‘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 Class D & non-towered aerodromes eLearning Online tutorials at your own pace, at any time. Complete each topic in 5-10 minutes. visit now www.casa.gov.au/elearning For general enquiries regarding the online tutorials please email [email protected] Be e heard h ard Be B e heard, hear hea he h ea e B h Be he hea heard ear eaarrden ea se see een n n,e a fe bbe be e seen, se s ee en, en e be sa safe safe be safe b ssa ae Be heard, be seen, be safe CONTENTS Features ISSUE NO. 75, JUL-AUG 2010 DIRECTOR OF AVIATION SAFETY, CASA John McCormick MANAGER, SAFETY PROMOTION Gail Sambidge-Mitchell 8 WRITER, FLIGHT SAFETY AUSTRALIA Robert Wilson DESIGNER, FLIGHT SAFETY AUSTRALIA Fiona Scheidel ADVERTISING SALES P: 131 757 or E: [email protected] CORRESPONDENCE Flight Safety Australia GPO Box 2005 Canberra ACT 2601 P: 131 757 F: 02 6217 1950 E: [email protected] W: www.casa.gov.au CHANGED YOUR ADDRESS? To change your address online, go to http://casa.gov.au/change For address-change enquiries, call CASA on 1300 737 032 DISTRIBUTION 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. EDITOR, FLIGHT SAFETY AUSTRALIA Margo Marchbank 20 ‘Wake in Fright’ Wake turbulence is your invisible enemy. 24 ‘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. CONTRIBUTIONS Stories and photos are welcome. Please discuss your ideas with editorial staff before submission. Note that CASA cannot accept responsibility for unsolicited material. All efforts are made to ensure that the correct copyright notice accompanies each published photograph. If you believe any to be in error, please notify us at [email protected] PRINTING IPMG (Independent Print Media Group) NOTICE ON ADVERTISING Advertising appearing in Flight Safety Australia does not imply endorsement by the Civil Aviation Safety Authority. Warning: This educational publication does not replace ERSA, AIP, airworthiness regulatory documents, manufacturers’ advice, or NOTAMs. Operational information in Flight Safety Australia should only be used in conjunction with current 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. Regulars 2 16 18 18 31 33. SDRs 38. Directives 46 Close Calls © Copyright 2010, Civil Aviation Safety Authority Australia. Copyright for the ATSB and ATC supplements rests with the ATSB and Airservices Australia respectively– these supplements are written, edited and designed independently of CASA. All requests for permission to reproduce any articles should be directed to FSA editorial (see correspondence details above). Registered–Print Post: 381667-00644. ISSN 1325-5002. COVER: Fiona Scheidel Flight Bytes–aviation safety news ATC Notes–news from Airservices Australia Accident reports–International Accident reports–Australian Airworthiness pull-out section 46 ’Thunderstorms in area’ 48 ‘Red means danger’ 51 ‘Fail safe’ 52 66 71 70 ATSB supplement Av Quiz Quiz answers Calendar POST HASTE 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. CHANGES FOR AIRSERVICES READERS This is the last edition of Flight Safety Australia that Airservices Australia employees will receive without directly subscribing to the magazine. FSA JUL-AUG10 2 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. WELCOME, MAAT 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. FLIGHT TRAINING AUSTRALIA ,QQRYDWRUVLQ3URIHVVLRQDO3LORW7UDLQLQJ 2010 FLYING COURSES Course Price Commercial Pilot – CPL-A from '3&&JGCFUGVHQTPGYDQQMKPIUOCFGKP,WPGQT,WN[ $59,750* Multi Engine Command Instrument Rating (MECIR) $12,850* Flight Instructor Course $16,850* from *Visit our website www.ﬂyfta.com for full details PLACES ARE LIMITED – BOOK NOW ph: (07) 3715 4000 email: [email protected] FLIGHT TRAINING AUSTRALIA ) Queensland’s largest ﬂight training organisation ) Proudly owned and managed by airline pilots CRICOS Provider code: 01208J RTO 32009 www.ﬂyfta.com 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 available. 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. ,QQRYDWRUVLQ3URIHVVLRQDO3LORW7UDLQLQJ 2010 COURSE DATES Course Dates Price CPL Theory 28 June, 16 August, 11 October $2950* IREX Theory 5 July, 2 August $1250 *All 7 subjects – individual subjects may be purchased, see www.ﬂyfta.com for full details PLACES ARE LIMITED – BOOK NOW ph: (07) 3715 4000 email: [email protected] FLIGHT TRAINING AUSTRALIA ) Queensland’s largest ﬂight training organisation ) Proudly owned and managed by airline pilots CRICOS Provider code: 01208J RTO 32009 www.ﬂyfta.com 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. SPORT AIRCRAFT & ‘TRANSITION TRAINING’ 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). 3 FLIGHT BYTES FLIGHT TRAINING AUSTRALIA SULLENBERGER RIGHT TO DITCH ROBOT ROCKS 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. FSA JUL-AUG10 4 State of the Art, Two Place, Touring and Training Aircraft – Certiﬁed IFR (FAR Part 23) 7Safety – robust modular design with incredible visibility 7Performance – advanced aerodynamics with high manoeuverability 7Comfort – 48” wide cockpit with huge baggage space 7Utility – Useful load after full fuel 192 kg 7Simplicity – FADEC Engine with digital engine monitoring display 7Economy – 132 knots cruise at 23 litres per hour, up to 500 nm range plus reserves 7Affordability – low purchase price and low operating costs Book a demonstration ﬂight now! Call 0419 355 303 Contact Nigel Hutchinson–Brooks Liberty Aircraft Company Pty Ltd A.C.N. 118 727 889 Tel 03 5662 5658 Fax 03 5662 5179 Email [email protected] Details at www.libertyaircraft.com BUSINESS GOING BUST 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. BEACON FOR THE FEW 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 generations. 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?) 5 FLIGHT BYTES 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 Britain. AIR NORTH REPORT 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 exercise. HELP US to HELP YOU FSA JUL-AUG10 6 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. ɕǸȘȐɕȰȨȐɕȘɄɑǸȵȵ 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. PROMISING START 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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ollowing 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 (CASA). 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 accidents. 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. 9 ACCIDENT INVESTIGATION 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.’ FSA JUL-AUG10 10 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 investigations.’ ‘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. 11 TELLING THE STORY (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). ACCIDENT INVESTIGATION 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. FSA JUL-AUG10 12 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 says. 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 walking through the silence of the forest approaching a crash site; it ’s an eerie sensation.’ 13 ACCIDENT INVESTIGATION ‘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. FSA JUL-AUG10 14 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 experts. 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 Internet 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/ The_Evolution_of_Flight_Data_Analysis_Neil_Campbell.pdf Aviation Safety Network: www.aviation-safety.net Books 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. 15 ACCIDENT INVESTIGATION 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? Y 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 FSA JUL-AUG10 16 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. Unless ‘CLEARED TO LAND’, ‘CLEARED TOUCH AND 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. 17 ATC NOTES 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 FSA JUL-AUG10 18 Date Aircraft Location Fatalities Damage Description 30 Mar Antonov 74 Ivanovo, Russia 0 Substantial Aircraft overran runway after take-off was aborted due to engine failure. 10 Apr Tupolev 154M Smolensk, Russia 96 Destroyed 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 Sabreliner near Blue Ridge, Georgia, USA 4 Destroyed 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, Indonesia 0 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 International Airport, Mexico 7 Destroyed 19 Apr de Havilland Canada DHC-6 Twin Otter 300 Kangel Danda Airfield, Nepal 0 Substantial Aircraft diverted by weather to remote mountainous airstrip where it was damaged in forced landing. 21 Apr Antonov 12BP Barangay Laput, Philippines 3 Destroyed 25 Apr Bell UH-1H Near Wellington New Zealand 3 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 Republic 0 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, Ukraine 0 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 Destroyed 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, Suriname Destroyed Aircraft departed from cruise flight and crashed in a wooded area of eastern Suriname. 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, Afghanistan 44 Destroyed 19 May Embraer EMB110 Bandeirante near Cascavel Airport, Brazil 0 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 Mangalore-Bajpe Airport, India 166 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.' 8 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 fog. 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 Date Aircraft Location Injuries A/C Damage Description 27 Mar North American Aviation AT-6D Harvard Piper PA-30 Twin Comanche Jamestown (ALA), SA Minor Serious Perth Aerodrome, Fatal E M 43Km, WA Serious 31 Mar Robinson R44 near Roper Bar (ALA), NT Nil Serious 1 Apr Piper PA-28-161 Warrior Moorabbin Aerodrome, VIC Nil Serious 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 Busselton Aerodrome, WA Nil Serious 4 Apr Victa Airtourer 115/A1 Serious 5 Apr Beech C24R Sierra Hobart Nil Aerodrome, 255° M 17Km, TAS Tyabb (ALA), VIC Nil 7 Apr Cessna 172N Skyhawk near Epic Energy Five (ALA), SA Nil Serious 10 Apr Cessna A188B/ A1 AgTruck Cessna 152 Fatal Unknown 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. Nil Serious The aircraft landed heavily damaging the nose landing gear. Nil Serious Nil Serious Mareeba Nil Aerodrome, S M 185Km, QLD Rolleston (ALA), S Nil M 25Km, QLD Serious 11 Apr 13 Apr Ayr (ALA), W M 9Km, QLD Bankstown Aerodrome, NSW Cessna 180K Coonamble Aerodrome, NW M 22Km, NSW Cessna 337H Goolwa (ALA), Super Skymaster 118° M 12Km, SA Serious Nil Serious Nil Serious Nil Serious The aircraft landed with the landing gear retracted. Minor Serious 11 May Air Tractor AT-502 Hillston (ALA), 057° M 16Km, NSW Nil Serious 12 May Eagle Aircraft Australia Eagle X-TS 150 Bell 206B Jetranger Jandakot Aerodrome, WA Serious Serious 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 continuing. During agricultural spraying operations, the helicopter struck a powerline and hit the ground. 18 Apr 19 Apr Schweizer 269C-1 22 Apr Cessna 180A 22 Apr Robinson R22 Beta 28 Apr 10 May 11 May 14 May 20 May Bell 206L-3 Longranger 21 May Piper PA-31-350 Chieftain Bell 206B (III) Jetranger 27 May 30 May Robinson R22 Beta Serious Mackay Nil Aerodrome, 260° M 30Km, QLD Latrobe Valley Fatal Aerodrome, 206° M 37Km, VIC Marree (ALA), SA Nil Serious Port Pirie Aerodrome, 016° M 19Km, SA Nil Serious Kowanyama Aerodrome, S M 22Km, QLD Serious Serious Serious Serious 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. 19 ACCIDENTS Alexandria Station (ALA), 148° M 62Km, NT Amateur-built Williamtown Rebel Aerodrome, ENE M 19Km, NSW Piper PA-44-180 Ballarat Seminole Aerodrome, VIC Amateur-built 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. W e k a r f in t h ig FSA JUL-AUG10 20 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 21 WAKE TURBULENCE 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 approach. 22 The light aircraft crosses the wake vortices at right angles, resulting in sudden pitching that can cause structural damage to the aircraft. FSA JUL-AUG10 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. 23 WAKE TURBULENCE Illustrations: Juanita Franzi, Aero Illustrations *7*<)1<¼;)>1)<176<0-7:A;+0774 Hangar N Wirraway Drive, Redcliffe Airport. QLD 4021 Check out our web page at www.bobtait.com.au BAK & PPL All CPL subjects plus IREX Courses available full-time or by home study 32%R[5HGFOLIIH1RUWK4/' 3 ) :ZZZEREWDLWFRPDX (EREWDLW#EREWDLWFRPDX a MATTER of DEGREE FSA JUL-AUG10 24 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 preventative medicine becoming key, and we would say the role of the airline, pilot has also evolved similarly.’ 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. e 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 something that separates us from the competition. 25 PILOT UNIVERSITY 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 FSA JUL-AUG10 26 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 airstrips. ‘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 training. 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.’ 27 PILOT UNIVERSITY '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 followership'. 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.’ Vnqjhmfhm`uh`shnmld`mrxntg`udsnadoqnfqdrrhud`mcekdwhakd-Sd`bghmf`uh`shnm hrmncheedqdms-Sg`sÔrvgxFqheehsgTmhudqrhsxneedqr`uh`shnmoqnfq`lro`qs,shld nqetkk,shld+uh`sgdHmsdqmds`rvdkk`rnmb`lotrNtqtmcdqfq`ct`sd`mconrsfq`ct`sdoqnfq`lrhm`uh`shnml`m`fdldmsneedqchqdbs dmsqxenq`uh`shnmoqnedrrhnm`krvhsgnqvhsgntsoqduhntrenql`k`b`cdlhbpt`khehb`shnmr- SgdA`[email protected]`shnmL`m`fdldmsoqnfq`lhrcdrhfmdcsncdudknod`qkx`uh`shnm oqnedrrhnm`krvgn`qd`hlhmfenq`b`qddqhmsgdhmctrsqx-Hshrrodbhehb`kkxs`hknqdcenq hmchuhct`krgnkchmfnqvhsg`lahshnmrsnv`qcrrtodquhrnqx`mcl`m`fdldmsonrhshnmr- 28 SgdFq`ct`sdBdqshehb`sd`mcL`[email protected]`shnmL`m`fdldmsoqnfq`lr`qdcdrhfmdcenq lnqddwodqhdmbdc`uh`shnmrtodquhrnqr`mcl`m`fdqrsntmcdqs`jdrstchdrsg`svhkk`rrhrshm qd`bghmfsgdghfgdrskdudkrnel`m`fdldms-Dmsqxl`xada`rdcnm`b`cdlhbnqoqnedrrhnm`k pt`khehb`shnmr-Rths`akxdwodqhdmbdc`hqkhmdb`os`hmr`mcl`m`fdqrl`xf`hmchqdbsdmsqx- FSA JUL-AUG10 Snqd`bgmdvgdhfgsrhmxntq`uh`shnmb`qddquhrhsfqheehsg-dct-`t.`uh`shnm BQHBNR//122D^itmhnqFT13818^@ Reach new heights with a degree in aviation management. PULL-OUT SECTION 29 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 activities. how old is too old ? AIRWORTHINESS ‘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. 30 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. FSA JUL-AUG10 PULL-OUT SECTION 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 different on aircraft than on cars. 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 developments. 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 directives. 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. 31 AIRWORTHINESS 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: PULL-OUT SECTION 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 systems. PULL-OUT SECTION 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. FSA JUL-AUG10 32 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 Airworthiness & Sustainment Conference to be held at the Brisbane Convention and Exhibition Centre (BCEC) from 17–19 August 2010. SELECTED SERVICE DIFFICULTY REPORTS 1 Apr 2010 – 14 May 2010 Note: Occurrence figures not included in this edition. AIRCRAFT ABOVE 5700KG 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 retracted. 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 continuing. 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 continuing. 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 continuing. 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 smell. 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 times. 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 motor. 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 clogged. 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 damage. Boeing 7773ZGER Galley oven dirty – overheated and smoking. Ref 510010441 Mid galley No2 oven overheated and smoking due 33 AIRWORTHINESS Airbus A330303 Aft galley circuit breakers covered by galley ceiling panel. Ref 510010331 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 510010477 No7 flight spoiler actuator faulty. Vibration experienced when right turn aileron applied. Actuator rod-end bolt also replaced during actuator replacement. 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. PULL-OUT SECTION 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. SELECTED SERVICE DIFFICULTY REPORTS ... CONT 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. PULL-OUT SECTION 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. FSA JUL-AUG10 34 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 continuing. 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 continuing. P/No: 1095123. Cessna 152 Alternator brushes worn. Ref 510010321 Alternator brushes worn out. Alternator failed in flight. 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. AIRCRAFT BELOW 5700KG 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 510010311 (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 unserviceable. 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 continuing. 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. SELECTED SERVICE DIFFICULTY REPORTS ... CONT 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 loose. 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. ROTORCRAFT 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 attachment. 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. 35 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 removed. P/No: 350A33105803. TSN: 2,002 hours/2,700 cycles. AIRWORTHINESS 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 unserviceable. P/No: 9603002104. TSN: 7,880 hours/10,497 cycles. Correct part number 27-24127-029. TSN: 16,243 hours/12,575 cycles. PULL-OUT SECTION Cessna 404 Wing panel disbonded. Ref 510010288 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. PULL-OUT SECTION SELECTED SERVICE DIFFICULTY REPORTS ... CONT FSA JUL-AUG10 36 Eurocopter AS350BA Engine startergenerator drive shaft fractured. Ref 510010472 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 fairing. 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. PISTON ENGINES Continental GTSIO520M Engine fuel injection fuel ﬂow line worn. Ref 510010489 LH engine fuel injection system fuel flow line chafed. 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 cylinder. 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. TURBINE ENGINES 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 lobe. 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. SELECTED SERVICE DIFFICULTY REPORTS ... CONT GE CFM567B Engine accessory drive bearing failed. Ref 510010353 No2 engine aft sump chip detector contained three metal flakes. Analysis identified flakes as bearing material. PWA PW123E Engine HBOV leaking. Ref 510010433 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 510010274 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 510010270 No3 engine failed. Engine stalled and EGT overtemp. Investigation continuing. Rolls Royce RB211524G Engine failed. Ref 510010299 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. COMPONENTS 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 510010358 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. I[hl_Y[:_\ÓYkbjoH[fehji TO REPORT URGENT DEFECTS 97BB0')'-+-<7N0&(,('-'/(& 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 37 AIRWORTHINESS Lycoming LTS101600A3A Engine startergenerator drive shaft fractured. Ref 510010472 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 contamination. 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. PULL-OUT SECTION GE CFM563B Thrust reverser failed. Ref 510010455 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. PROPELLERS APPROVED AIRWORTHINESS DIRECTIVES 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 Helicopters 2010-0023R1 - Engine and Main Gearbox Cowling Learjet 45 Series Aeroplanes 2010-06-13 - Flap Actuator Ballscrew Assembly Sleeves 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 Aeroplanes AD/A320/225 Amdt 1 - Elevator Servo-Control Rod Eye-End - CANCELLED 2010-0046 - Elevator Servo-Control Rod Eye-end 12 - 25 March 2010 PULL-OUT SECTION Eurocopter BO 105 Series Helicopters 2010-0049 Correction - Cyclic-Stick Locking Device FSA JUL-AUG10 38 Eurocopter SA 360 and SA 365 (Dauphin) Series Helicopters 2010-0052-E - Equipment / Furnishings - External Life Raft Mooring Line Attachment - Inspection / Rework 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 Device Pratt and Whitney Turbine Engines - JT8D-200 Series 97-17-04R1 - Front Compressor Hub Part 39 - Below 5700kg Part 39 - Equipment Beechcraft 55, 58 and 95-55 (Baron) Series Aeroplanes 2010-06-02 - Installation of Stand-off Hardware Radio Communication and Navigation Equipment 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 Aeroplanes 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 Restriction 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 Autopilot 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 Helicopters 2010-0043R1-E - Hydraulic Power - Hydraulic Pumps - Identification / Replacement Eurocopter BK 117 Series Helicopters AD/GBK 117/19 - Rotor Control Bearing Attachment - CANCELLED 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 - CANCELLED 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 Aeroplanes 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 Beams 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 Reduction APPROVED AIRWORTHINESS DIRECTIVES ... CONT 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 Equipment 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) Turbochargers 2010-07-08 - Rebuilt Kelly Aerospace Turbochargers 9 April 2010 - 22 April 2010 Part 39 - Rotorcraft Part 39 - Below 5700kg Gippsland Aeronautics GA8 Series Aeroplanes 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 Aeroplanes AD/A320/19 Amdt 1 - Hydraulic Fire Shut-Off Valve AD/A320/146 Amdt 3 - Airworthiness Limitation Items - CANCELLED AD/A320/163 Amdt 1 - Wing Trailing Edge Cable Routes - CANCELLED 2007-0276R1 Correction 2 - 80VU Rack Attachments 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 - CANCELLED 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 / Replacement 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 Series 2010-01-04 (Correction) - Inspections of Fan Blades and Actuator Head Hoses General Electric Turbine Engines - CF700 Series 2010-09-08 - Combustion Liner Cracks 39 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 Equipment 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 - CANCELLED 2006-0357R1 - Fuselage Frame 5700 Middle Section Eurocopter AS 350 (Ecureuil) Series Helicopters 2010-0082-E (Correction) - Tail Rotor - Tail Gearbox (TGB) Control Lever - Inspection / Rework / Replacement Eurocopter AS 355 (Twin Ecureuil) Series Helicopters 2010-0082-E (Correction) - Tail Rotor - Tail Gearbox (TGB) Control Lever - Inspection / Rework / Replacement Part 39 - Piston Engines Volkswagen Derivative Piston Engines AD/VW/1 - Assurance Inspection - CANCELLED General Electric Turbine Engines - CJ610 Series 2010-09-08 - Combustion Liner Cracks Rolls Royce Germany Turbine Engines - BR700 Series 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 / Replacement 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 Helicopters 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 AIRWORTHINESS Bell Helicopter Textron Canada (BHTC) 430 Series Helicopters CF-2010-11 - Transmission Planetary Pinion Gear Damage 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 PULL-OUT SECTION 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 Calibration CF-2009-08R1 - Pressurisation System: Cabin Pressure Control (CPC) uints and Cabin Pressure Control Panel (CPCP) Deficiency PULL-OUT SECTION when it all comes FSA JUL-AUG10 40 unstuc k 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 strength.’ 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. 41 AIRWORTHINESS 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.’ PULL-OUT SECTION ‘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. APPROVED AIRWORTHINESS DIRECTIVES ... CONT Part 39 - Below 5700kg Embraer EMB-110 (Bandeirante) Series Aeroplanes 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 PULL-OUT SECTION Gippsland Aeronautics GA8 Series Aeroplanes AD/GA8/5 Amdt 4 - Horizontal Stabiliser Inspection FSA JUL-AUG10 42 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 Assembly 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 Failure 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 Series 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 / Implementation Bell Helicopter Textron 205 Series Helicopters 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 Aeroplanes 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 Aeroplanes 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 Failure 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 Card 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 Series 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 CLOSE $500 CALL? 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. 43 ADVERTISING AOC HOLDERS’ SAFETY QUESTIONNAIRE 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 information. 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 6% RPT 3% QUESTIONNAIRE RESULTS 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% Training 33% 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 operations. Medical 7% 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 50% Power driven aeroplane Rotorcraft 40% Proportion of aircraft FSA JUL-AUG10 44 30% 20% 10% 0% <1970 1970-79 1980-89 Decade of manufacture 1990-99 2000-10 STABILITY OF OPERATIONS PERCEIVED SAFETY RISKS 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 70% 60% 50% 25% 20% 15% 10% 5% 0% ‘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. 40% 30% 20% 10% 0% EASIER than usual Above average HARDER than usual SATISFACTION WITH CASA Recruiting - 2009 and 2010 2009 2010 Proportion of valid responses 60% 50% 40% 30% 20% 10% 0% 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] 45 AOC SURVEY 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 30% Phillip Zamagia s found himself having to make split-second de a cision after be ing fooled by ra pidlyy changing tropic al weather. 46 FSA JUL-AUG10 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 menacing. 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 lessons. 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 second). 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 overload! 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 disastrous. 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 decision. 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 haphazard. 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. 47 CLOSE CALLS 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. FSA JUL-AUG10 48 A young engineer, who followed his training and d stood his groun when others assured him there was no problem, may d well have save his airline from disaster. 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 afternoon. 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. 49 CLOSE CALLS 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 counterfeit. FSA JUL-AUG10 50 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 aircraft. 51 CLOSE CALLS 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. ;OL(\Z[YHSPHU Chief Commissioner’s message 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. FSA JUL-AUG10 52 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 incidents 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. T 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 Q Martin Dolan Chief Commissioner aviation_statistics.aspx> (]PH[PVU:HML[`0U]LZ[PNH[VY Airport introduces safety innovation O 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. ATSB employed two motorised drums on a swivel base, to hold the two 36 m by 1.8 m lengths of painted rubber. 53 Investigation briefs FSA JUL-AUG10 54 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 length. 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 pressurisation. 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 landing. 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 55 ATSB 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. FSA JUL-AUG10 56 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 others. If you wish to obtain advice or further information, please contact REPCON on 1800 020 505. Unsafe practices at an aerodrome R200900006 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 turbulence R200900075 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; and (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 stage. 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 crew. 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) 57 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 117 Total 2008 121 Total 2009 118 Total 2010 a 55 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. ATSB CASA has reviewed the report and will request that the operator review their turbulence procedures in accordance with Civil Aviation Regulation 251 s1(d). FSA JUL-AUG10 58 repercussions of the CONCORDE DISA STER 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. 59 CONCORDE DISASTER AirFrance inaugurated its supersonic 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. FSA JUL-AUG10 60 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 runway altogether and heading directly towards an arriving Air France Boeing 747 waiting on an adjoining taxiway, the co pilot called out in alarm, 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 envelope. 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. 61 CONCORDE DISASTER 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 Administration. 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. 62 FSA JUL-AUG10 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 calculations. 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 63 CONCORDE DISASTER 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 diabetics? CASA medical ofﬁcer, Dr David Fitzgerald, writes about new protocols for pilots with type 1 diabetes. FSA JUL-AUG10 64 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 complications. 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/ wcmswr/_assets/main/manuals/regulate/dame/080r0204.pdf If you have type 1 diabetes and would like to enter the protocol, please get in touch with [email protected] 65 TYPE 1 DIABETES 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. FLYING OPS 1. 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. 2. FSA JUL-AUG10 66 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 5. (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. 3. 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. 6. 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. 4. 7. (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 8. 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 intentions. 9. be ntrolled aerodrome should A departure from a non-co made by reaching the runway heading when (a) turning 45 degrees from n. atio elev 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 n tha er usually be no low elevation. (a) 150 0ft above aerodrome should (b) 150 0ft above MSL. ome elevation. (c) 200 0ft above the aerodr (d) 200 0ft above MSL. 67 MAINTENANCE for tyre inﬂation Dry nitrogen is often used e gas on risk from the combus tibl (a) to minimise the explosi atures . per tem d ate elev at tyre which is liberated from the the loss due to diff usion through (b) to reduce the pressure 1. tube. (a) galling. re. a is also lage-moun ted VHF antenn The structure below a fuse this can es, pos pur cal ctri ele , 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 enna. (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. 2. (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. 4. ing of , damage or wear consist Referring to a ball bearing h forces hig to due es rac ring bea circular indent ations on the ed term is l, or high static loads, on inst allation, or remova 5. which sys tem has two elemen ts Where a windshield heating high a give to er ord in l or paralle may be connec ted in series ration ope l one elemen t during paralle and low heat, a failure of rmal cracking due to a high the (a) may cause windshield a. are ed eat ted and unh gradien t bet ween the hea uences, other than heater seq con (b) will have no potent ial failure in the ser ies mode. reduced 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 ned itio pos 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 blade. er accumulating in the low QUIZ of pressure wit h temperatu (c) to reduce the change of a magnesium ﬁre. (d) to reduce the probability 7. 3. 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 departures? 4. 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? 5. 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? 6. 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? 7. 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? 8. (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 report? 9. 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. 8. 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. 68 9. 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. FSA JUL-AUG10 (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. IFR OPERATIONS 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. 1. 2. 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 ntaining 900 0.’ (h) Report not required. Departure & airborne rep orts (i) ‘ML Cen tre ABC departe d Wy nyard at (minutes) trac king 338 passing 250 0 climbing 800 0, “CA MUS” at (minut es) .’ Frequency 122 .6. (j) ‘ML Cen tre ABC departe d Wy nyard at (minutes) trac king to “CA MU S” climbing 800 0.’ Frequency 122 .6. (k) ‘ABC departed (minut es) via SCO TI ONE DEPART URE 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 itude 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) IFR tax iing Lat robe Valley for Essendon Runway 03’, Fre quency 124 .0. 69 Con tac ting a ‘procedural (non-radar)’ tower (t) ‘Alice Tower, ABC (dis tance) DME on the 137 rad ial maintaining 800 0 visual rec eived (AT IS) reques t clea rance’. (u) ‘Alice Tower, ABC (dis tance) maintaining 800 0 visu al received (AT IS) reques t clea rance’. Invest wisely in your C IR training with Peter BINI ADVANCED FLIGHT TRAINING When it comes time for you to invest in your Co mmand Instrument Rating, you need to know your inve stment is spent wisely. Peter Bin i Advanced Flight Tra ining has been teaching and succes sfully producing quality pilots for over 30 years. :LWKRYHUKRXUVR IÀ\LQJH[SHULHQFH&),6W HYH3HDUFH and his team of instructors not only teach what is req uired, but DOVRHQVXUH\RXEHQH¿WIUR PWKHLUSUDFWLFDONQRZOHGJ H Invest in pearls of wis dom, not just the basics . Call us for a tour of our facilities, aircraft, and me et our friendly staff. 3KRQH (PDLOLQIR# ELQ LÀLJKWWUDLQLQJFRPDX QUIZ (o) ‘ML departures ABC DOSEL SEV EN DEPART URE passing (alt itude to the nea res t 100 ’) climbing 500 0ft. ’ Taxi report CALENDAR 2010 S M T W 4 5 6 7 11 12 13 14 18 19 20 21 25 26 27 28 T F S 1 2 3 8 9 10 15 16 17 22 23 24 29 30 31 S 1 8 15 22 29 M T W T F S 2 3 4 5 6 7 9 10 11 12 13 14 16 17 18 19 20 21 23 24 25 26 27 28 30 31 S M 5 12 19 26 T 6 7 13 14 20 21 27 28 W T F S 1 2 3 4 8 9 10 11 15 16 17 18 22 23 24 25 29 30 70 july Regional Airspace and Procedures Advisory Committee 16-18 z Australian Centenary of Powered Flight 8 11 FSA JUL-AUG10 T W T 3 4 5 6 7 10 11 12 13 14 17 18 19 20 21 24 25 26 27 28 31 F S 1 2 8 9 15 16 22 23 29 30 Regional Airspace and Procedures Advisory Committee 14 Regional Airspace and Procedures Advisory Committee 15-17 z Regional Aviation Association Australia annual conference 9 Australian Centenary of Powered Flight Mia Mia Inc. Jill James secretary: m: 0418 388 919 e: [email protected] Goolwa www.casa.gov.au Brisbane Convention & Exhibition Centre, QLD AASC/Ageing Aircraft - chairman Richard Gauntlett e: [email protected] Darwin www.casa.gov.au Cairns www.casa.gov.au Hyatt Regency Resert Coolum, QLD www.raaa.com.au/convention.html Regional Airspace and Procedures Advisory Committee Regional Airspace and Procedures Advisory Committee Hobart www.casa.gov.au Canberra www.casa.gov.au Sydney www.casa.gov.au Adelaide Convention Centre http://convention.airports.asn.au/ october 7 Regional Airspace and Procedures Advisory Committee 24-28 z Australian Airports Association national conference 25-28 z Sixth Triennial Int'l Aircraft Fire & Atlantic City, Cabin Safety Research Conference New Jersey 29 M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Mia Mia, VIC september 28 S AvSafety seminar 17-19 z The Australian Aircraft Airworthiness & Sustainment Conference 30 M www.casa.gov.au august 23 S Melbourne Regional Airspace and Procedures Advisory Committee Regional Airspace and Procedures Advisory Committee Register online at www.fire.tc.faa.gov/ or email [email protected] for more information. Adelaide www.casa.gov.au Perth www.casa.gov.au Milan Marriot Hotel, Italy http://flightsafety.org Brisbane www.casa.gov.au Singapore Aviation Academy, Changi Village, Singapore http://flightsafety.org november z Flight Safety Foundation International Air Safety Seminar 2010 Regional Airspace and Procedures 9 Advisory Committee 10-11 z Business Aviation Safety Seminar-Asia 2-5 KEY: CASA events zOther organisations' events COMING SOON!!! 7KH$23$1DWLRQDO$LU¿HOG'LUHFWRU\ LVFRPLQJVRRQ 0 )LUVWSXEOLVKHG\HDUVDJRWKH1DWLRQDO$LU¿HOG'LUHFWRU\LV WKHRQO\FRPSUHKHQVLYHFROODWLRQRISODFHVWRODQGDQDLUFUDIW DFURVV$XVWUDOLDEHLW\RXU%HHFKFUDIWRU\RXU%RHLQJ,W JLYHVYLWDOLQIRUPDWLRQWRDLGVDIHHI¿FLHQWÀLJKWSODQQLQJE\ DYLDWRUVWUDYHUVLQJWKHFRQWLQHQW /RJRQWRwww.aopa.com.auDQGKHDGWRWKH µ,QIRUPDWLRQ&HQWUH¶WRGRZQORDG\RXURUGHUIRUPDQGVHQG LWLQWRWKHRI¿FHE\SRVWHPDLORUID[WRVHFXUH\RXUFRS\ Nationa $LUÀHOG l 'LU HFWR U\ 201 Aircra ft RRP $6 Owners and Pi 5 lots A ssocia tion of Austral ia Ph: 02 9791 9099 Email: [email protected] u Web: Web W eb:: www.aopa.com.au www ww w.ao aopa pa.com com.au au QUIZ ANSWERS QUIZ ANSWERS 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 transmission. 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 recommendation. 71 IFR Operations Question Answer Reference 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 Maintenance 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 overlooked. 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) FSA JUL-AUG10 72 =NEDM>66A:GIIDDA6I:8DB:HIDDFJ>[email protected] 9dZh ndjg igV^c^c\ Xdbean l^i] 86D '%#&& VcY 86G '*(4 HV[ZVcYZ[ÒX^ZcicdgbdWVg^X]nedm^VigV^c^c\^hcdl VkV^aVWaZ Vi 6jhigVa^Vc XZcigZh# >cY^k^YjVa dg \gdje hZhh^dch[dgVaaÓ^\]ieZghdccZa# I]Z <D'6ai^ijYZ cdgbdWVg^X ]nedm^V VlVgZcZhh hnhiZb ^cXdgedgViZh XdbeaZiZ ZYjXVi^dcVa eVX`V\Z/ i]ZdgZi^XVaVcYegVXi^XVa]nedm^V`cdlaZY\Z!Xd\c^i^kZ nh^dad\^XVa eZg[dgbVcXZ iZhi^c\ l]^aZ bdc^idg^c\ e]nh^dad\^XVa eVgVbZiZgh# ;jaan VjidbViZY VcY ^chiVci k^YZd VcY VcY eg^ciZYgZedgi[dgVaahijYZcih# `cdlaZY\Zd[i]ZZ[[ZXihd[Vai^ijYZ BZaWdjgcZEZgi]6YZaV^YZBVgddX]nYdgZlll#]nedm^V"ZYjXVi^dc#Xdb flightsafety … essent essential t ial aviation reading INSIDE NEXT ISSUE The truth about volcanic ash Alcohol and other drugs: 12 months on A place for everything: tool management and safety And … more close calls 73 ADVERTISING ;OLYLOHZUL]LYILLUHIL[[LY[PTL [VIL^P[ONVVKWLVWSL *RRGSHRSOHWREHZLWK 8),0UZ\YHUJL(\Z[YHSPH3PTP[LK()5! 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