that two of three oil transfer
o-rings P/No 6515407 located between the solenoid
valve and regulator were misaligned causing
incorrect governing of the propeller.
P/No: 6506714.
GE CFM563B Thrust reverser failed. Ref
Both thrust reversers failed to operate when
selected on landing. Investigation found circuit
breakers open. Further investigation found that the
reversers had been deactivated for maintenance
and not reset.
Part 39 - Rotorcraft
Fokker F100 (F28 Mk 100) Series Aeroplanes
2009-0269R1 - Landing Gear - Main Landing Gear
(MLG) - Modification / Replacement
Eurocopter AS 355 (Twin Ecureuil) Series
2010-0023R1 - Engine and Main Gearbox Cowling
Learjet 45 Series Aeroplanes
2010-06-13 - Flap Actuator Ballscrew Assembly
Partenavia P68 Series Aeroplanes
AD/P68/43 Amdt 5 - Wing and Airframe - Fatigue
Life Limit - CANCELLED
2010-0051 - Wing Safe Life Fatigue Limits / Wing &
Stabilizers Structures
Eurocopter BK 117 Series Helicopters
2010-0049 Correction - Cyclic-Stick Locking Device
Part 39 - Turbine Engines
Part 39 - Above 5700kg
AlliedSignal (Garrett/AiResearch) Turbine
Engines - TFE731 Series
2010-06-11 - Second Stage Low-Pressure
Compressor Rotor (LPCR) Disc Bore
Airbus Industrie A319, A320 and A321 Series
AD/A320/225 Amdt 1 - Elevator Servo-Control Rod
2010-0046 - Elevator Servo-Control Rod Eye-end
12 - 25 March 2010
Eurocopter BO 105 Series Helicopters
2010-0049 Correction - Cyclic-Stick Locking Device
Eurocopter SA 360 and SA 365 (Dauphin)
Series Helicopters
2010-0052-E - Equipment / Furnishings - External
Life Raft Mooring Line Attachment - Inspection /
General Electric Turbine Engines - CF6 Series
2010-06-15 - Low Pressure Turbine Stage 3 Disk
International Aero Engines AG V2500 series
2010-06-18 - Vortex Reducers
Sikorsky S-76 Series Helicopters
2010-06-08 - Metallic Foil Shunt on Floatation
Pratt and Whitney Turbine Engines - JT8D-200
97-17-04R1 - Front Compressor Hub
Part 39 - Below 5700kg
Part 39 - Equipment
Beechcraft 55, 58 and 95-55 (Baron) Series
2010-06-02 - Installation of Stand-off Hardware
Radio Communication and Navigation
AD/RAD/91 - Rockwell Collins TDR-94/94D
Transponder - Air/Ground Discrete Inputs
AD/RAD/92 - Rockwell Collins TDR-94/94D
Transponder/Honeywell AZ800/810 Air Data
Computer Selected Altitude Data Inputs
AD/RAD/93 - Rockwell Collins TDR-94/94D
Transponders - Aircraft Type Category
Part 39 - Above 5700kg
Airbus Industrie A319, A320 and A321 Series
AD/A320/210 - 80VU Rack Attachments CANCELLED
2007-0276R1 - 80VU Rack Attachments
Airbus Industrie A330 Series Aeroplanes
2010-0042-E - Fuel - Main Fuel Pump System Water Scavenge System - Deactivation / Dispatch
2010-0048 - Time Limits / Maintenance Checks ALS Part 3
Boeing 737 Series Aeroplanes
2010-06-51 - Inspection of the Aft Attach Lugs of
the Elevator Control Tab Mechanisms
Boeing 777 Series Aeroplanes
2010-06-09 - Inadvertent Engagement of the
Boeing 767 Series Aeroplanes
2010-06-16 - Fuselage Skin Scribe Lines
Bombardier (Boeing Canada/De Havilland)
DHC-8 Series Aeroplanes
CF-2010-08 - Electrical Power - AC Wiring Harness
Chafing on Centre Wing Lower Flap Shroud
British Aerospace BAe 125 Series Aeroplanes
AD/HS 125/115 Amdt 1 - NLG Bay Sidewall CANCELLED
AD/HS 125/116 - Standby Inverter Cover CANCELLED
AD/HS 125/117 - Instrument Integral Lighting
Dimmer Unit - CANCELLED
AD/HS 125/118 - Fire Extinguisher Electrical
Connectors - CANCELLED
AD/HS 125/121 Amdt 1 - Fuel Feed Pipe Joints CANCELLED
AD/HS 125/184 - Main Entry Door Frame Pressing
26 March 2010 - 8 April 2010
Part 39 - Rotorcraft
Agusta A119 Series Helicopters
2010-0059-E - Tail Rotor Drive - Tail Rotor Gearbox
Assembly - Inspection / Replacement / Reidentification
Eurocopter AS 332 (Super Puma) Series
2010-0043R1-E - Hydraulic Power - Hydraulic Pumps
- Identification / Replacement
Eurocopter BK 117 Series Helicopters
AD/GBK 117/19 - Rotor Control Bearing Attachment
2010-0045 2nd Correction - Upper Rotor Control
Bellcrank Assembly
2010-0058 - Rotor Control Bearing Attachment
Eurocopter BO 105 Series Helicopters
AD/BO 105/27 - Cyclic-Stick Locking Device CANCELLED
Eurocopter EC 135 Series Helicopters
AD/EC 135/16 - Rotor Control Bearing Attachment
2010-0058 - Rotor Control Bearing Attachment
Eurocopter SA 360 and SA 365 (Dauphin)
Series Helicopters
AD/DAUPHIN/100 - Fuselage Frame N.9 CANCELLED
2010-0064-E - Fuselage Frame N.9
Part 39 - Below 5700kg
Airbus Industrie A330 Series Aeroplanes
AD/A330/90 - Time Limits/Maintenance Checks ALS Part 3 - CANCELLED
AD/A330/110 - Fuel Line Inspection
AD/A330/111 - GE Engine - Forward Mount Bolts
Avions de Transport Regional ATR 42 Series
2010-0061 - Fire Protection - Halon 1211 Fire
Extinguishers - Identification / Replacement
Boeing 717 Series Aeroplanes
AD/B717/4 Amdt 3 - Rudder Trim Control
Boeing 737 Series Aeroplanes
AD/B737/286 - Fuselage Skin Scribe Lines CANCELLED
2010-05-13 Correction - Fuselage Skin Scribe Lines
Boeing 747 Series Aeroplanes
2010-07-03 - Sections 41 and 42 Upper Deck Floor
Boeing 767 Series Aeroplanes
2010-06-10 - Centre Tank Fuel Densitometer
Bombardier BD-700 Series Aeroplanes
CF-2010-10 - Hydraulic Systems Number 2 and 3:
Damage caused by Main Landing Gear Tire Failure
British Aerospace BAe 125 Series Aeroplanes
AD/HS 125/1 - Flight Control Castings Modification - CANCELLED
AD/HS 125/2 - Fuselage Frame 17 - Modification CANCELLED
AD/HS 125/3 - Aileron Shroud Clearance Modification - CANCELLED
AD/HS 125/4 - Cabin Pressure Safety and Inward
Relief Valve - Modification - CANCELLED
AD/HS 125/6 - Aileron Upper Hinge Fairing
Attachment Bold - Modification - CANCELLED
AD/HS 125/7 - Nose Gear Torque Links Modification - CANCELLED
AD/HS 125/8 - Engine Mounting Beam Modification - CANCELLED
AD/HS 125/119 Amdt 1 - MLG Torque Links CANCELLED
Dornier 328 Series Aeroplanes
2010-0054 - Tab-to-Actuator Linkage
Part 39 - Turbine Engines
Pratt and Whitney Canada Turbine Engines PW300 Series
CF-2010-09 - Engine Impeller in-service Life
Rolls Royce Turbine Engines - Tay Series
AD/TAY/17 Amdt 1 - Low Pressure Turbine Disc
Corrosion - CANCELLED
2010-0060 - Low Pressure Turbine Discs Stage 2
and 3
Turbomeca Turbine Engines - Makila Series
2010-0055 - Engine Fuel & Control - Digital Engine
Control Unit - Replacement
Part 39 - Equipment
Propellers - Variable Pitch - Dowty Rotol
AD/PR/35 Amdt 4 - Propeller Hub Wall Cracking
Radio Communication and Navigation
AD/RAD/76 Amdt 1 - Honeywell Primus II RNZ-850
or -851 Integrated Navigation Units - CANCELLED
2010-07-02 - Honeywell Primus II RNZ-850 or
-851 Integrated Navigation Units (supersedes AD/
RAD/76 Amdt 1)
2010-07-08 - Rebuilt Kelly Aerospace Turbochargers
9 April 2010 - 22 April 2010
Part 39 - Rotorcraft
Part 39 - Below 5700kg
Gippsland Aeronautics GA8 Series
AD/GA8/5 Amdt 3 - Horizontal Stabiliser Inspection
Liberty Aerospace XL Series Aeroplanes
2009-08-05R1 - Muffler Cracking
Part 39 - Above 5700kg
Airbus Industrie A319, A320 and A321 Series
AD/A320/19 Amdt 1 - Hydraulic Fire Shut-Off Valve
AD/A320/146 Amdt 3 - Airworthiness Limitation
AD/A320/163 Amdt 1 - Wing Trailing Edge Cable
2007-0276R1 Correction 2 - 80VU Rack
2008-0051R1 - Fuel / Electrical Power - Prevention
of Fuel Tank Explosion Risks - Electrical Cables Modification
2010-0071 - Aiworthiness Limitation Items
Airbus Industrie A330 Series Aeroplanes
AD/A330/109 - Pitot Probe Quick-Disconnect Union
2009-0202R1 - Navigation - Pitot Probe QuickDisconnect Union - Torque Check
Airbus Industrie A380 Series Aeroplanes
2010-0038 - Flight Controls - Outboard Elevator
Electro Hydrostatic Actuator (EHA) - Inspection /
Boeing 747 Series Aeroplanes
2010-09-03 - Fuselage Lap Joints at Stringer 6 from
STA 340 to STA 400
Bombardier (Canadair) CL-600 (Challenger)
Series Aeroplanes
AD/CL-600/107 - Angle of Attack Transducer CANCELLED
AD/CL-600/120 - Angle of Attack Transducer CANCELLED
Part 39 - Turbine Engines
Part 39 - Turbine Engines
Turbomeca Turbine Engines - Makila Series
2010-0068-E (Correction) - Engine Fuel & Control Digital Engine Control Unit - Replacement
General Electric Turbine Engines - CF34
2010-01-04 (Correction) - Inspections of Fan Blades
and Actuator Head Hoses
General Electric Turbine Engines - CF700
2010-09-08 - Combustion Liner Cracks
British Aerospace BAe 146 Series Aeroplanes
2010-0072 - Nose Landing Gear Main Fitting Nose
Landing Gear Main Fitting
Part 39 - Equipment
Radio Communication and Navigation
AD/RAD/91 Amdt 1 - Rockwell Collins TDR-94/94D
Transponder - Air/Ground Discrete Inputs
23 April 2010 - 6 May 2010
Part 39 - Rotorcraft
Agusta AB139 and AW139 Series Helicopters
AD/AB139/4 - Fuselage Frame 5700 Middle Section
2006-0357R1 - Fuselage Frame 5700 Middle
Eurocopter AS 350 (Ecureuil) Series
2010-0082-E (Correction) - Tail Rotor - Tail Gearbox
(TGB) Control Lever - Inspection / Rework /
Eurocopter AS 355 (Twin Ecureuil) Series
2010-0082-E (Correction) - Tail Rotor - Tail Gearbox
(TGB) Control Lever - Inspection / Rework /
Part 39 - Piston Engines
Volkswagen Derivative Piston Engines
AD/VW/1 - Assurance Inspection - CANCELLED
General Electric Turbine Engines - CJ610
2010-09-08 - Combustion Liner Cracks
Rolls Royce Germany Turbine Engines - BR700
2010-0077 - Change of Life Cycle Counting Method
for Touch-and-Go and Overshoot
2010-0076 - HP Turbine Discs Life Limits
2010-0075 - HP Turbine Discs Life Limits
Rolls Royce Turbine Engines - Tay Series
2010-0060R1 (Correction) - Engine - Low Pressure
Turbine Discs Stage 2 and 3 - Inspection /
Part 39 - Equipment
Auxiliary Power Units
2010-0079 - Airborne Auxiliary Power - Auxiliary
Power Unit Turbine Wheel Life Limit - Reduction
Instruments and Automatic Pilots
2010-09-04 - APEX Flight Management Systems
Eurocopter EC 120 Series Helicopters
2010-0078-E - Electrical Power - Emergency Switch
(EMER SW) Wiring - Modification
7 May 2010 - 20 May 2010
Part 39 - Below 5700kg
Eurocopter AS 350 (Ecureuil) Series
2010-0088-E - Equipment and Furnishing Emergency Flotation Gear Wiring - Modification
Liberty Aerospace XL Series Aeroplanes
AD/XL/1 - Muffler Cracking - CANCELLED
Part 39 - Above 5700kg
Airbus Industrie A330 Series Aeroplanes
AD/A330/37 Amdt 2 - Elevator Servocontrols CANCELLED
2010-0081 - Elevator Servocontrols
2010-0083 - Operational Test of the Fuel Pump NonReturn Valve (NRV)
Part 39 - Rotorcraft
Eurocopter EC 225 Series Helicopters
2008-0007R3 - Limitations - 14Hz Vibrations at Low
Density Altitude
Sikorsky S-76 Series Helicopters
2010-11-52 - LITEF LCR-100 AHRS
continued p42
Bell Helicopter Textron Canada (BHTC) 430
Series Helicopters
CF-2010-11 - Transmission Planetary Pinion Gear
Bombardier (Boeing Canada/De Havilland)
DHC-8 Series Aeroplanes
AD/DHC-8/144 - De-Ice Busbar Sealant CANCELLED
CF-2009-01R1 - Dual AC Generator Shutdown
Boeing 737 Series Aeroplanes
2010-09-05 - Aft Attach Lugs of the Elevator
Control Tab Mechanisms
Fire Protection Equipment
2010-0062 - Fire Protection - Halon 1211 Fire
Extinguishers - Identification / Replacement
Bombardier (Canadair) CL-600 (Challenger)
Series Aeroplanes
CF-2008-35R1 - Angle of Attack Transducer Heating Element Degradation and Inaccurate
CF-2009-08R1 - Pressurisation System: Cabin
Pressure Control (CPC) uints and Cabin Pressure
Control Panel (CPCP) Deficiency
when it all comes
Adhesive bonding has been part of aircraft construction since the
beginning of powered flight when wooden components would be
glued together. It has also been a widely-used construction technique
in metal aircraft for over 40 years.
Many aircraft, whether fixed or rotary wing, use bonded components,
some in critical parts of their structures. The advantages of adhesive
bonding over mechanical bonding using fasteners such as rivets, bolts
and screws include greater strength, less weight and, sometimes,
lower cost.
But as aircraft age, the service life of adhesive bonds becomes a critical
issue. The casein glues used in wooden aircraft did not last as well as
they did when used in furniture and musical instruments, where they
can last for hundreds of years. Although waterproof in the short term,
if exposed to high atmospheric humidity over many years, caseinglued joints in aircraft had the alarming characteristic of dissolving.
The failure is caused by micro-organisms consuming proteins in the
milk-based casein glue. Adhesive bond failure has also affected metal
aircraft. The extraordinary near-loss of Aloha Airlines Flight 243 in
1988, where part of the fuselage blew away on a flight between two
Hawaiian islands, was attributed in part to disbonding of cold-bonded
lap joints that were used on the early model Boeing 737. Again high
atmospheric humidity during production was implicated.
Max Davis’s career has been in studying bonded joints in aircraft and
devising techniques to repair them, working with the Royal Australian
Air Force, and recently as a consulting engineer. He presented a
paper at the recent Australian and New Zealand Society of Air Safety
Investigators on the subject. The paper, co-written with New Zealand
forensic engineer, Andrew McGregor, reached the unsettling conclusion
that one form of disbonding was harder to detect and possibly more
common than previously assumed.
Bonds fail in two distinct ways, described by Davis as adhesion failure
and cohesion failure. Adhesion failure is when the glue and the surface
being glued come apart. This happens at less force than the cured
strength of the bond. Cohesion failure is when the glue itself comes
apart. This requires greater force than the cured strength of the bond.
Often a cohesion failure will include a bond
coming apart at the carrier cloth, which is
used in construction to facilitate handling of
the adhesive material and becomes a line of
relative weakness in the bond.
‘The failure mode which is least understood
is mixed-mode failure, where there is a
combination of cohesion and adhesion
failure within the same bond,’ Davis told
the conference. A mixed-mode failure has
elements of adhesion and cohesion failures. It
leaves behind a component with some traces
of adhesive on it and some bare metal.
Davis strongly supports the use of bonding
as a technique. From his conference paper:
‘Adhesive bonded structures are rigorously
tested for static strength and fatigue
performance as part of the certification
basis for the aircraft, and also undergo
rigorous quality assurance assessment during
production. Hence it can safely be assumed
that such structures leave the production line
with bonds that demonstrate an adequate
What worries him is the occurrence of
mixed-mode bond failures in service and the
difficulty of detecting them.
‘Fatigue may usually be excluded from the
causes of mixed-mode and adhesion failures.
The excellent fatigue performance of highquality adhesive bonds has been known
for many years. There is only one cause of
mixed-mode failure: the interface produced
by the bonding process was not resistant to
the service environment.’
Non-destructive inspection (NDI) techniques
are used to check the strength of bonds in
aircraft, but Davis has reservations about the
usefulness of these methods.
‘Current NDI methods are only generally
effective at finding production voids where
there is an air gap. These are the types of
defect which cause cohesion failures because
the effective area of the adhesive is reduced,
or adhesion failure after the bond interface
has degraded,’ the paper says.
He says the ability of NDI to interrogate
interfaces, or detect weak bonds such as
kissing disbonds that are typical of the onset
of mixed-mode failure, is extremely limited.
‘For example, surfaces bonded with doublesided adhesive tape will pass many NDI
‘A critical factor relevant to the continuing airworthiness of bonded
structures is the fact that using current technologies, NDI can readily
find cohesion failures and adhesion failures, but can not find degraded
bonds which are susceptible to mixed-mode failure.’
Davis says it is not possible to predict the extent of strength loss due to
mixed-mode and adhesion disbond growth rates, and once hydration
has begun, defects may grow without any flight loads.
Without implying any criticism of air safety investigators, Davis says
mixed-mode failures are difficult to interpret because the investigator
can’t be sure if the bond failure caused the crash, or if the bond failed
as a result of the crash. The only certainty is that where mixed-mode
failures occurred, the strength of the bond was less than for bonds
which had not degraded.
He says many adhesively bonded principal structural elements
are managed using damage tolerance methodology, based on an
invalid assumption that the adhesive surrounding a defect maintains
full strength.
‘There is therefore a significant risk to continuing airworthiness of
any bonded structures which have been constructed using processes
which are susceptible to mixed-mode or adhesion failure,’ the paper
concludes. Davis stated that the FAA had recently amended an advisory
circular (AC 20-107) to address adhesive bond durability testing and
suggested that these changes may need to be supported by regulation.
Davis proposes durability testing using the wedge method used for the
RAAF’s F-111 fleet. A wedge is driven into a sample bonded joint which
is left in hot and humid conditions (50 degrees C and 95 per cent) for
the test period. Any interface that survives such extreme demands
should produce acceptable service durability without mixed-mode and
adhesion failures, he says.
Degradation or hydration are engineering
language for breakdown caused by water or
atmospheric moisture. This can react with
the oxides on the metal surface. It is, in
essence, the same problem that made life
difficult, and in some cases short, for pilots of
some wooden aircraft in the 1960s and 70s.
However, degradation of adhesive bonds to
composite materials may be different to that
for metals because of the absence of surface
oxides susceptible to hydration.
inspection methods, especially the tap-test, despite the obvious
weakness of the bond compared to effective structural bonds. In
effect, NDI can only tell whether or not the bond has a physical defect,
it can not determine the strength of the bond.’
‘Because of the comprehensive rigour of
certification and quality assurance, a very
large proportion of these defects are either
adhesion failures or mixed-mode failures
due primarily to degradation/hydration of the
bond interface,’ Davis told the conference.
Part 39 - Below 5700kg
Embraer EMB-110 (Bandeirante) Series
AD/EMB-110/54 Amdt 1 - Corrosion of Wing and
Vertical Stabiliser to Fuselage Attachments, Rib 1
Half-ing and Cabin Seat Tracks - CANCELLED
2006-10-01R2 - Wing and Vertical stabiliser to
Fuselage Attachments, Rib 1 Half-Wing and Cabin
Seat Tracks
Gippsland Aeronautics GA8 Series
AD/GA8/5 Amdt 4 - Horizontal Stabiliser Inspection
Part 39 - Above 5700kg
Airbus Industrie A330 Series Aeroplanes
AD/A330/98 - Fuel Pump Non Return Valve CANCELLED
2010-0086 - Electric and Electronic Common
Installation - Hydraulic Pump Electrical Motor
Connectors - Modification
2010-0089 - Indicating & Recording Systems - Flight
Warning Computer (FWC) - Software Installation
Boeing 737 Series Aeroplanes
AD/B737/307 Amdt 2 - Main Slat Track Downstop
Bombardier (Canadair) CL-600 (Challenger)
Series Aeroplanes
CF-2010-12 - Wing Leading Edge Thermal
Switches and Wing Anti-Ice Duct Piccolo Tubes Airworthiness Limitation Tasks
CF-2010-13 - Angle of Attack (AOA) Transducers Resolver Oil Contamination
CF-2010-15 - Main Landing Gear - Piston Axle
Bombardier (Boeing Canada/De Havilland)
DHC-8 Series Aeroplanes
AD/DHC-8/88 Amdt 1 - Flap Drive Actuator Inspection - CANCELLED
CF-2002-26R2 - Flap Drive Actuator Assembly Lubrication and Backlash Check
Part 39 - Turbine Engines
CFM International Turbine Engines - CFM56
2010-09-14 - EGT Margin Deterioration
Part 39 - Equipment
Fire Protection Equipment
2010-0062R1 - Fire Protection - Halon 1211 Fire
Extinguishers - Identification / Replacement
21 May 2010 - 2 June 2010
(RAT) Gerotor Pump - Replacement
2010-0091 - Stabilizers - Elevators - Inspection
Part 39 - Rotorcraft
BAe Systems (Operations) Jetstream 4100
Series Aeroplanes
2010-0098 - Time Limits / Maintenance Checks
- Airworthiness Limitations - Amendment /
Bell Helicopter Textron 205 Series
2010-10-16 - Aeronautical Accessories Inc (AAI)
Low Skid Landing Gear Forward Crosstube
Bell Helicopter Textron 212 Series Helicopters
2010-10-16 - Aeronautical Accessories Inc (AAI)
Low Skid Landing Gear Forward Crosstube
Bell Helicopter Textron 412 Series Helicopters
2010-10-16 - Aeronautical Accessories Inc (AAI)
Low Skid Landing Gear Forward Crosstube
Eurocopter BK 117 Series Helicopters
2010-0096 - Airworthiness Limitations Tail Rotor
Intermediate Gear Box (IGB) Bevel Gear - Reduced
Life Limit
Eurocopter SA 360 and SA 365 (Dauphin)
Series Helicopters
2010-0100-E - Navigation - Vertical Gyro Unit
Data Output - Operational Limitation / Operational
procedure / Reinforcement
Sikorsky S-76 Series Helicopters
2010-10-02 - Leaking Servo Actuator
Sikorsky S-92 Series Helicopters
2010-10-03 - Main Gearbox Filter Bowl Assembly Failure of Mounting Studs
Part 39 - Below 5700kg
Aerospatiale (Socata) TBM 700 Series
AD/TBM 700/52 Amdt 1 - Oxygen - Pilot Operating
Handbook - CANCELLED
2010-0090 - Oxygen - Chemical Oxygen Generator
- Modification
Pilatus PC-12 Series Aeroplanes
2010-0093 - Engine Controls - Power Control Lever
Reverse Thrust Latch - Inspection / Modification
Part 39 - Above 5700kg
Airbus Industrie A319, A320 and A321 Series
AD/A320/224 - Hydraulic Power - Ram Air Turbine
Georotor Pump - CANCELLED
2010-0071R1 - Time Limits and Maintenance
Checks - Damage Tolerant Airworthiness Limitation
Items - ALS Part 2 - Amendment
2008-0034R1 - Hydraulic Power - Ram Air Turbine
Boeing 747 Series Aeroplanes
AD/B747/142 - Fuselage Skin Lap Joints CANCELLED
2010-10-05 - Fuselage Skin Lap Joints
Bombardier BD-700 Series Aeroplanes
CF-2010-14 - Passenger Door - Tensator Springs
Bombardier (Canadair) CL-600 (Challenger)
Series Aeroplanes
CF-2003-23R3 - Main Landing Gear Door Separation
During Flight
Bombardier (Boeing Canada/De Havilland)
DHC-8 Series Aeroplanes
CF-2010-16 - Cockpit Windshield Lower Frames Potential for Corrosion
British Aerospace BAe 125 Series Aeroplanes
AD/HS 125/89 Amdt 3 - Elevator Mass Balance
Sideplate and Spigot
Embraer ERJ-190 Series Aeroplanes
2009-08-02R1 - Deployment Failure - Escape Slide
2006-11-01R5 - Low Pressure Check Valves
2010-01-02R1 - Air Management System Controller
Part 39 - Piston Engines
Teledyne Continental Motors Piston Engines
2010-11-04 - TCM Engine Hydraulic Lifters
Part 39 - Turbine Engines
General Electric Turbine Engines - CF34
2009-26-09 (Correction) - Fan Disk Inspection for
Electrical Arc-Out Indications
Part 39 - Equipment
Compressed Gas Cylinders
2010-11-05 - AVOX Systems and B/E Aerospace
Oxygen Cylinder rupture
Aircraft Airworthiness & Sustainment
2010 Conference
Book now for the Australian Aircraft Airworthiness
& Sustainment Conference
Brisbane Convention and Exhibition Centre (BCEC)
17–19 August 2010
Contact the event co-ordinator on (07)
3299 4488.
ever had a
Write to us about an aviation
incident or accident that you’ve
been involved in. If we publish
your story, you will receive
Write about a real-life incident that
you’ve been involved in, and send it
to us via email: [email protected]
Clearly mark your submission in the
subject field as ‘CLOSE CALL’.
Articles should be between 450 and 1,400 words. If preferred, your identity will be kept confidential. Please do not submit articles regarding
events that are the subject of a current official investigation. Submissions may be edited for clarity, length and reader focus.
Each year, CASA surveys holders of air operator
certificates (AOC) to collect detailed information
from them about their activities, types of aircraft,
hours flown and other factors impacting on safety.
The survey does not include the 14 largest regular
public transport (RPT) operators.
Why exclude the larger RPT operators?
The larger RPT operators (such as QANTAS and
Virgin Blue) carry the substantial majority of
passengers and perform the majority of combined
passenger and charter flight-hour operation
in Australia. Data which includes these large
operators may therefore obscure important
In February 2010, some 789 Australian AOC holders
(some operators were no longer operating and
non-contactable) completed CASA’s AOC holders’
survey questionnaire.
Whilst these large operators are obviously a
critical part of the industry, the focus of this article
is on the smaller AOC holders. There will be more
on the larger RPT operators in a future article.
A BIG THANK YOU to these respondents,
who provided valuable information that will assist
us in ongoing improvement to safety oversight,
including targeted industry safety education.
Proportion of hours flown
Agricultural work
Some 133 operators either ceased activities, or were
active for fewer months than planned in 2009. Of
operators who were contactable, 37 per cent ceased
to exercise their AOC due to insufficient demand, and a
further 31 per cent ceased operations voluntarily.
Charter (32%)
Scenic - 7%
Transport - 21%
Freight - 4%
In total, the 789 AOC holders operate 3713 aircraft
(with 301 of these being used by multiple operators), or
around a quarter of civil aircraft on the Australian VHregister. Together, these AOC holders flew 1.3 million
hours, with about a third of these hours being for flight
training (not including the operator’s internal training
activities), and another third for various charter
Aerial work* 19%
*Aerial work includes aerial advertising and
fire fighting operations
Fixed-wing aircraft account for three-quarters of
the fleet used by AOC holders, with the remainder
comprising 23 per cent rotorcraft and two per cent
balloons. The age profile of aircraft differs markedly
between the three categories, with the majority of the
rotorcraft fleet manufactured after 1990, while around
half of the power-driven fleet was manufactured
before 1980.
Many operators are relatively small, with the majority
(60 per cent) reporting flying fewer than 1000 hours
per year. In terms of the number of aircraft, 22 per
cent of AOC holders operate a single aircraft, with a
further 20 per cent operating two aircraft. Of the larger
operators, 12 per cent (or one in eight) fly more than
4000 hours each, and 16 per cent operate more than
ten aircraft.
The majority of AOC holders (58 per cent) performed
some type of passenger-carrying activity (such as
regular public transport, scenic charter or transport
charter operations).
Decade of manufacture by aircraft class
Power driven aeroplane
Proportion of aircraft
Decade of manufacture
Whilst change is a natural and often necessary aspect
of the aviation industry, it may result in increased risk
if not managed effectively. When identifying safety
concerns, it is appropriate to discuss and analyse the
rate of change within the industry.
In a new and important addition to the 2010 survey,
AOC holders were asked what they consider to be the
current risks to aviation safety in Australia.
A key risk identified by AOC holders is the ability to
retain and recruit operational staff. The results of the
survey indicate that retaining key staff is currently less
of a challenge than recruiting. The 2009 survey showed
that it was often harder than usual to recruit key staff.
This issue appears to have reduced in 2010, although
40 per cent of respondents still found recruiting more
difficult than usual.
Recruit staff
Retain staff
‘Other factors’ include airmanship and flight crew training, levels of flight crew
experience and also regulatory practices.
The risk identified most often by AOC holders is
adverse economic conditions. These may result from
increases in fuel, maintenance and other costs, and
may place economic pressure on operators to reduce
safety standards.
Despite the identification of these risks, it is important
to note that only two per cent of respondents thought
the Australian aviation industry was not very safe,
whilst 56 per cent thought the industry was either
extremely or very safe. This is consistent with results
from previous years.
EASIER than usual
Above average
HARDER than usual
Recruiting - 2009 and 2010
Proportion of valid responses
EASIER than usual
Above average
HARDER than usual
Maintenance of aircraft: 71 per cent of respondents
indicated the maintenance of their aircraft is performed
by maintenance facilities independent of the AOC. Of
these, 78 per cent indicated that there has been no
change in the maintenance provider for at least two
years. Only eight per cent of respondents indicated that
the AOC does not oversee maintenance (for example, all
aircraft are cross-hired).
Of obvious interest to CASA is the industry’s perception
of how well we contribute to the safety of each
organisation. Of the 479 AOC holders providing us this
information, 42 per cent thought CASA was extremely,
or very helpful in identifying important safety issues
that organisations had not previously been aware
of, whilst seven per cent thought CASA was not at
all helpful.
Similarly, 45 per cent of AOC holders thought CASA
was extremely, or very helpful in providing useful
information about risk management principles and
concepts, whilst eight per cent thought CASA was not
at all helpful.
The data provided by AOC holders will allow more
detailed and targeted analysis to be performed, and
the comments made by AOC holders will be analysed
further, and, where appropriate, provided to the
relevant CASA business areas. The feedback you have
provided assists CASA to continue improving aviation
safety in Australia.
For further information, please contact the AOC
Holders’ Survey team at [email protected]
Proportion of valid responses
Recruiting and retaining staff
Proportion of valid responses
The chief pilot is a key position for an air operator
(and an AOC cannot be exercised without a suitable
appointment). These positions appear to be relatively
stable, with 93 per cent of survey respondents
indicating that their chief pilot has been in the position
for more than six months.
Operator identified risks
Phillip Zamagia
s found himself
having to make
split-second de
cision after be
ing fooled by ra
changing tropic
al weather.
Australia’s north is a training ground for many a new commercial
pilot. Aviation is a way of life, as aircraft are used almost as readily
as taxis to supply essential services and administer government
programs in remote communities.
I was one of many pilots who went north feeling quite chuffed that
I had made it through my company’s rigorous flight training and
orientation program. I was now in command of a trusty workhorse,
a Cessna 206.
I was now in
command of a
trusty workhorse
a Cessna 20 6.
The company I flew with was world-renowned for its experience in
bush flying and had an enviable safety record. I had received much of
the company’s collective wisdom during bush orientation; however,
learning to apply this knowledge was another thing.
The wet and dry seasons of northern Australia present two very
different scenarios to pilots. In the dry, the wind is always a southeasterly and the sky is almost always clear.
In the wet, the winds shift to north-westerlies, and the weather
builds up from isolated cumulonimbus to full monsoonal cloud and
rain. In the transition between the two, anything can happen.
It was my first wet season and as the isolated cumulonimbus started
to appear, I was mindful of the advice of many senior pilots warning
me about windshear. A general rule of thumb was that landing and
takeoff within five miles of an active cell should be avoided.
That sounded reasonable enough, but when there is only one cell in
the vicinity and clear skies all-round a single cell doesn’t look that
After a long day of flying, the last sector was a simple matter of
picking up one passenger from a small aboriginal outstation in
Arnhem Land and taking him back to base.
What I did was based on split-second reasoning
in a set of circumstances that is not readily
transferable. But I did learn some valuable
The parking area was near the western threshold, and the windsock
was beside it so that it could get some clear air and be seen more
readily. There was one minor problem; the strip had a rise in the
centre, making the windsock invisible from the eastern threshold.
Be aware of weather in the vicinity of an
aerodrome. Note what is happening when
you arrive and watch for trends while you
are on the ground.
Never underestimate the ability of
thunderstorms to change the local wind
conditions, even if it goes against the
normal seasonal wind.
Be ready to abort every takeoff early
enough if it doesn’t seem right - even more
so if you have a short runway. Things
happen fast even at 80 knots (40 metres per
Know your aircraft’s V speeds and don’t
deviate from them. The maker’s test pilots
had a vested interest in getting the best
performance figures to put in the type’s
publicity material. You won’t do better.
Ask for windsocks to be moved to places
where they can be seen from each
threshold, or have additional ones installed.
Know the expected performance of your
aircraft both empty and fully laden. Never
Be aware of the terrain surrounding the
airfield. Brief yourself on which direction to
turn for the lowest ground, clear areas etc.
I cannot condone my actions but I still believe
that to have aborted by the time I had worked
out what was happening would have been
As I taxied for takeoff, the wind was a westerly, just as I had
encountered during the landing. I was aware that the thunderstorm
was nearby and to the north-east of the field. Lining up for departure,
I could not do a final check of the windsock as it was obscured by
the rise.
I opened the throttle gently to avoid stone damage and checked for
full power, oil temps and pressures in the green, airspeed rising. All
was good to go.
Reaching the middle of the runway, I could sense that something
wasn’t quite right. I was travelling very fast, but the airspeed was
still very low. For a brief moment I could not make sense of it, but I
had the presence of mind to check the windsock as it came into view.
To my horror, it was pointing in the direction I was travelling and
perpendicular to the pole supporting it! I guessed it was showing 30
knots downwind component.
Time seemed to slow down as I tried to evaluate the situation.
Normally, I should have aborted by that point, but with a much
faster groundspeed and a roaring tailwind, I was faced with a tough
To abort now would mean a definite overrun into the trees. To
continue the takeoff would be risky. I reasoned that in my favour was
an aeroplane I knew was a good performer (it was the only one that
I flew every day) and it was very lightly loaded. The trees were the
only obstacles, as the ground surrounding the strip was flat.
I held the aircraft on the ground until rotate speed and the plane broke
ground easily. I knew that I could not wring any better performance
from my trusty 206 than to maintain Vx (max angle climb speed) and
pray for the best.
The aircraft made it over the trees with little margin; I even checked
for twigs in the landing gear when I arrived home. The climb out was
very shallow and highlighted the effect of the massive tailwind we
were experiencing. It was a very quiet flight home. My passenger
said nothing. I volunteered nothing.
I have thought long and hard about it over the past 20 years. Common
wisdom would say that I should have aborted; maybe I should have.
I know of several others who did abort and ended in the trees with a
plane written off and significant injuries to passengers.
In bush flying, I was always taught to use all the
runway available for take-off using short-field
technique. Operating in a standard, consistent
way will alert you of something being amiss
much earlier than if every departure is
Thankfully, I got away with this one, but I have
not forgotten its lessons. In the subsequent
twenty years of flying I have tried to ensure that
I allow sufficient margins for the unexpected.
The outstation landing strip was typical of many in the area.
It was 700m long, reasonably well maintained, and surrounded by
moderately dense bushland with tree-tops around 25m (80 feet)
above the runway elevation.
A young
engineer, who
followed his
training and
stood his groun
when others
assured him
there was no
problem, may
well have save
his airline from
In the mid 1980s I worked in line maintenance for a large, great
Australian airline, sadly now gone.
During this time I worked with some great fellows on a tight-knit
maintenance crew. The age and experience of this crew’s members
varied from LAMEs and AMEs who had been in the industry since
the days of Australian National Airways, right up to recent exapprentices, including some who were the sons of current and former
airline workers, plus a good spread of LAMEs of various backgrounds
and experience. It mixed in a nice balance of youth and experience.
I was a LAME and as a recent refugee from a competing airline, I had
been made to feel welcome in this crew. I enjoyed my time with this
eclectic group.
On a pleasant, late-spring Saturday afternoon, our line maintenance
crew happened to be rostered for duty on a 14.30 to 22.30 afternoon
shift. Afternoon shift meant that the whole crew would be on the
tarmac at the company’s passenger terminal doing turnarounds and
maintenance activities on company and customer aircraft.
I do recall thinking that the weather was so nice that day that it would
have been an ideal afternoon to be at home with the family, or at a
barbecue with friends, but if you must go to work on the weekend, and
in the great outdoors, then the days didn’t come much nicer than this;
warm soft sunshine and a gentle breeze.
As a fast, heavy aircraft like the 727 generates
a lot of heat, and dissipates a lot of energy
through its wheel brakes, it was a mandatory
company requirement not to reuse the main
landing-gear brake retaining nuts when a
brake assembly was replaced, but to replace
them with new ones.
When our young maintenance worker
travelled to the company parts store and
ordered a serviceable 727 brake assembly,
he diligently ordered a packet of new brake
retaining nuts.
This company’s flying activities on Saturdays were always somewhat
quieter than during the other days of the week. This meant that some
of our line maintenance crew would be looking after the needs of
transiting aircraft, whilst others of the crew would focus on deferred
maintenance - maintenance outstanding on aircraft which had
finished their day’s flying and were parked at various gates on tarmac
at Melbourne airport.
This young man had joined our crew only in recent months. He was a
keen well-liked ex-apprentice who had previously spent a lot of time
in the aircraft overhaul department working on and getting to know
intricately the inner workings of Boeing 727s. He was enthusiastic and
had a particular like of the type.
During his end-of-the-day flying check he discovered that one of the
four main landing-gear brake assemblies was worn to limits, and this
would require changing before the next day’s flying.
The 727 brake unit is a line-replaceable one, and although its
replacement would normally be carried out when the aircraft was
positioned in the hangar, it was a task that could be carried out on the
tarmac. It would be no real chore to do it in the open on such a nice
The 727 brake unit is a large and heavy multi-disc assembly that
fits co-axially over the landing gear axle, and the main landing-gear
wheel and tyre assembly fits over, and engages with it. Unlike general
aviation aircraft, the brake unit is not relined with friction material,
but rather the whole module is changed as a complete assembly. This
module is fastened to the landing gear with a dozen or so nuts, which
are tightened onto large studs projecting from the main landing-gear
brake housing through corresponding mating holes in the aircraft’s
landing-gear axle flange.
On closer inspection, the nuts
he had just ordered appeared
identical to the ones he had
removed, and while they were
clearly new parts, each new nut in
this packet had a small innocuous
dot of red dye on it.
Although they had come supplied with a GRN
- which is normally proof that maintenance
workers can rely upon to indentify serviceable
aircraft parts, with acceptable history and
traceability - our young LAME was troubled
by the red dye stains. He knew from his
time in the company component overhaul
department that when aircraft parts were
determined to be beyond repair and scrapped
it was normal practice to mark them with
red paint as a visual cue of their soon-to-bediscarded status.
He decided to confer with some older hands
on the shift about this conundrum. He was
assured by all the maintenance crewmembers
present, including me, that if the parts were
the correct part number, and they had been
supplied with a GRN, then he could rely
on them to be serviceable and he should
use them.
One such aircraft was a company Boeing 727 that had been parked at
a standoff bay. A young LAME was assigned to check the aircraft over
and ‘put it to bed’. This included a visual external check of the aircraft
and its systems.
When he received the brake unit retaining
nuts from the storeman, they were correctly
packaged in a vendor’s bag, which identified
the parts as the items he had ordered. The
package was also supplied as required with a
general release note (GRN) number.
Our young worker wasn’t convinced by the assurances of his more
senior peers. As events unfolded, it was good that he wasn’t.
He decided to order more nuts from the store to see if he could get a
set that were not marked with any red dye. As this airline was a large
operator of 727s they had good stock of these parts, and he managed
to find a set of new fastening nuts that were unmarked with red dye.
He then quarantined the nuts that had dye marks for the quality
assurance (QA) department’s attention and submitted a report asking
them to follow up his concerns.
Some weeks later, our young LAME, rather proudly and with more
than a hint of gloating to his more experienced peers, announced
to the crew room that he had been correct about the brake nuts. He
went on to explain that QA had investigated the matter, and they had
discovered that, although the parts came from a reputable and
trustworthy vendor that the airline had used for years, they were
Further, QA investigations had discovered that the nuts were made by
a reputable overseas aircraft fastener manufacturer with all the correct
part manufacturing approvals. However, during the post-production
quality testing they had been rejected as below the required Rockwell
hardness value and sent to be scrapped - hence the red dye marks.
Around this time, it was believed that person or persons unknown
had taken these rejected parts, forged the paperwork and sold them
back into the aircraft parts supply chain in the USA, from which they
eventually ended up in our young LAME’s hands.
His discovery prompted a company-wide alert
to check other 727s with recent brake changes
to ensure they didn’t have any red-dyed nuts
installed. There was also a worldwide alert to
727 operators advising other operators who
may have purchased these nuts from the
same supplier.
Fortunately, this episode did not result in
anything more than some light-hearted
teasing of the more experienced members
of the maintenance crew, but it was a telling
reminder that maintenance workers must
always be vigilant for evidence of bogus
aircraft parts, and always, to follow their
instincts if things don’t seem right.
The morals are:
If it doesn’t seem right or feel right, don’t
just accept it at face value. It pays to check
it out.
You can teach old dogs new tricks.
And thirdly, just because some workers
are young and relatively inexperienced,
it doesn’t mean that they cannot bring a
new perspective.
The devil is in the details of your
aircraft’s systems, Lloyd Knight writes
It seems to me that often pilots do not understand the principle of
failsafe design, as it applies to electrical/electronic control of aircraft
systems. To illustrate this, I will describe an incident that almost had
a nasty outcome involving the operation of the hydraulically-boosted
control system in the Bell 205 helicopter.
Because of the heavy forces needed to control the rotor system,
a transmission-driven hydraulic pump supplies pressure to servos that
reduce the stick loads felt by the pilot. In the case of total hydraulic
failure the helicopter can still be flown, although with some difficulty.
Because hovering in this condition would be virtually impossible,
a run-on landing would be required.
The hydraulic disable system is failsafe. This means that an electrical
circuit is used to hold the hydraulic system in the disabled condition.
When the hydraulic system switch is in the ‘on’ position, this circuit
is switched off and the hydraulic boost is switched on. Likewise, if the
electrical system fails, this circuit will be de-energised, or off, and the
control linkages will continue to be boosted, regardless of the position
of the hydraulic override switch. This prevents loss of the aircraft
electrical system from causing a total hydraulic failure. In short: if
electrics ‘off’, then hydraulics ‘on’; for hydraulics ‘off’, electrics must
be ‘on’.
I was returning from an offshore sortie one day when the pilot of
another aircraft called on the radio, in a highly-agitated voice, that he
was losing control. He said the hydraulics kept cutting in and out, and
the aircraft was rolling and pitching violently. There was real panic in
his voice and I could hear his passengers shouting in the background.
Another pilot called, ‘Switch off the hydraulics’. He responded with,
‘I’ve switched off the hydraulics, and pulled the circuit breaker, I think
we’re going in’. I called out as calmly as I could, ‘Leave the switch in
the off position and push the circuit breaker back in.’
We all learned from that, about following the
flight manual procedures and not applying
our own overkill additional actions.
The bottom
line is :
Know your
A more difficult failure may occur when one hydraulic servo fails, but
the others continue to work. This means that the controls are boosted
in some parts of their movement, but not in others. Such a failure could
easily result in an aircraft that is ‘unflyable’ by the average pilot. Bell
therefore provides a switch allowing the pilot to disable the hydraulic
system. The pilot still has to contend with a total hydraulic failure, but
all the stick forces are equally high, and the aircraft is still flyable.
After a minute’s silence he came back with,
‘I did that and I have control back with no
hydraulics.’ What he had done by pulling
the circuit breaker was negate the override
system by de-energising it, which was the
same as turning the hydraulic system back
on. Pushing the circuit breaker in turned the
hydraulics off again. He proceeded back to
base and made a run-on landing on the flight
strip beside the runway.
Chief Commissioner’s
On 12 April I signed a renewed
memorandum of understanding
(MoU) with the President of the
Australian and International
Pilots Association (AIPA),
Captain Barry Jackson.
Representing around 2,500
Qantas flight crew, the AIPA
is the largest representative body of airline pilots in
Australia. The AIPA plays a valuable role in contributing
the expertise of these flight crew to the government’s
legislative and regulatory processes. The association
also contributes resources and expertise to a broad range
of local and international initiatives that significantly
contribute to improving aviation safety.
This MoU strengthens our relationship with AIPA and
articulates how we will work cooperatively to support
aviation safety investigations. With Australian flight
crew being widely regarded as the most experienced and
respected in the world, the ATSB recognises the great
value AIPA adds to our safety investigations.
On 20 April I had the pleasure of addressing the ninth
International Symposium of the Australian Aviation
Psychology Association on the topic Safety Management
Systems: Is there a role for an independent investigator?
Safety management systems (SMS) are increasingly
important in aviation, with ICAO actively requiring
aviation operators to implement an acceptable safety
management system. The progress that Australia has
made in this area is encouraging, although it will continue
to present new challenges for all of us.
Australian aviation accidents and
he ATSB has just released its aviation occurrence statistics report.
Each year, the ATSB receives reports on aviation accidents and
incidents, collectively termed occurrences. These reports are used
by the ATSB to assist with the independent investigation of occurrences and for identifying safety trends. This report, published twice a
year, provides aviation occurrence data for the period 1 January 1999 to
31 December 2009.
over the reporting period.
For commercial air transport (high capacity regular public transport
[RPT], low capacity RPT and charter), although the accident rate had
climbed in 2007 and 2008, the number of accidents reduced from
registered Airbus A340-500 in Melbourne on 20 March. Most fatal
accidents in commercial air transport are in charter operations, and it
has a similar rate of fatal accidents to all general aviation. Charter has
high capacity RPT.
From the ATSB’s perspective, these developments
emphasise the importance of taking a systems view of
safety occurrences: of looking at what we can learn to
improve future safety each time something goes wrong.
and (VH-registered] sport aviation), accidents and serious incidents
have remained generally consistent since 2007. In 2009, there were
126 accidents, including 18 fatal accidents, and 95 serious incidents.
While we encourage everyone in aviation to focus on
learning from errors and problems, we also believe that an
independent investigator brings something important to
SMS arrangements: a dispassionate capability to assess
and identify safety issues and learn and communicate
safety lessons. To be most effective at this, we continue
to rely on comprehensive reporting of safety occurrences
by pilots and others. Your contribution to our knowledge
of what is happening remains essential.
reporting period, has an accident rate per million hours that is two
times higher, and private/business has an accident rate that is 2.5 times
training, the fatality rate in aerial work is three times higher, and
private/business is at least six times higher.
in interpreting accidents by the number of engines. In part this may
Martin Dolan
Chief Commissioner
Airport introduces safety innovation
n 9 May 2008, a Boeing Company
PK-GEF, was being operated on
a scheduled passenger service between
Denpasar, Republic of Indonesia and
six cabin crew and 76 passengers.
established in the cruise, they reviewed
runway thresholds that were displaced
recommended by the International Civil
Aviation Organization (ICAO). When
compared with the likely visibility of
the ICAO-recommended 36 m closed
runway markings, the Australian 6 m
markings, as used in this case, increased
threshold for runway 21 at
Perth was displaced due to
runway works.
vehicles on the runway during the initial
landing approach, they may have landed
within the runway works area.
As a result of this incident, the airport
operator undertook a number of safety
actions and proactively implemented
the use of ICAO compliant 36 m closed
runway crosses.
and retrieving the crosses in
a timely manner, made from
several tonnes of rubber,
was overcome by the use of
specially-designed trailers
that were constructed by the
On approach to land at
Perth, the aerodrome
crew with the landing
clearance, ‘... runway 21
displaced threshold, cleared
was about 15 seconds from
questioned the presence
of cars on the runway and
conducted a go-around.
appropriate location, the
swivel base is unlocked and
On the second approach,
deployed as the trailer is
issued the landing clearance ‘... runway 21,
precise location of the displaced threshold.
As a result, there was an increased risk of
aerodrome controller recalled observing
to the permanent threshold/touchapproach to land on the closed section of
to go around and provided information
ICAO Annex 14
Aerodromes, would have been visible to
approach, allowing additional time for
level over the runway works area prior to
landing beyond the displaced threshold.
At the time of the incident, the permanent
runway 21 threshold and touch-down
markings were unobscured and clearly
works area, which included the threshold
and touchdown markings, was marked by
6 m closed runway crosses.
have allowed an early adjustment to their
approach path, ensuring a stabilised
approach and landing.
Despite an apparent awareness of the
crew to conduct consecutive approaches to
the runway works area suggested that the
temporary markings that were used were
Retrieval is accomplished by reversing the
process and is assisted by electric motors
which drive the rollers. Deployment or
retrieval takes about 10 minutes.
During a recent works programme to
re-surface the entire length of runway 21,
the 36 m crosses were successfully used
to identify the closed runway sections
without reported incident.
by the airport operator in proactively
addressing this safety issue. Q
ATSB investigation report AO-2008-033, released
on 6 June 2009, is available on the website.
employed two motorised
drums on a swivel base, to
hold the two 36 m by 1.8 m
lengths of painted rubber.
Investigation briefs
Ambiguous design standards
Taxiway takeoff
Flight instrument reliability
ATSB Investigation AI-2008-038
ATSB Investigation AO-2007-064
ATSB Investigation AO-2007-047
Following the construction of a new
hangar adjacent to runway 28 right (28R)
at Archerfield Airport, Queensland, the
ATSB received a number of submissions
asserting that the building infringed
safety standards or reduced flight safety.
On 25 November 2007, a Gulfstream
Aerospace Corporation G-IV aircraft,
registered HB-IKR, with two pilots, a
cabin attendant and five passengers was
being operated on a charter flight from
Brisbane Airport, Queensland to Sydney,
New South Wales.
During the early evening of 17 October
2007, the pilot of a Cessna Aircraft
Company C210M, registration
VH-WXC, was fatally injured when his
aircraft impacted terrain during a flight
from Warburton to Kalgoorlie, Western
Australia. That flight was being conducted
at night under the visual flight rules and
the pilot was the sole aircraft occupant.
Drawing on an independent thirdparty review, the ATSB determined that
the building does not breach obstacle
limitation surfaces. The ATSB also
conducted an initial examination of
the instrument departure procedure
from runway 28R. The ATSB found
that the procedure complied with the
extant instrument departure design
requirements, but identified an ambiguity
in the guidance for designing instrument
departure procedures.
The ATSB assessed that this ambiguity
could lead to inconsistent expectations
about the extent of clearance from
obstacles provided to aircraft when pilots
were following an instrument departure
procedure. This had the potential to
increase the risk of a collision with an
obstacle. In response, on 30 May 2008,
the (then) Executive Director of the ATSB
commenced a safety issue investigation.
As a result of that investigation, the Civil
Aviation Safety Authority and Airservices
Australia have, in consultation, reviewed
their understanding of how the design
standards for instrument departure
procedures should apply in Australia.
They have also re-examined the runway
28 instrument departure procedure at
Archerfield in the light of that review
and have advised that they intend to
amend the requirements for instrument
departures from runway 28R.
The potential for inconsistent
interpretation of the instrument
departure procedure design requirements
has also been notified to the International
Civil Aviation Organization instrument
flight procedures panel, which monitors
the international standards for the design
of instrument procedures. Q
At about 2215 Eastern Standard Time
(EST), the crew was issued with an air
traffic control (ATC) clearance to taxi via
taxiway Foxtrot 2, to the east, then right
onto taxiway Bravo for an intersection
departure on runway 01 at Alpha 7. An
intersection departure had earlier been
offered to, and accepted by the pilot in
command (PIC). The PIC taxied the
aircraft while the co-pilot conducted
the taxi checks and conducted the radio
communication with ATC. At about
2225 EST, the PIC of the aircraft
commenced the take-off run while on
taxiway Alpha, which was adjacent to
the active runway 01. The aerodrome
controller (ADC) instructed the crew
to cancel the take-off clearance. The
crew stopped the takeoff and the ADC
instructed them to taxi to the end of the
runway for a takeoff using the full runway
There were no injuries, or damage to the
aircraft or airport infrastructure. The
investigation found that a combination of
a cockpit equipment failure, inadequate
pilot rest, deficient cockpit resource
management practices and unfamiliarity
with the airport layout were likely factors
that led to the occurrence. The time of the
flight and the PIC’s reported tiredness,
possible jetlag and interrupted sleep
patterns may have impacted on his ability
to make effective decisions. The PIC did
not use the available means to assist in
guiding the aircraft during the taxi. Q
The aircraft was seriously damaged by
impact forces. There was evidence that the
engine was producing significant power
at that time. The aircraft was inverted
when it collided with terrain, which was
consistent with an in-flight loss of control.
The accident was not survivable.
Examination of the aircraft wreckage
found evidence that the aircraft’s suctionpowered gyroscopic flight instruments
were in a low energy state. That was most
probably because the vacuum relief valve
was at a low suction setting. There was
no lockwire fitted to the associated lock
nut that would have ensured the security
of the vacuum relief valve’s adjustment
spindle. The design of the valve was such
that any in-service loss of friction on the
lock nut could allow the spindle to move
to a lower suction setting. In consequence,
the aircraft’s flight instruments may not
have been providing reliable indications
to the pilot.
The pilot was appropriately qualified to
conduct the flight. However, dark night
conditions probably prevailed in the
vicinity of the accident site which meant
that the pilot would have had few
external visual cues. In such conditions,
the pilot was reliant on the indications
from the aircraft’s flight instruments to
maintain control of the aircraft. The pilot
would have had limited time to identify
and react to any unreliable indications
from the suction-powered flight
instruments. Q
Oxygen masks deployed
Bad data represents safety risk
ATSB Investigation AO-2007-062
ATSB Investigation AO-2009-013
On 17 November 2007 a Boeing Company
737-7Q8 aircraft, registered VH-VBC,
with two flight crew, four cabin crew
and 145 passengers was being operated
on a scheduled passenger service from
Coolangatta, Queensland to Melbourne,
Victoria. During the takeoff, the Master
Caution system activated and the right
BLEED TRIP OFF light illuminated. The
pilot in command elected to continue
the takeoff. Once airborne the Bleed Trip
Off non-normal checklist was actioned.
The right engine bleed could not be reset
with the result that, when above flight
level (FL) 170 (17,000 ft above mean sea
level), only the left engine bleed air was
available for airconditioning and cabin
On 7 April 2009, at about 1210 EST,
the flight crew of a Boeing 737-800
aircraft, registered VH-VYL, received
an enhanced ground proximity warning
system alert while passing through
129 ft above ground level during an
autoland approach and landing at Sydney
Airport, NSW. At the same time, the left
radio altimeter (RA) display reduced
in altitude to minus 7 ft, the autopilot
disconnected and the engine thrust levers
moved toward the idle position. The pilot
in command, who was the handling pilot,
immediately re-positioned the thrust
levers and conducted an uneventful
The investigation found that a
combination of technical faults
contributed to the loss of pressurisation
and identified a number of safety factors
relating to operational procedures and
cabin crew knowledge of the passenger
oxygen system.
The operator conducted an internal
investigation of the incident and carried
out a number of safety actions. Those
actions included the enhancement of a
number of the operator’s manuals and the
amendment of the operator’s cabin safety
recurrent training. In addition,
the operator’s passenger oxygen use
in-cabin brief was enhanced to include
advice that oxygen would flow to
passengers’ masks even if the associated
bag was not inflated. Q
The maintenance history for the aircraft
operator’s fleet of 38 Boeing 737-800’s
revealed that, over the previous
12 months, the operator had removed
and replaced 24 RA antennas. The
replacements (including for this event)
were as a result of 11 antennas having
failed bonding checks, and 12 antennas
exhibiting RA system faults or alerts.
Three months after the occurrence,
a further RA warning flag event was
experienced by another crew in this
aircraft. As a result, the left and right
RA transceivers were removed and
tested with internal faults found on the
left unit. Q
Inaugural Level 5 Bulletin
ATSB Investigation AB-2010-020
The ATSB receives around 15,000 aviation occurrence notifications each year, equating to
about 8,000 reportable matters. The Bureau, however, is only resourced to undertake a certain
number of investigations each year, and while professional judgment is required in making
decisions about which are investigated, there are a significant number of occurrences that are
only entered into the ATSB’s data base for future statistical analysis and trend monitoring.
There are times, however, when more detailed information about the circumstances of the
occurrence would have allowed the ATSB to make a more informed decision both about
whether to investigate at all and, if so, what necessary resources were required. In addition,
further publicly available information on accidents and serious incidents should increase safety
awareness in the industry and enable improved research activities and analysis of safety
trends, leading to more targeted safety education.
To enable this, the ATSB established a small team to manage and process short, factual
investigations, the ‘Level 5 Investigation Team’. The Team has recently released its first
quarterly bulletin of level 5 investigations, providing a set of professional-level examinations of
occurrences that would not traditionally have been investigated.
The summary reports in the bulletin were compiled from information provided to the ATSB by
individuals or organisations involved in an accident or serious incident between the period
1 December 2009 and 30 March 2010.
The bulletin covers a range of occurrences, examining the circumstances surrounding a pilot
incapacitation, a ground handling event, an instance of total power loss, a depressurisation, a
situation in which aircraft control was lost, and an in-flight fire.
The bulletin, with details of the investigations, can be found on the ATSB’s website at
<www.atsb.gov.au> Q
At FL318 during the climb, the flight
crew observed the left PACK TRIP OFF
light illuminate, followed by a rapid loss
in cabin pressure and the cabin rate of
climb indicator showing a rate of climb of
about 2,000 ft/min. The crew fitted their
emergency oxygen masks, commenced
the Emergency Descent checklist and
began a rapid descent to 10,000 ft. During
the descent, the cabin altitude exceeded
14,000 ft, at which time the passenger
oxygen masks deployed automatically.
The aircraft was diverted to Brisbane for
landing. There were no reported injuries
to passengers or crew and no damage to
the aircraft.
The investigation determined that
spurious data from the left radio altimeter
(RA) provided an indicated altitude of
minus 7 ft, resulting in the autopilot
disconnecting and the thrust lever
movement. An examination found that
the left RA receive antenna displayed
rubbing wear adjacent to the attachment
screw inserts. A bonding check of the
antenna indicated that its resistance was
outside the aircraft manufacturer’s limits.
The antenna was replaced and the aircraft
was returned to service.
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
action. You may also wish to consider
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.
Unsafe practices at an
Report narrative:
The reporter expressed safety concerns
that incidents/accidents are increasing
and operating procedures appear to be
deteriorating at the named aerodrome.
Occurrences and deteriorating operating
procedures include; not restraining
aircraft when unattended, collisions with
other aircraft and structures, dangerous
hand starting procedures, unconventional
circuits being flown, and non standard
radio calls.
resume their seats in turbulence, the food
service was continued and cabin crew
moved through the cabin with hot liquids
and food.
The reporter believes that CAO (Civil
Aviation Order) 20.16.3 requires all
passengers and crew to occupy a seat
during turbulent conditions. On other
airlines that the reporter has flown with,
whenever the seat belt sign is illuminated
due to turbulence, both passengers and
crew are instructed to be seated and
fasten seatbelts.
Action taken by REPCON:
REPCON supplied CASA with the deidentified report and CASA advised that
it was aware of increased activity at the
aerodrome as a result of aircraft operating
from Parafield Aerodrome. CASA
has recently conducted surveillance
activity on operations in the vicinity
of the aerodrome and is satisfied that
aircraft operators are meeting their
safety obligations in accordance with
the applicable civil aviation legislation.
Further surveillance activity is planned.
Without more specific information, CASA
is unable to action or comment further on
the issues raised in the REPCON.
Safety of cabin crew in
Report narrative:
The reporter expressed safety concerns
about cabin crew not being seated with
seatbelts secured during turbulence
when the seat belt sign illuminated. The
reporter estimated that over the last
7 years flying with the operator, with an
estimated 300 to 400 sectors, that only
once were cabin crew observed to resume
their seats in turbulence. This occurred
when the turbulence was so severe that
crew found it extremely difficult to stand.
During the flights where the crew did not
Action taken by REPCON:
REPCON supplied the operator with the
de-identified report and the operator
advised that CAO 20.16.3 states:
3.1 Each crew member and each passenger
shall occupy a seat of an approved type:
(a) during take-off and landing; and
(b) during an instrument approach; and
(c) when the aircraft is flying at a height
less than 1000 feet above the terrain;
(d) in turbulent conditions:
The operator advised that the CAO does
not define the level of severity of the
turbulence at which crew and passengers
must be seated. The operator ensures
that passengers are seated at a lesser level
of turbulence than for cabin crew and
this is stated in their procedure manual.
Contained therein are procedures for
dealing with the levels of severity of
turbulence and also included is the
following note:
NOTE: Crew should be seated immediately
if they feel their safety is in jeopardy at any
The operator also noted that CAO
20.16.3 and Civil Aviation Regulations
(1988) 251 lists duties for cabin crew
that require certain actions if turbulence
is encountered. The operator believes
that assumes cabin crew are to perform
functions other than immediately assume
their seat in all cases of turbulence
encounters. The operator therefore, in
keeping with the drafting of the relevant
CAO, published procedures that detail
duties of cabin crew in turbulence as long
as the overriding embodied intent is to
ensure the safety of both passengers and
REPCON supplied CASA with the
de-identified report and a version of the
operator’s response. CASA provided the
following response:
REPCON Operation types First quarter 2010
Sports aviation 2% (1)
Regional airlines 5% (2)
Charter 5% (2)
Flight training 5% (2)
Aerial work 5% (2)
High capacity air
transport 44% (19)
All 7% (3)
General aviation 27% (12)
Reported issues First quarter 2010
Radio communications 5% (2)
Maintenance 5% (2)
Ground handling 2% (1)
Organisational safety culture 2% (1)
Flight publications 2% (1)
Aircraft defects 7% (3)
Operating procedures 26% (11)
Cabin safety 9% (4)
Cabin crew fatigue 18% (8)
Aerodrome safety 12% (5)
Airmanship 12% (5)
Who is reporting to REPCON? a
The operator has subsequently advised that
they are in the process of revising their
turbulence procedures.
Cabin crew 3% (12)
Air Traffic controller 4% (14)
Facilities maintenance
personnel/ground crew 1% (4)
Passengers 8% (33)
Flight crew 37% (150)
Aircraft maintenance
personnel 22% (92)
REPCON reports received
Total 2007
Total 2008
Total 2009
Total 2010
Othersb 25% (100)
a. 29 January 2007 to 30 April 2010
b. examples include residents, property owners, general public.
a. as of 30 April 2010
What is not a reportable safety concern?
How can I report to REPCON?
To avoid doubt, the following matters are not reportable safety concerns and
are not guaranteed confidentiality:
(a) matters showing a serious and imminent threat to a person’s health or life;
(b) acts of unlawful interference with an aircraft;
(c) industrial relations matters;
(d) conduct that may constitute a serious crime.
Note 1: REPCON is not an alternative to complying with reporting obligations
under the Transport Safety Investigation Regulations 2003
(see <www.atsb.gov.au>).
Reporters can submit a REPCON report online via the ATSB website.
Reporters can also submit via a dedicated REPCON telephone
number: 1800 020 505
by email: [email protected]
by facsimile: 02 6274 6461
or by mail: Freepost 600, PO Box 600, Civic Square ACT 2608
Note 2: Submission of a report known by the reporter to be false or misleading
is an offence under section 137.1 of the Criminal Code.
How do I get further information on REPCON?
If you wish to obtain advice or further information on REPCON,
please visit the ATSB website at <www.atsb.gov.au> or call REPCON on
1800 020 505.
CASA has reviewed the report and will
request that the operator review their turbulence procedures in accordance with Civil
Aviation Regulation 251 s1(d).
repercussions of the
Nearly 10 years after Air France’s Concorde, F-BTFC,
crashed shortly after lift-off, killing all 109 occupants and
four people on the ground, French authorities have brought
manslaughter charges against the US-based Continental
Airlines, two of its employees and three French nationals
closely involved with the development and operation of
Concorde aircraft, writes Macarthur Job.
Air France and British Airways were the only two
airlines in the world to operate regular supersonic
services, continuing daily transatlantic Concorde
flights for two decades.
Air France Flight 4590, departing Paris for New York City on 25 July 2000,
under the command of Captain Christian Marty, was a charter for a German
shipping company, Peter Deilmann Cruises. The 100 passengers, mostly
from the western German town of Monchengladbach, were on their way to
join a 16-day luxury cruise around South America.
There was a delay of about 45 minutes in the aircraft’s scheduled departure
from Charles de Gaulle Airport; some of the passengers’ luggage was
late arriving, and the thrust reverser for the No 2 engine was found to be
malfunctioning and had to be changed. But as the passengers waited in the
VIP lounge, they were in high spirits, singing and chatting to pass the time.
Finally the thrust reverser work was completed and 19 bags of passengers’
luggage arrived at the Concorde’s parking bay. They went in the aircraft’s
rear hold, and by 1400 hours the Concorde was ready. The surface wind
was then calm, and the flight crew contacted the control tower to request
the entire length of runway 26R for a take-off at 1430.
Ten minutes later, the tower’s ground controller
passed the crew their start-up clearance,
confirming that 26R would be available. As the
six cabin crew briefed the passengers pre-flight,
the engines were started, the flight engineer’s
calculations showing the aircraft’s total weight
was 186.9 tonnes with 95 tonnes of fuel on board.
Calculated take-off speeds were V1 at 150 knots,
a VR at 198kt and V2 at 220kt.
At 1434 hours, the ground controller cleared
the aircraft to taxi to the holding point for
runway 26R. Six minutes later, after a US-bound
Continental Airlines DC-10 had taken off from the
runway, the Concorde was cleared to line up, the
flight engineer announcing that the aircraft had
used 800kg of fuel during taxiing - 1.2 tonnes less
than allowed for in the flight plan.
At 1442 the airport controller cleared the
Concorde for take-off, adding that surface wind
was now from 090 degrees at 8kt. The crew
read back the clearance, and Captain Marty,
in the left-hand seat, opened the throttles.
Half a minute later, as the aircraft continued to
accelerate, the co-pilot called 100kt, and nine
seconds afterwards, V1.
Seconds later, the right-front tyre of the port
main undercarriage bogie ran over a strip of
titanium, about 43cm long and 3cm wide, that had
fallen from a thrust reverser cowl door on the
preceding DC-10. The metal punctured the fastspinning tyre, which immediately disintegrated,
hurling substantial pieces of rubber forcefully
against the underside of the port wing where fuel
tank No 5 was located.
service, from Paris to
Rio de Janeiro via Dakar,
with the revolutionary AngloFrench Concorde in January 1976.
Operations across the Atlantic to the
United States were initially delayed because of
noise protests, but flights began to Mexico City via
Washington DC later that year. The following year direct
services to New York and to Washington DC began. The flight
time to New York from Paris was only three hours and 23 minutes,
cruising at about twice the speed of sound.
The impact, as well as severing a 115V AC electrical cable, propagated a shock
wave through the full tank of jet fuel, rupturing its wall. Fuel pouring from the tank
ignited by arcing from the broken cable, touched off a spectacular conflagration
beneath the port wing. In a moment, the two port engines began surging as
hot gases from the fire were ingested into the port side under-wing air intakes.
No 1 engine lost some power, while the No 2 engine lost a substantial amount
of thrust.
At this stage, the Concorde’s take-off run became directionally unstable, the aircraft
veering to the left side of the runway where one of its port-side wheels demolished
a steel landing light, throwing some of its debris into the No 2 engine air intake. In
danger of leaving the runway altogether and heading directly towards an arriving Air
France Boeing 747 waiting on an adjoining taxiway, the co-pilot called out in alarm,
‘Watch out!’
Having passed V1, the crew had little option but to take off, the captain attempting
to retrieve the situation by pulling the aircraft into the air at 188kt, 11kt below the
recommended minimum VR.
As he did so, the airport controller transmitted an urgent warning of flames behind the
aircraft. The captain acknowledged the tower’s transmission as the cockpit engine
fire alarm began sounding; and he ordered the shut-down of No 2 engine. The flight
engineer confirmed he was doing so, and the captain called for the engine fire procedure.
The No 2 fire handle was pulled and after about 12 seconds the fire alarm ceased. The
airspeed was still indicating only 200kt, the first officer drawing this to the captain’s
attention, and the flight engineer announced No 2 engine was no longer operating.
The tower controller, thoroughly alarmed by the magnitude of the now-fierce plume
of flame extending behind the Concorde’s tail for more than 60m, again warned the
crew. The captain ordered the undercarriage up, but 10 seconds later, after the engine
fire alarm again sounded briefly, the first officer reported that it was not retracting.
Unable to gain airspeed on the three functioning engines because the undercarriage
would not retract, the aircraft was hardly climbing. Still only 200 feet above the
ground, it would not accelerate beyond 210kt and, as the first officer continued to
call out airspeed readings, the fire alarm began sounding for the third time. The first
officer transmitted that they would divert to Paris’ Le Bourget Airport, not far away.
In danger of
leaving the
altogether and
towards an
arriving Air
France Boeing
747 waiting on
an adjoining
taxiway, the co
pilot called out
But with No 1 engine now also failing rapidly and the aircraft pitching up
uncontrollably as the fire affected the port wing structure, asymmetric
thrust lifted the starboard wing steeply. In a vain attempt to regain control,
the crew reduced power on the starboard engines, but with the nose now
up almost vertically, the bank to the left increasing beyond 90 degrees and
airspeed falling rapidly, the crew finally lost all vestige of control.
Moments later the Concorde stalled as its airspeed fell to zero. Sliding
rearwards and rolling to the left as it fell with the nose dropping, it fell
tail first on to a small hotel in the village of Gonesse on the outskirts of
Paris. The aircraft exploded, killing all on board as well as four people in
the hotel. The flight had taken less than two minutes.
The most significant finding from the wreckage
examination was that a spacer was missing from
the undercarriage beam for the port side bogie
assembly. The spacer locates two steel shear
bushes on the pivot connecting the bogie assembly
to the main undercarriage oleo leg, thus keeping
the four wheels of the bogie in correct alignment.
Without the snug fit provided by the spacer, the
bogie and its wheels can move up to three degrees
either way.
Four days before the accident, the aircraft’s port side undercarriage
assembly had been serviced, and the undercarriage beam changed. Refitting
the spacer to the replacement beam had apparently been overlooked when
the bogie was reassembled. After the accident, the missing spacer was
found in Air France’s workshop, still attached to the old beam.
Other significant evidence found on the runway
were tyre scuff marks near where the aircraft
had veered to the left and hit a landing light before
lifting off. The marks indicated that the port side
bogie had moved out of alignment at or before this
point, and could have been responsible for the
Concorde’s directional instability on the runway.
It was also possible that if the bogie was out
of alignment earlier in the take-off run, it could
have retarded the aircraft’s acceleration on
the runway.
Two highly-experienced, retired Air France
Concorde flight crew members, a pilot and a flight
engineer, believed the bogie was already out of
alignment when the aircraft began its take-off
run. Their detailed calculations showed that,
without the consequent retardation, the aircraft
should have been able to lift off after 1694m before reaching the point where the metal strip
had fallen from the DC-10.
Several other factors could have together
contributed to the catastrophe. Indeed, it
appears that even before the Concorde hit the
metal strip on the runway, it could have been
operating beyond the limitations of its safe flight
When the 19 bags of overdue passengers’
luggage, an additional 500kg not included in
the manifest, finally arrived at the aircraft, they
were hastily loaded into the rear cargo hold. This
not only raised the Concorde’s total weight to
186 tonnes—a tonne over the type’s maximum
structural weight—it also moved the centre of
gravity further aft than had been calculated.
The aftermath
The point on Charles de Gaulle Airport’s runway
26R where the Concorde’s tyre had disintegrated
was clearly evident from the marks and rubber
debris it had left. The riveted titanium strip from
the DC-10 which caused the tyre failure was
found seven metres ahead and 37m to the right
of where the Concorde’s tyre blew out. It was
found to be a non-standard part, not approved for
use on DC-10 aircraft by the US Federal Aviation
During development of the Concorde, test pilots
established that its safe aft centre-of-gravity
limit was 54 per cent. But the investigation
showed that the accident aircraft’s C of G at the
time it began its take off would have been 54.2
per cent, and possibly as much as 54.6 per cent
with the additional luggage.
As one Concorde authority commented: ‘even
with all four engines working normally, this
was beyond where test pilots would have be
willing to tread’. And as fuel gushed from
the breached wing tank, the C of G would
have progressively moved even further
behind the aft limit.
Had they done their calculations again, using the changed data, they would
have found that their new regulated take-off weight (as the determination
is officially called), was six tonnes less than the aircraft’s total
actual weight!
Another experienced Concorde captain commented: ‘I’ve probably taken
off overweight — after all, you can never be sure because you don’t weigh
the passengers or the hand luggage. But not six tonnes! They were already
at the limits of the envelope. Once the wind changed they were beyond it.’
The final ‘nail in the coffin’ for the flight was evidently the decision to shut
down the ailing No 2 engine. Experienced Concorde pilots, both French and
British, said it was a disastrous mistake breaching all set procedures. The
engine was not on fire, and its thrust output would probably have recovered,
at least to some degree. The standard procedure for shutting down an
engine requires the flight to be stable at a height of at least 400 feet.
As the aircraft lined up for take-off, it was also carrying 1.2 tonnes more
fuel than allowed for in the flight plan. The crew had expected this fuel to
be consumed during taxiing. And finally, there was the unexpected tailwind
of 8kt that developed while the aircraft was taxiing to the runway. These
three factors together effectively rendered useless the crew’s take-off
Start of take-off roll: 14:42.31
Weight approx 6 tonne over
crew’s calculated weight.
C of G slightly beyond safe
aft limit.
8kt tailwind
Less fuel burnt
than expected
during taxi.
Port undercarriage bogie
possibly out of alignment
and retarding acceleration.
Tyre punctured
by DC-10 debris.
Tyre fragments damage fuel
tank, leaking fuel ignites.
Aircraft veers to left.
Heading towards B747 on
intersecting taxiway, pilots
pull aircraft into air 11kt
below Vr. Time: 14:43.13
Late luggage loaded
into rear hold.
Illustrations: Juanita Franzi, Aero Illustrations
Because the crash initially appeared to have come about solely because a
tyre had disintegrated during take-off, all Concorde aircraft were promptly
grounded pending investigation of the accident. An Air France Concorde in
New York at the time was granted a ferry permit to return to Paris without
passengers. The Concorde fleets in both France and Britain were modified
to guard against a recurrence of the problem. The costly changes included
greater impact protection for the electrical wiring looms in the wings, fireprotective Kevlar lining in the fuel tanks, and specially developed burstresistant tyres.
Late in 2001, 15 months after the accident, supersonic trans-Atlantic
services by both Air France and British Airways resumed with the modified
Concorde. But shortly before they did so, the twin towers terrorist attack
occurred in New York.
The result was a marked drop in custom for the premium-price flights,
contributing eventually to their demise for economic reasons. Air France
discontinued Concorde operations in May 2003, and British Airways
followed suit the following October.
In March 2005, French authorities instituted
a criminal investigation into the part that
Continental Airlines had played in the tragedy.
Several months later, the former head of the
Concorde Division at Aerospatiale, together
with the Concorde chief engineer also came
under investigation for negligence. As a result
of these enquiries, manslaughter charges were
brought against Continental Airlines, together
with one of their maintenance engineers and his
maintenance manager,
Aerospatiale’s former Concorde Division head
and its chief engineer, and a former Director of
Technical Services at the French civil aviation
authority. If convicted, Continental Airlines
stands to pay a penalty of US$500,000. Its two
employees, together with the French defendants.
could face substantial fines, or up to five years
in jail.
The trial opened at the beginning of February
this year, and a verdict is expected late in
the year.
No 2 engine fire
alarm sounds.
No 2 engine shut down.
Airspeed 200kt.
Undercarriage fails to retract.
No 1 engine losing power.
Altitude 200ft above ground.
Unable to accelerate above
210kts, unable to climb.
Aircraft pitching up
uncontrollably and
rolling to left.
Aircraft stalls and crashes
tail-first into hotel-motel
buildings. Time: 14:44.50
By this time it had become evident that fiery end of F-BTFC on the outskirts
of Paris, far from being a ‘single cause accident’ as first believed, was, like
so many other aircraft disasters, the final result of a chain of errors and
unfortunate circumstances.
Relatives of the victims were granted substantial
financial compensation by Air France, Continental
Airlines, and Goodyear, the manufacturer of the
Concorde’s tyres, provided they agreed not to
take legal action against the companies.
A new
road for
CASA medical officer, Dr David Fitzgerald, writes about
new protocols for pilots with type 1 diabetes.
Diabetes is a condition of the body’s endocrine system (the system
of hormones which controls body processes) and is characterised by
inadequate control of blood glucose levels. Overly high blood glucose,
or hyperglycaemia, damages the body; while overly low blood glucose,
hypoglycaemia, can lead to impaired judgement and coordination,
unconsciousness, seizure, and rarely, death.
There are two distinct types of diabetes. Type 1 diabetes is an
autoimmune condition. It is characterised by inadequate levels of
insulin in the blood, due to destruction of the islets of Langerhans in
the pancreas. These are the structures responsible for the production
and secretion of insulin. Type 1 diabetes tends to present early, often
in childhood, and requires treatment with exogenous insulin, or
insulin administered by injection.
The consequence of a diagnosis of Type 1 diabetes and its relationship
to aviation is an emotive issue. Several issues must be faced when
certifying a pilot who is diagnosed with diabetes. They are:
What is the risk the pilot may be suddenly incapacitated due to the
disease or its treatment?
What, if any complications of diabetes are present, and what is
the risk that they will adversely affect flight performance?
What are the accepted aeromedical standards, and does the pilot
meet those standards?
If the pilot does not meet the standards, can they be issued a
certificate, and if so under what criteria?
What are the monitoring requirements pre-, and in-flight?
What ongoing monitoring of the disease and its consequences are
required to ensure there is no appreciable risk to flight safety?
Hypoglycaemia is the most concerning risk
in the aviation setting for a diabetic. A pilot’s
in-flight hypoglycaemic episode puts the pilot,
passengers, other aircraft and people on
the ground at risk. To ensure safety, insulindependent diabetic pilots need to satisfy
themselves, and the regulator, that they
are not at risk of becoming hypoglycaemic
in flight; or if they are, that they are able to
recognise the symptoms and can reverse the
situation very quickly by taking either oral
glucose or glucagon.
An additional level of physiological protection
from hypoglycaemia in place in most people
is, unfortunately, reduced or absent in type
1 diabetics. Their adrenalin response to
hypoglycaemia compared with non-diabetics
may be reduced, and therefore of less value.
Hypoglycaemia in a non-diabetic person
causes symptoms such as hunger, tachycardia
and sweating.
However, in people with type 1 diabetes, the
level at which the adrenalin response kicks in
is reset to a lower blood-glucose level, so that
the blood-glucose level has to fall much lower
before they are aware of hypoglycaemia.
Why did CASA develop its own protocol rather than
use the FAA’s?
By this time, the diabetic may already be
subtly incapacitated due to the effect of the
low blood glucose on the brain, and may be
experiencing functional impairment without
knowing it. This is even more pronounced in
diabetics who have developed nerve damage.
Ideally, a diabetic would satisfy this
requirement by simply running their blood
sugar levels high enough to virtually make
hypoglycaemia impossible by maintaining an
inadequate insulin regime. However, this is
hard to do because of the many factors which
affect hypoglycaemia. Maintaining high blood
sugars also increases the risk of diabetic
While some jurisdictions allow the use of
insulin, (most notably the FAA, which has a
protocol for such pilots), in Australia, insulindependent diabetics have been limited
to flying with a safety pilot as a means of
risk mitigation against incapacity due to
hypoglycaemic episodes.
To review its stance on diabetes in light of
up-to-date evidence, CASA recently convened
a workshop on insulin-dependent diabetes
and aviation, to examine options for relaxing
restrictions on insulin-dependent aviators.
From that workshop a protocol was designed.
In many ways it mirrored the FAA protocol,
but had some very significant differences.
The protocol was further refined after the
workshop, and is now at a stage where CASA
is satisfied it can be safely applied.
The protocol is aimed at keeping blood glucose levels within safe
tolerances during flight (5-15mmol/L) and has strict requirements
with respect to the frequency of pre-flight and in-flight blood glucose
monitoring and glucose loading. Entry to the protocol will require
detailed reports from treating endocrinologists regarding the status
and control of the diabetes, and review of the applicant’s blood glucose
records and accident records. Key exclusion criteria include poorlycontrolled diabetes, frequent hypoglycaemic episodes, presence of
complications and demonstration of hypoglycaemia unawareness.
Certification is only to be available for Class 2 applicants for day VFR
flight only.
A key difference between the FAA and CASA protocols is that CASA’s
involves a discussion between the endocrinologist and the pilot about
diabetes control while flying. This discussion will result in a ‘safety
case’ being forwarded to CASA, and CASA’s experts reviewing the
treatment regime. Only when CASA is satisfied that the regime is safe,
will the individual be authorised to proceed to the next step.
Another key difference is that CASA will require insulin-dependent
pilots to undertake a number of ‘proving flights’ (a minimum of 15
flights - details of types of flights and durations will be tailored by
CASA to meet individual requirements) where the pilot will be required
to adhere to the protocol whilst still carrying a safety pilot. Doing this
will give CASA some measure of evidence that the protocol is effective
at maintaining blood glucose levels within safe tolerances in the
individual case. After the 15 flights, these pilots must submit details
of the in-flight monitoring to CASA, as well as an operational check by
a chief flying instructor or approved testing officer to document their
ability to comply with the practical issues of monitoring in-flight blood
glucose. CASA’s panel of doctors will then review the reports, and if
the individual is deemed to be safe whilst adopting the protocol, the
safety pilot restriction will be removed.
CASA will continue to monitor and review the individuals in the
protocol closely, and if there is evidence that the protocol does not
maintain glucose levels safely, the individual requirements in the
protocol may be modified. CASA will also carry out a periodic group
analysis to review the outcomes of the protocol.
A copy of the protocol is available in the Dame Handbook—
Endocrinology [2.4-9] available online at http://www.casa.gov.au/
If you have type 1 diabetes and would like to enter the protocol, please
get in touch with [email protected]
The most accurate and safest way to minimise
hypos is to have a device that regulates blood
sugar accurately and frequently, such as an
insulin pump which measures blood glucose
constantly, and makes small adjustments as
required to a constant infusion of insulin.
Even more desirable would be a device that
can also give a dose of glucose in the event
of undesirably low levels of blood glucose.
Unfortunately, these devices are not in
widespread use as yet.
Firstly, the FAA protocol is fairly old, and there have been significant
developments in insulins, and their delivery devices since it was
written. Secondly, the FAA protocol bases its measures to determine
success of the program on the number of incidents and accidents
among the insulin-dependent diabetics. This is an unacceptable
measure for Australia, because the Australian Civil Aviation Act
requires the regulator to make flight safety the priority, and waiting for
an incident or accident to occur is unacceptable as a control measure.
If, after maintaining a flight planned heading of 333(m) in order
to track 322(m), you determined your position as 3nm right of
track having travelled 30nm, you have experienced
(a) left drift.
(b) right drift.
(c) zero drift.
(d) some drift, but the actual amount cannot be determined
from the information given.
The cleanliness and security of the base of a VHF antenna,
where it is in contact with the aircraft fuselage, is critical to
the functioning of the antenna because any increased electrical
resistance in this area due to corrosion
(a) severely reduces antenna efficiency.
(b) reduces the shielding effect of the fuselage, which is
particularly noticeable on transmit.
(a) ready to join the circuit, overflying.
(c) reduces the shielding effect of the fuselage, which is
particularly noticeable on receive.
(c) inbound, base, final.
(d) increases the parasitic current losses in the shield of
the feeder cable.
When operating in the vicinity of a non-towered aerodrome,
other than when joining on base leg or final, pilots are expected
to make the following minimum broadcasts: intending to takeoff
(taxiing call), intending to enter the runway,
(b) inbound, ready to join the circuit, base.
(d) inbound, overflying, base, final, clear of the runways.
In an ATC environment, aircraft acknowledging a clearance
correctly would have the aircraft callsign at
A broadcast in the vicinity of a non-controlled aerodrome,
for example Snake Gully, should begin with
(a) ‘Snake Gully traffic’ and end with ‘Snake Gully traffic’.
(b) ‘Snake Gully traffic’ and end with just ‘Snake Gully’.
(a) the beginning of the transmission.
(c) ‘All stations Snake Gully’ and end with ‘Snake Gully’.
(b) the end of the transmission.
(d) ‘All stations Snake Gully’ and end with ‘Snake Gully traffic’.
(c) either the beginning or the end.
(d) both the beginning and the end and with the word ‘traffic’
at the beginning.
(a) licensed aerodromes.
(b) aerodromes designated as CTAF(R).
With respect to horizontal distance, in the vicinity of an
uncontrolled aerodrome is defined as within
(c) all certified, registered, and military aerodromes and
at certain designated aerodromes.
(a) 3 nm or less.
(d) all security controlled aerodromes.
(b) 5 nm or less.
(c) 8 nm or less.
(d) 10 nm or less.
Carriage and use of radio is mandatory at
A broadcast relating to a non-controlled aerodrome must
include: the name of the aerodrome,
(a) whether VFR or IFR.
(b) and the distance from or the ETA at the aerodrome
(c) the distance from the aerodrome.
(d) the aircraft type and call sign, the aircraft position and
ntrolled aerodrome should
A departure from a non-co
made by
the runway heading when
(a) turning 45 degrees from
700 ft above the aerodrome
the runway heading in the
(b) turning 45 degrees from
n reaching 700 ft above the
direction of the circuit whe
aerodrome elevation.
standard circuit legs .
(c) extending one of the
when on
the direction of the circuit
(d) turning 45 degrees in
any leg.
a non-controlled aerodrome
10. The overfly height of
usually be no low
(a) 150 0ft above aerodrome
(b) 150 0ft above MSL.
ome elevation.
(c) 200 0ft above the aerodr
(d) 200 0ft above MSL.
for tyre inflation
Dry nitrogen is often used
e gas
on risk from the combus tibl
(a) to minimise the explosi
atures .
which is liberated from the
loss due to diff usion through
(b) to reduce the pressure
(a) galling.
a is also
lage-moun ted VHF antenn
The structure below a fuse
this can
, for
termed the ground plane and
be regarded as
t widens the bandwidth .
(a) an antenna element tha
t narrow s the bandwidth .
(b) an antenna element tha
(c) the other half of the ant
spurious radiation.
(d) a shield that reduces
a pitot
itoring the curren t flow into
3. A typical device for mon
head heating elemen t is a
(b) brinelling.
(c) skidding
(d) peening.
(a) shunt relay.
on an AC sys tem .
(b) a curren t transformer
on a DC sys tem .
(c) a curren t transformer
(d) a volt meter.
ing of
, damage or wear consist
Referring to a ball bearing
h forces
circular indent ations on the
l, or high static loads,
on inst allation, or remova
sys tem has two elemen ts
Where a windshield heating
or paralle
may be connec ted in series
one elemen t during paralle
and low heat, a failure of
cracking due to a high the
(a) may cause windshield
ted and unh
gradien t bet ween the hea
uences, other than heater
(b) will have no potent ial
failure in the ser ies mode.
consequences, other than
(c) will have no potent ial
ed area.
visibilit y through the unheat
consequences .
(d) will have no potent ial
ked for some
h a wooden propeller is par
6. When an aircraft wit
should be
time, the propeller blade
nes ting birds.
(a) ver tically to discourage
the risk of injury.
(b) ver tically to minimise
age nes ting birds.
(c) hor izon tall y to discour
alance due to water
(d) hor izon tall y to avoid imb
accumulating in the low
of pressure wit h temperatu
(c) to reduce the change
of a magnesium fire.
(d) to reduce the probability
You are airborne from runway 27 at Melbourne (YMML) having
been cleared via ‘DOSEL SEVEN DEPARTURE’ to 9000ft with
an initial level of 5000ft. Melbourne tower advise you of the
frequency transfer to ‘Departures. What will be in this call to
You are setting course outbound during tower hours from
Alice Springs (YBAS) having been cleared via the ‘SCOTI ONE
DEPATURE’ to 8000ft. What will be the content of the report to
Alice Tower?
You are setting course outbound from Wynyard (YWYY)
tracking via ‘CAMUS’ en route to Moorabbin (refer ERC L1) and
climbing to 8000ft, presently passing 2500ft. What will be in the
departure report and on what frequency?
You have departed Swan Hill (YSWH) tracking along V255 for
Wagga Wagga (YSWG) (refer ERC L2). You have levelled out in
the cruise at your planned level of 9000ft. Is a report required
and if so, what content?
You are inbound to Alice Springs (YBAS) along W584 from
Broken Hill (YBHI) at 8000ft and in VMC. Approaching the CTA
step you are instructed to call Alice Tower for clearance. What
will be the content of this call?
(Refer to ERC L2). Your position is overhead ‘NEVIS’ on H345
tracking Melbourne (YMML) to Adelaide (YPAD) at 8000ft. A
position report is required. What will be the content of this
You are established on downwind for runway 35 at Echuca
(YECH) and elect to cancel SARWATCH at this time. What is the
content of this call and on what frequency?
Prior to engine start, a rough check of the accuracy of the
manifold pressure gauge may be made by comparing the gauge
reading with the
(a) QFE on the basis that 1013 HPa = 29.5in Hg.
(b) QNH on the basis that 1013 HPa = 29.5in Hg.
(c) QFE on the basis of 1000 HPa = 29.52 or 1016 HPa =
30.00in Hg.
(d) QNH on the basis of 1000HPa = 29.52 or 1016 HPa =
30.00in Hg.
A spark plug gap of 0.026” is closest to
(a) 0.015 mm
(b) 0.15 mm
(c) 6.6 mm
(d) 0.66 mm.
The apparent drift of a directional gyro heading indicator due
to the earth’s rotation, if uncorrected, is at a maximum of
(a) 5 degrees per hour at the poles.
(b) 5 degrees per hour at the equator.
(c) 15 degrees per hour at the poles.
(d) 15 degrees per hour at the equator.
10. When two wheels are installed on one undercarriage leg, an
under-inflated tyre on one wheel
(a) cannot be reliably detected visually.
(b) can be readily detected by additional bulging of the
inboard wall.
(c) can be readily detected by additional bludging of the
outboard wall.
(d) can be readily detected by comparing the top camber.
10. You are tracking along W188 between Eildon Weir (ELW) and
‘COLDS’, destination Essendon (YMEN), (Refer ERC 2) at 10,000
in cloud. Melbourne Centre have you radar identified and have
issued your clearance. At 35 DME ML, Centre instructs you to
call Melbourne Approach. What will be the content of this call
to Approach?
Radio Phraseology
In each of the following situations (1-10) match from the list of
possible calls (A-U) the appropriate radio report. For simplicity,
use the callsign Alpha Bravo Charlie in each case.
You are taxiing for runway 03 at Latrobe Valley (YLTV),
destination Essendon (YMEN). The CTAF broadcast has been
given. What is the content of the taxi report to ATC and on
what frequency?
You are ready to taxi at Essendon (YMEN), destination Albury
(YMAY) during tower hours. What is the content of this call?
Contacting Approach
(a) ‘ML Approach, ABC maintaining one zero thousand in cloud,
received (ATIS)’.
(b) ‘ML Approach, ABC three five DME Melbourne north east
maintaining one zero thousand in cloud, received (ATIS)’.
SAR cancellation
(c) ‘ML Centre ABC Circuit area Echuca, cancel SARTIME’.
Frequency 134.325
(d) ‘ML Centre ABC Circuit area Echuca, cancel SARWATCH’.
Frequency 126.8
Position report
(e) ‘ML Cen tre ABC, “NE
VIS ” at (minutes) 800 0ft Bor
der tow n
at (minutes) ’.
(f) ‘ML Cen tre ABC, over
“NE VIS ” at (minutes) 800
0ft nex t
position Border tow n at (mi
nutes) following poin t “DU
KES ”.’
Level maintaining
(g) Report required. It wou
ld be ‘ML Cen tre ABC mai
900 0.’
(h) Report not required.
Departure & airborne rep
(i) ‘ML Cen tre ABC departe
d Wy nyard at (minutes) trac
338 passing 250 0 climbing
800 0, “CA MUS” at (minut
Frequency 122 .6.
(j) ‘ML Cen tre ABC departe
d Wy nyard at (minutes) trac
to “CA MU S” climbing 800
0.’ Frequency 122 .6.
(k) ‘ABC departed (minut
climbing to 800 0, est imating
SCO TI at (minutes) ’.
(l) ‘Alice Tower, ABC dep
arted (minutes) tracking 346
climbing 800 0’.
(m) ‘ML Departures, ABC
passing (alt itude to the nea
res t
100 ft) climbing 500 0’.
(n) ‘ML departures, ABC
climbing 500 0 passing (alt
to the neares t 100 ft)’.
(p) ‘Essendon Ground ABC
(persons on board if not RPT
received (AT IS) IFR to Alb
ury, reques t tax i’.
(q) ‘Essendon Ground ABC
IFR to Albury via (tracking
poin t/s)
received (AT IS) reques t tax
i clearance’.
(r) “ML Cen tre ABC (aircra
ft type) I.F.R tax iing Lat rob
e Valley
for Essendon Runway 03”
, Frequency 124 .0.
(s) ‘ML Cen tre ABC (aircra
ft type) (persons on board)
tax iing Lat robe Valley for
Essendon Runway 03’, Fre
124 .0.
Con tac ting a ‘procedural
(non-radar)’ tower
(t) ‘Alice Tower, ABC (dis
tance) DME on the 137 rad
maintaining 800 0 visual rec
eived (AT IS) reques t clea
(u) ‘Alice Tower, ABC (dis
tance) maintaining 800 0 visu
received (AT IS) reques t clea
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(o) ‘ML departures ABC
passing (alt itude to the nea
res t 100 ’) climbing 500 0ft.
Taxi report
5 6
12 13 14
18 19 20 21
25 26 27 28
1 2 3
8 9 10
15 16 17
22 23 24
29 30 31
2 3
4 5 6
9 10
11 12 13 14
16 17 18 19 20 21
23 24 25 26 27 28
30 31
6 7
13 14
20 21
27 28
1 2 3 4
8 9 10 11
15 16 17 18
22 23 24 25
29 30
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Flying Ops
1. (a) heading 333(m) and TMG
328(m) drift 2 degrees left.
2. (a) the electrical integrity of
the antenna mounting to the
fuselage is critical.
3. (b)
4. (d)
5. (a) CAAP 166-1(0) table 2
6. (b) ‘Traffic’ is required
at the beginning of the
transmission, but should not
be used at the end of the
7. (c) CAR166D, CASR 139.B
and 139.C.
8. (d) CAR166C.
9 (c) CAAP 166-1(0) para. 4.4
10. (c) CAAP 166-1(0) makes this
IFR Operations
Question Answer
1 (s) AIP GEN 3.4-47 Para 5.14.4 Item 1 and AIP ENR
1.1-72 Para 42.2
2 (p) AIP GEN 3.4-47 Para 5.14.4 Item 1
3 (m) AIP ENR 1.1-14 Para 8.1 and AIP GEN 3.4-55
Para 5.14.8 Item 2
4 (k) AIP GEN 3.4-55 Para 5.14.8 Item 3 and AIP ENR
1.1-15 Para 8.2.1 and 8.2.2
5 (i)
AIP GEN 3.4-56 Para 5.14.8 Item 4 and AIP ENR
1.1-73 Para 43.3
6 (g) AIP ENR1.1-45 Summary and AIP ENR
1.1-74 Para 44.4
7 (t)
AIP ENR1.1-20 Para 12.1.6a and c
8 (e) AIP GEN 3.4-104 Appendix 2
9 (d) AIP ENR1.1-84 Para 52.1.2
10 (a) AIP ENR 1.1-20 Para 12.1.6b
1. (a) the combustible gas
emitted from heated
rubber is called isoprene.
2. (c) the importance
of the ground plane,
and particularly the
cleanliness of the
mounting to it, is often
3. (b) a current transformer
connected to a warning
system is mostly used on
AC systems.
4. (b)
5. (a)
6. (d)
7. (c)
8. (d)
9. (c)
10. (a)
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