Flight Safety Australia Magazine - Mar-Apr 2010

Flight Safety Australia Magazine - Mar-Apr 2010
‘Untiring global FRMS efforts’
Managing fatigue: case studies & update
Mar-Apr 2010
Issue 73
‘Plunge into the sea’
Flash Airlines’ 737-300
fatal accident
‘Investigating defects’
Defect reporting from the
other side
‘Submitting SDRs
Closes 9 April 2010
‘Class D-Day approaches’
The 3 June transition from GAAP to Class D
ISSUE NO. 73, MAR-APR 2010
John McCormick
Gail Sambidge-Mitchell
Margo Marchbank
P: 131 757 or E: [email protected]
Flight Safety Australia
GPO Box 2005 Canberra ACT 2601
P: 131 757 F: 02 6217 1950
E: [email protected]
W: www.casa.gov.au
‘Untiring global FRMS efforts’
Some fatigue-related aviation accidents & an FRMS update.
20 ‘D-day approaches’
The transition to Class D airspace.
25 ‘Warbird aircraft operators’
Limited category aircraft & approved operations manuals.
31 ‘Investigating defects’
Defect reporting from the other side.
37 ‘When the shift hits the fan’
Work from the FAA on maintenance and fatigue.
To change your address online, go to
For address-change enquiries, call CASA on
1300 737 032
58 ‘Egyptian Boeing 737-300 plunges into sea’
Bi-monthly to 87,000 aviation licence
holders, cabin crew and industry personnel
in Australia and internationally.
Stories and photos are welcome. Please
discuss your ideas with editorial staff before
submission. Note that CASA cannot accept
responsibility for unsolicited material.
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copyright notice accompanies each published
photograph. If you believe any to be in error,
please notify us at [email protected]
Spectrum Graphics – www.sg.com.au
IPMG (Independent Print Media Group)
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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.
Macarthur Job on Flash Airlines’ 2004 accident.
64 ‘New radio carriage requirements’
Changes to CAR 166 – procedures at non-towered aerodromes.
2 AirMail
4 Flight Bytes–aviation safety news
16 ATC Notes– news from Airservices
18 Accident reports– International
19 Accident reports– Australian
31 Airworthiness pull-out section
44 Close Calls
ATSB supplement
Av Quiz
Quiz answers
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.
© 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: Spectrum Graphics
33 SDRs
39 Directives
‘Murphy rears his ugly head’
‘Fickle fate’
‘A foggy idea’
‘Shonky scenario’ A IR M A IL
Thank you to the readers who respond
after every issue of Flight Safety hits
the mail boxes, and increasingly,
cyberspace, as more people sign-up to
receive email alerts of the new pageturning version of the magazine online.
If you haven’t had a chance yet, go to
www.casa.gov.au/fsa/ and click on the
‘View online’ link. Of course, there’s
always the .pdf option as well, which
you can download and print out.
FSA MAR–APR10 Issue 73
However, we do have a correction
to make from the feature in the
January-February 2010 last issue.
Our article on performance-based
navigation was well-received – thank
you for the very positive feedback,
but there was a mistake in the
chart on p10. Please see the correct
diagram opposite.
Area navigation
RNAV 10 (RNP 10)
Oceanic & remote
2, RNAV 1
Continental en
route & terminal
RNP 4 (Oceanic
& remote
(basic &
Required navigation performance (RNP) - should have been RNP 2 as indicated.
$16,860 - 12 weeks
Monday 18th January 2010
Monday 15th March 2010
Monday 10th May 2010
$12,850, C310 upgrade extra $2,500 - 5 weeks
Monday 22nd February 2010
Monday 19th April 2010
Monday 21st June 2010
$2,950 - 8 weeks
Monday 25th January 2010
Monday 8th March 2010
Monday 3rd May 2010
$1,250 - 2 weeks
Monday 8th February 2010
Monday 5th April 2010 Monday 7th June 2010
Price on application
Monday 11th January 2010 Monday 8th March 2010 Monday 3rd May 2010
Contact our Business Development Manager for further information:
[email protected]
Ph: (07) 3277 8544
Queensland’s Largest Flight Training Organisation
Owned & Managed By Airline Pilots
CRICOS Provider code: 01208J
RTO 32009
Soon … ‘Sunshine
Coast Airport’
On 3 June 2010, Maroochydore/
Sunshine Coast Airport will complete
the final stages of a two-step process to
change its name from Maroochydore
to Sunshine Coast Airport.
Early advice of the planned changes
is being provided, so that industry
can plan for any necessary system
Changes to take effect
The aerodrome name, tower call
sign, meteorological products such
as forecasts etc, NOTAM, airspace
and chart titles will all change from
Maroochydore to Sunshine Coast.
For example, pilots should expect to
call ‘Sunshine Coast Tower’.
What you need to do
The data elements being changed
are used in a variety of databases,
documents and other information
databases should be managed
through your service provider’s
normal amendment process
Operational documents and other
data sources such as operations
manuals, route supplements,
in-flight guides etc will need to be
Stored flight notification, met
briefing or planning profiles should
be checked
Maps, charts and other AIP
documents should be replaced with
the current version when issued
Providing quality services for certification,
manufacturing & maintenance requirements.
Independent auditing to ISO, AS or regulatory
Specialising in Quality Management Systems
for Part 21 manufacturing, maintenance &
John Niarchos
Grad Dip Aircraft Eng Mgt, LAME
T/F: 61 3 9885 8662
M: 0449 768 449
E: [email protected]
ABN 1942 358 1785
Sales /reservations
graphics, imasges and other
information sources should be
reviewed and/or amended.
Further information
AIP Supplement
H64/09 Aerodrome Name Change
Sunshine Coast Airport dated 14 Jan 10
Sunshine Coast Airport
Danny Eatock, Operations Manager
P: 07 5453 1505
E: [email protected]
W: www.sunshinecoastairport.com.au
The ICAO location identifier will
change from YBMC to YBSU. NAVAID
identifiers (VOR, DME, NDB and RNAV
(GNSS)) will change from MC to SU.
These changes will be reflected in
electronic databases such as AVFAX,
Airservices Australia location briefing,
flight management computers, GPS
data files etc.
YOUR 406
[email protected]
Since February 2009, it
has been mandatory to
carry an approved
emergency locator
transmitter (ELT)
for most flights in
Australian airspace.
FSA MAR–APR10 Issue 73
Not only should you
406MHz ELT, but you must
also register your digital ELT
with the Australian Maritime Safety
Authority (AMSA). This is required
so that when an activated ELT is
detected, the search and rescue
agency can immediately determine
who requires assistance, and what to
look for (a boat; a bush walker; or in
our case, an aircraft).
AMSA has advised CASA that
there appears to be a number of
unregistered beacons being carried
in Australia. There have also been a
number of activations of unregistered
beacons. This has caused difficulties
in search and rescue missions,
and also caused problems during
inadvertent activations of beacons
where the beacon’s operator could
not be contacted.
Consequently, it is timely to remind
pilots and aircraft operators that
registration of your digital 406 MHz
ELT is mandatory (refer to CAR 252A
[4] [b]). Registration is free and easy.
Once you’ve registered your ELT,
AMSA will send you a registration label
which you must fix to the beacon.
CASA also understands that some
pilots and aircraft operators may be
purchasing ELTs from overseas. If
considering this, you should exercise
caution, as many ELTs sold overseas
cannot be registered in Australia
because of the way in which these
devices are coded. Check with AMSA as
to which devices sold overseas conform
to Australian coding requirements.
However, the simplest solution is to
avoid the temptation to buy your ELTs
overseas. Supply in Australia is good
and pricing is competitive.
You can register your ELT online at http://beacons.amsa.gov.au,
or you can call the AMSA hotline on 1800 406 406 for details
on other ways to register your beacon.
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Victoria Park Racecourse in Sydney,
on Thursday 9 December 1909. He
made the flight in a short straight
line, before a crowd of about 150-250
people. Defries made a second flight
on 18 December 1909.
Beginning in December last year,
Australia geared up for celebrations
to acknowledge the importance of a
century of powered flight in building
Australia – breaking down the
tyranny of distance.
However, it was the famous magician,
come escapologist, Harry Houdini,
who ‘demonstrated the practical
possibilities of the aeroplane’ when he
performed the first controlled, circling
flight in Australia on 18 March 1910.
Flying a Voisin he had shipped to
Australia, Houdini made his first flight,
which lasted little more than one
minute, at Diggers Rest in Victoria. At
least nine people, as well as reporters
from The Argus and The Age, witnessed
his circuit of the paddock.
September 1909, established the
first aeroplane factory in Surry Hills,
Sydney. Taylor achieved the first
untethered flight, in his own Voisintype glider at Narrabeen Heads on
Sydney’s northern beaches on 5
December 1909.
Source: The Royal Aeronautical Society–
Australia Division
Among the planned celebrations for
the year is an event to be held from
16-17 July 2010 at Mia Mia in Victoria,
the site of Duigan’s first flight. The
‘Australian Centenary of Powered
Flight’ Mia Mia, will not only celebrate
Duigan’s activities in 2010, but the
committee will initiate the ongoing
program. Under the program, in
keeping with Duigan’s aerospace
achievements, awards will be given
to individuals and groups in a number
of categories recognising aerospace
excellence and innovation.
For more information, email the
committee chairman, Paul Fox:
[email protected]
Colin Defries was the next record
setter. Flying a Wright Model A,
imported into Australia, Defries made
the first powered flight in Australia at
However, the honour of being the
first Australian to ‘design, build and
successfully fly a powered aircraft in
Australia’ goes to John Duigan. He
designed a biplane, powered with
a 25hp engine, and flew his first
controlled flight on 16 July 2010 at the
family property, ‘Spring Plains’ at Mia
Mia in Victoria. The Duigan biplane is
preserved in the Museum of Victoria.
Airworthiness &
The Australian Aircraft Airworthiness
and Sustainment conference will be
held at the Brisbane Convention and
Exhibition Centre from 17-19 August
2010. The conference is jointly supported
by the Royal Australian Air Force and the
Civil Aviation Safety Authority.
FSA MAR–APR10 Issue 73
The conference will bring together engineers, operators,
maintainers, technicians, logisticians and managers,
from both the military and commercial aerospace
communities, to share their knowledge, experience, ideas
and technologies relating to platform sustainment.
The conference scope will include all aspects of
sustainment, including:
A call to the
aviation industry
Fleet management
Wiring, mechanical and propulsion systems
Structures & corrosion
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.
Support equipment
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.
Workforce capability – knowledge retention
*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.
safe skies for all
Condition monitoring
Spares, logistics, supply chain design.
This event is for the benefit of the entire aerospace
community–government, defence, industry and academia
alike. By becoming involved, whether as a speaker,
discussion participant, or simply networking with other
members of the aerospace community, you are making
a valuable contribution to our fleets and to our great
This conference was formerly given the ‘ageing aircraft’
nametag, but has been retitled to better reflect the
applicability of the event to all airworthiness and
sustainability issues on both new and old platforms, both
new and old.
The new title also matches that of the
renamed US event (formerly ‘Aging
Aircraft Conference’), and reflects
Australia’s ongoing collaborative
relationship with our US colleagues.
Representatives from the US fraternity
will attend the conference as guest
For more information, contact:
Richard Gauntlett
Conference chairman
P: 61 (0)7 3281 2466
M: 0437 812 468
E: [email protected]
For registration enquiries, contact:
Event coordinator
P: 61 (0)7 3299 4488
E: [email protected]
Registrations close 13 August 2010
Conference 17-19 August 2010
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 education 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 education products that will contribute to
‘safe skies for all’.
FSA MAR–APR10 Issue 73
Ben Cook, manager human factors with
CASA, looks at an insidious issue with serious
aviation safety implications, not just for flight
crew, but in ATC and maintenance.
Fatigue within the aviation industry continues to capture headlines
around the world. Some may remember the reports of a 2008
incident where two pilots fell asleep overhead Hawaii and flew past
their destination toward the open ocean for 18 minutes. The two
pilots had been flying together for three arduous days involving
early start times and a demanding sequence of short flights.
Moreover, following the incident, the captain was diagnosed with
severe obstructive sleep apnoea, which can be readily cured.
On a personal note, it is only recently that my
young children have reached an age where
they both started to sleep consistently through
the night. My wife and I were very excited—
we now feel as if some semblance of normal
life has returned. We have just survived a
three-year period of sleep deprivation, and
the myriad factors associated with that: mood
swings; degraded performance, including a
whole bunch of absent-minded errors;
lapses of memory, judgement; the list
goes on. I clearly recall driving the
car home from work one night
and at the end of the journey
having no recollection of
any of the details—doing a
fair impression of a zombie
on autopilot. Some of you who are
parents of young children may also
recall that the language at 2am
with two sleep-deprived parents
and an unsettled baby can be
quite colourful.
And during this period of sleep deprivation
I kept thinking how lucky it was that I didn’t
have to get up in the morning and serve as
a crew member on an aircraft, or as a shift
worker within the aviation industry. My
extended period of sleep deprivation was
also a time when I’ve reflected on a powerful
presentation provided by Captain Jim Chapo,
the pilot in command and survivor of an
aircraft accident in which fatigue was found
to be a primary contributing factor.
Others may think back to when you first
commenced shift work, a back-of-theclock type operation, and your struggle to
perform in the wee morning hours (2-6am)
when your body most naturally wants to be
asleep. You can adapt to working these hours
over time, but your performance will always
be reduced when you compare it to your
performance during more ‘normal’ daylight
hours. Fatigue remains an ongoing threat:
one which needs to be managed carefully. It
has the potential to have a negative impact on
many workplaces within the aviation industry
– cockpit, workshop or control tower. The
negative impact of degraded performance
because of fatigue is particularly important
when conducting safety critical activities.
CASA was fortunate enough to have the US
National Transportation Safety Board (NTSB)
provide a fatigue factors training course to
a number of its regulatory staff. As part of
this presentation Captain Chapo provided a
personal recollection of the accident, which
has had a profound impact on his life. Jim
recalled in great detail what was going
through his mind as he was being pulled
from the wreckage of the aircraft and the
ongoing feelings of guilt after the accident.
His presentation was very moving and one
that continues to evoke emotions in both
Jim and the listening audience. One could
only feel privileged to be allowed to enter
this very personal space within Jim’s life as
he recalled his story. He was a competent,
highly-experienced and well-trained captain,
with a competent and well-trained crew.
But fatigue is no respecter of competence
or experience: it is insidious, affecting even
the most proficient and highly trained. Once
you’re significantly fatigued, you no longer
recognise the symptoms, such as your
degraded performance, your compromised
decision-making skills – self-diagnosis is
no longer possible and a potential accident
spiral can begin.
Jim Chapo (l.) with the NTSB’s
Jana Price and Malcolm Brenner.
FSA MAR–APR10 Issue 73
On August 18, 1993 at 1656 (all times are
local), a Douglas DC-8-61 freighter collided
with level terrain approximately a quarter of
a mile from the approach end of runway 10,
after the captain lost control of the airplane
while approaching an airfield at the United
States (US) Naval Air Station, Guantanamo
Bay, Cuba. Impact forces and the post
accident fire destroyed the airplane, and the
three flight crewmembers sustained serious
injuries. Visual meteorological conditions
prevailed. The crew survived in part because
the forward portion of the fuselage, including
the cockpit, separated from the remainder
of the airplane and came to rest partially
inverted outside the fire burn area.
The NTSB determined the probable cause of
the accident was the impaired judgement,
decision-making and flying abilities of the
captain and flight crew due to the effects of
fatigue; the captain’s failure to assess properly
the conditions for landing and to maintain
vigilant situational awareness of the airplane
while manoeuvring onto final approach; the
failure to prevent the loss of airspeed and
avoid a stall while in a steep bank turn; and
the failure to execute immediate actions to
recover from a stall.
the inadequacy of the flight and duty
time regulations within the US and the
circumstances that resulted in the extended
flight/duty hours and fatigue of the flight
crew. Also contributing were the inadequate
crew resource management training and
inadequate training and guidance by the
airline to flight crew for operations at special
airports, such as Guantanamo Bay; and the
Navy’s failure to provide a system that would
assure the local tower controller was aware
of the inoperative strobe light so as to be able
to provide the flight crew such information.
At the time of the accident the aircraft had
not breached any of the existing flight and
duty time limitations. A full copy of the NTSB
report is available and a few areas specific to
the accident will be discussed further.
The captain had just completed a sequence of
flights and was on his way home to his family.
After calling his wife enroute he was told the
company needed him back at the airport
immediately to fly an unexpected trip. The first
officer and flight engineer were also notified by
the company and rejoined the captain. Another
crew scheduled to operate the flight to Guantanamo Bay had been
cancelled due to mechanical problems. This additional flight required
a transit to another airfield to load freight, followed by a flight to
Guantanamo Bay and a ferry flight back to Atlanta. This could be
accomplished within the company’s ‘24-hour crew duty-day policy’.
An overview of the route and times is opposite:
In accident investigations, three background factors are commonly
examined for evidence related to fatigue. They are:
cumulative sleep loss,
continuous hours of wakefulness, and
time of day.
In this case all crew members met all three conditions for
susceptibility to the debilitating effects of fatigue. None of the
three crew members had received his normal level of sleep
in the days before the accident and the accident occurred
during a period of time (3-5pm) associated with sleepiness.
Researchers examined the crew members’ sleep/wake
periods in the 28.5 hour period prior to the accident, and
found the cumulative totals for sleep and wakefulness for
the captain, first officer and flight engineer respectively
were: 23.5 hours awake with five hours sleep; 19 hours
awake with eight hours sleep; and 21 hours awake with
six hours sleep.
On Duty
Maps courtesy
the NTSB
Furthermore, long crew duty days were a part of the company’s
culture (the norm and accepted practice). During an interview, the
chief executive officer (CEO) of the airline described the operating
philosophy of the company, and indicated that flight and duty time
schedules were an important issue in airfreight service. He said
in order to remain competitive the company must often assign
long duty times and ‘work everything right to the edge’ of what
was allowed by the regulations. He indicated that this practice
was ‘common’ in the airfreight industry. The company was also
structured and operated using a ‘lean management’ philosophy
rather than over staffing, which required management personnel
to be responsible for, and perform multiple roles. Hence, the
director of operations was responsible for aircraft dispatch, crew
training, crew scheduling and fleet management. Safety culture has a
powerful influence on crew behaviour.
FSA MAR–APR10 Issue 73
One of the events contributing to the situation
was a late decision by the captain to change
the previously planned approach to runway
28 to a tighter and more challenging
approach to runway 10. At 1641:53, the
cockpit voice recorder (CVR) recorded
the captain stating to the other
crewmembers. ‘Otta make that a one
zero approach just for the heck of it to
see how it is: why don’t we do that, let’s tell
’em we’ll take one zero; if we miss we’ll just
come back around and land on two eight.’ Some
may question such a decision, but we must not forget
the captain had been sleep deprived for three days and
awake for almost 24 hours. In an interview after the accident,
the captain said he felt lethargic and indifferent. The NASA
fatigue specialist stated a finding from sleep deprivation
studies that in such situations, people will put in more
effort, in spite of the fact their performance goes down,
but they don’t care what happens. That’s indifference.
The proximity of the runway 10 threshold to the boundary
fence between US and Cuban airspace placed a burden upon
pilots of aircraft landing on runway 10. In nearly all other
approaches the pilot will ensure the aircraft is aligned with the
runway centreline a minimum of two miles from the threshold
and at a height greater than 500 feet above the threshold (part of
stabilised approach criteria at the time). In contrast, the runway 10
approach requires a tight radius turn from base leg to final approach,
using a steeper than normal angle of bank and rolling out on runway
heading over (or nearly over) the runway threshold. The roll out to wings
level is completed at low altitude with minimum distance to correct for
runway misalignment. The downwind leg for the right-hand approach
is flown over water; thus, there are no visual landmarks to aid the pilot
in determining the proper position to initiate the base leg and final
approach. The strobe light, which was inoperative, is used to establish
the downwind to base flight track.
A NASA researcher and fatigue specialist provided the following
testimony relating to the captain’s performance and fatigue:
‘… with sleep loss, people would have problems making decisions.
People who otherwise would make fine decisions deciding among
three alternatives, could go with the worst one. They don’t process
critical information very well. Reaction time can be degraded … People
get tunnel vision. They can literally focus on one piece of information
to the exclusion of other kinds of information… The fixation on the
strobe light. I counted seven comments in the CVR transcript about
the strobe … I think what’s really critical about this is that … in sleep
loss situations, you get people with tunnel vision. They get fixated on a
piece of information to the exclusion of other things …
The other thing is right in the middle of that, he [the captain] disregards
a critical piece of information … the first officer or flight engineer …
someone saying, “I don’t know if we’re going to make this”… So besides
just fixating, you’ve got disregard for a critical piece of information.’
An extract of the cockpit voice recorder highlights some of the effects
of fatigue, particularly the tunnel vision and fixation associated with
finding the strobe light:
Flight Engineer
First Officer
Flight Engineer
First Officer
Flight Engineer
First Officer
First Officer
First Officer
Flight Engineer
Sound similar to stall warning
Unidentified crew (don’t)
stall warning
First Officer
Flight Engineer
where’s the strobe
right over there
right inside there, right inside there
you know, we’re not getting our airspeed back there
where’s the strobe
right down there
I still don’t see it
we’re never goin’ to make this
where do you see a strobe light
right over there
where’s the strobe
do you think you’re gonna make this
yeah…if I can catch the strobe light
five hundred, you’re in good shape
watch the, keep your airspeed up
I got it
stall warning
stall warning
I got it, back off
This was a highly experienced, well-trained and proficient crew
suffering the debilitating effects of fatigue, the final outcome resulting
in the stick shaker (stall warning) being ignored.
‘The crew’s debilitating fatigue resulted in the following:
Self-diagnosis of fatigue was no longer possible
Reduced memory capacity, forgetfulness, missed radio calls
Diminished interpersonal skills, and a corresponding difficulty in
communicating clearly
Moodiness as a crew member displays impatience when dealing
with other crew members
Poor judgment which led the crew to choose a difficult approach
path against that previously briefed
Tunnel vision and poor instrument scan
Reduced flying skills resulting in a poor approach
Faulty decisions through continuing a bad approach
Slowed reaction time resulting in a late recovery from a stall’.
While some may consider this duty period an exception, the aviation
industry continues to move towards ultra-long range (ULR) operations.
ULR involves any sector between a specific city pair in which the
planned flight time exceeds 16 hours, taking into account mean wind
conditions and seasonal changes, and flight-duty periods from 18 hours
to 22 hours. Increasingly, developments in fatigue science, combined
with practical research, are used to build safety cases to substantiate
safe ULR operations. Typically, this takes the form of a partnership
between an airline and a fatigue specialist organisation/university,
which together develop detailed safety cases clearly delivering safe
operations under such conditions. The Flight Safety Foundation
has contributed significantly through the
development of ULR recommended operational
guidelines, which can help airlines worldwide
to expand their operational envelope while
maintaining safety. The latest developments
in fatigue science, combined with formal
processes of risk management, ensure flight
duty times similar to that of the Guantanamo
Bay accident are managed safely, in stark
contrast to the operating environment of
Captain Chapo.
There are further instances of fatigue closer to home. Consider the following case studies:
Date / Location
16 July 1999
The Cessna 172 was being used to assist a ground party of station hands to muster sheep
on a station property. The manager of the station reported that the aircraft was being
used to spot livestock on the ground and to muster sheep using a pilot-activated siren on
the underside of the fuselage. The station manager reported that the pilot appeared to be
attempting to position the aircraft to cut off a mob of sheep that had broken away from the
group he was following. He saw the aircraft pass approximately overhead and in a westerly
direction before it commenced a left turn.
Cessna 172, 46km
south west Onslow,
FSA MAR–APR10 Issue 73
The manager looked away from the aircraft but reported that he could clearly hear its
engine, which sounded normal. He immediately looked up when he heard the sound of an
impact and saw that the aircraft had crashed approximately 100-200 metres from where he
was standing.
During the course of the investigation the pilot’s recent flight and duty times were reviewed
to determine whether fatigue had been a factor leading to the occurrence. He had flown
at least 68 hours in the nine days since arriving at the station and had not taken a day off
during this period. On the day of the accident, he had flown at least eight hours 30 minutes.
11 August 2007
Boeing 737-476,
50km NW of Swan
Hill, VIC
On 11 August 2007, a Boeing Company 737-476 aircraft, registered VH-TJE, was being
operated on a scheduled passenger service from Perth, WA to Sydney, NSW. The flight crew
consisted of a pilot in command, who was the pilot flying, and a co-pilot. The aircraft departed
from Perth at 0544 Western Standard Time. About two hours 40 minutes later, the master
caution light illuminated associated with low output pressure of the aircraft’s main tank
fuel pumps. The pilot in command observed that the centre tank fuel pump switches on the
forward overhead panel were selected to the OFF position and he immediately selected them
to the ON position.
Other safety factors identified include: the pilot in command was experiencing considerable
life-stress before and during the four-day trip, related to a divorce that had been ongoing
for three years; the pilot in command did not maximise the rest opportunities before and
during the four-day trip, partially due to personal life-stress, and he was probably fatigued
during the previous flight (Jakarta to Perth). Adequate rest was obtained for the incident
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ATC Notes
FSA MAR–APR10 Issue 73
The future of
Flying Around
irservices web-based flight planning tool, Flying Around, is set to be replaced this year by an exciting
new online CASA-Airservices initiative.
The interactive, multimedia web-based tool will provide pilots with detailed information about flying
in and around controlled airspace. Its launch will coordinate with the transition to Class D procedures in June
this year.
It will initially provide excellent information about flying in and around the general aviation aerodromes which
transition to Class D procedures in June 2010 (Archerfield, Bankstown, Camden, Moorabbin, Parafield and
Airservices is working collaboratively with CASA on the online multimedia tool, which pilots will be able to
access on both the CASA and Airservices websites.
Are VCAs making you sick?
Airservices data shows that Violations of Controlled Airspace
(VCAs) assessed as ‘critical’ increased steadily during 2009.
A VCA occurs when an aircraft enters controlled airspace
without ATC clearance. A critical VCA occurs when aircraft
are in critical proximity to each other. It can also occur at
a critical location and point in time that interferes with the
processing of other traffic in controlled airspace.
A recent critical VCA involved an Airbus A320 inbound to
Melbourne’s Runway 16 from the north. A VFR Piper Warrior
returning to Moorabbin from a NAVEX was observed by ATC
to approach the Control Zone (CTR) boundary near Sunbury,
tracking eastbound toward the Airbus.
Controllers attempted to call the pilot of the Warrior on all
Melbourne frequencies and made broadcasts to alert the
pilot of the pending danger, but the pilot did not respond and
subsequently entered the CTR.
A breakdown of separation occurred, with the distance
between the two aircraft reduced to 2nm and 700ft at the
closest point. The separation standard in this airspace is 3nm
or 1000ft. The A320 was then re-sequenced, causing delay to
the flight.
The Piper Warrior enters the Melbourne
CTR near Sunbury with the Airbus on final
for Runway 16 at Melbourne. The Airbus
has been instructed to climb back to 3,500
ft but is still descending at that moment
Airservices’ ongoing VCA Survey highlights pilot distraction
as a major cause of VCAs. In this incident example,
airmanship suggests that when the pilot of the Warrior became
unable to navigate the aircraft accurately, they should have
sought assistance from ATC by declaring a PAN.
The Warrior may still have flown where it did, but ATC would
have cleared other traffic out of the way in a timely fashion.
Alternatively, ATC could have assisted the pilot by providing
suggested headings to avoid controlled airspace.
The lessons from this incident are:
1. Accurate navigation around controlled airspace is essential.
Plan your trip, carry accurate charts, identify appropriate
ATC frequencies for all stages of flight, and add a buffer to
the control area steps to ensure you remain clear.
2. Distraction can arise in different ways. Aviate, Navigate,
then Communicate. If you can’t navigate, you need to
communicate with ATC!
3. Ask for assistance early – ATC is available to help.
The Airbus has stabilised at 2,800 ft before
climbing. It has also been instructed to
turn left on to a heading of 090 degrees.
The ATC Short Term Conflict Alert (STCA)
has activated
The Airbus is turning away from the
Warrior and climbing as the Warrior
approaches the Runway 16 centreline
The A320 was then instructed by ATC to climb and turn away
from the traffic.
The Warrior kept tracking eastbound and was followed on
radar to Moorabbin where the control tower was able to
identify the aircraft involved. Later information indicated that
the pilot had suffered a medical event, including vomiting,
which caused severe disorientation.
International Accidents/Incidents 7 Dec 2009 - 10 Jan 2010
7 Dec
George Airport,
South Africa
17 Dec
Falcon 20D
Matthew Town,
Great Inagua
Island, Bahamas
An Embraer passenger was damaged after a runway excursion on landing at George
Airport. The aircraft was cleared for an instrument landing system (ILS) approach
runway 11. At the time, it was overcast with light rain. The aircraft touched down
nearf the fourth landing marker, veered to the right at the end of the runway, and
went past the ILS localizer. It collided with eleven approach lights before it burst
through the aerodrome perimeter fence, and came to rest in a nose-down attitude
on a public road.
A Falcon 20D corporate jet departed Dr Joaquin Balaguer Airport, Dominican
Republic with the planned destination Fort Lauderdale Executive Airport. According
to Flightaware.com tracking data the flight was en-route at FL280, speed 360 kts
when radar contact was lost near Great Inagua Island. Press reports indicate that
small bits of debris were discovered in rough, bushy terrain. Both pilots were killed.
Tonj Airfield,
22 Dec Boeing 737-823 KingstonNorman Manley
Airport, Jamaica
25 Dec Airbus A330323X
Wayne County
Airport, USA
29 Dec de Havilland
Canada DHC3T Otter
2 Jan Boeing 727231F
off Vomo Island,
Airport, Congo
20 Dec British
FSA MAR–APR10 Issue 73
5 Jan
Gates Learjet
Chicago-Executive 2
Airport, USA
6 Jan
Cessna 208B
Piajo Airstrip,
Grand Caravan Botswana
7 Jan
Saab 340A
8 Jan
Falcon 20C
10 Jan
Airbus A319131
Airport, Bahamas
Vail-Eagle County 0
Airport, USA
Airport, USA
A British Aerospace turboprop plane was damaged when it suffered a runway
excursion at Tonj Airport, Warrap State, southern Sudan. None of the occupants
was injured but a woman on the ground was killed after being hit by the plane.
After leaving the runway, the aircraft struck a group of houses being built, causing
severe damage to the nose and the port undercarriage was ripped off. Apart from
the woman on the ground being killed, a child of the same woman is missing and
believed to be beneath the aircraft.
A Boeing 737-823 was damaged in a runway excursion while landing on rwy 12 at
Kingston-Norman Manley International Airport, Jamaica during a rainstorm. The six
crew members and 148 passengers survived the accident. The plane skidded across
a road and came to rest on a beach. The plane’s fuselage was cracked, its right
engine broke off from the impact and the main landing gear collapsed. According
to Jamaican investigators the airplace landed approximately 4,000 feet down the
8,900 foot runway.
An Airbus passenger jet was involved in a failed attempt to blow-up the aircraft.
Northwest Airlines flight NW253 from Amsterdam-Schiphol International Airport
was approaching Detroit when a passenger attempted to ignite some kind of
incendiary device. The 23 year old Nigerian national had explosive powder taped to
his leg and used a syringe of chemicals to mix with the powder that was to cause
an explosion. A small fire erupted, but this was put out using a fire extinguisher. The
passenger was immediately subdued and was arrested by authorities after safety
landing at Detroit.
According to Fiji news sources a DHC-3 Otter on floats was involved in an accident
when it tipped over near Vomo Island.
A Boeing 727 sustained substantial damage following a runway excursion on
landing at Kinshasa Airport. The airplane reportedly landed in very heavy rain and
substantial standing water on runway 06 and slid off the side of the runway.
A Learjet plane operating as Royal Air Freight flight RAX988 was destroyed when
it impacted water and terrain while maneuvering to final approach to runway 34
at Chicago-Executive Airport. The wreckage came to rest on the west bank of the
Des Plaines River in a forest preserve south of the airport. During the right turn to
final approach, the airplane was observed to enter a 90-degree bank right turn, roll
inverted, and enter a nose down descent toward terrain.
The aircraft suffered a loss of engine power on take-off and crashed in a wet
flood-plain and overturned. Some injuries to the passengers on board, one of whom
suffered a broken hip.
A Saab 340A turboprop plane was damaged when the undercarriage retracted as
it was standing on the apron of the airport. Two crew members were on board,
preparing the airplane for a scheduled service to Marsh Harbour International
A corporate jet was damaged in a runway excursion during takeoff from Eagle
County Airport. Takeoff was aborted when the airplane blew the left main gear tyre,
but the captain was unable to stopin the distance remaining. The airplane proceeded
past the departure end of the runway and past the overrun area, 400 feet into deep
An Airbus A319-131 landed with its right hand main landing gear retracted. The
occupants were evacuated using the emergency slides. While on finals, the crew
apparently experienced problems getting the undercarriage down and locked. The
crew carried out a missed approach and climed to an altitude of 2000 feet. The
flight circled the area west of the airport before a new approach was carried out to
runway 041. The airplane landed with the right main gear retracted and came to rest
on the runway with the number 2 engine touching the runway surface.
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 3 Dec 2009 - 28 Jan 2010
Date Aircraft
3 Dec Yakovlev Aircraft
Factories YAK-18T
8 Dec Robinson R44 II
Injuries Damage
Oakey Aerodrome, Nil
Aerodrome, NSW
8 Dec Bell TH-1F
Aerodrome, NSW
Dorrigo (VFR)
Warnervale (ALA), Nil
9 Dec Bell 206L-1
10 Dec Grumman GA-7
13 Dec American Aircraft Rockhampton
Corp AA-5B
Aerodrome, N M
11Km, QLD
15 Dec Robinson R44 II
Aerodrome, VIC
Cocklebiddy (ALA), Minor
18 Dec Cessna 206H
23 Dec Garlick Helicopters Canowindra (ALA), Serious
Nangar NP-NSW
Hamilton Island Serious
24 Dec Cirrus SR22
Aerodrome, QLD
26 Dec Kavanagh Balloons Beaudesert
Hospital (HLS),
351° M 4Km, QLD
4 Jan
De Havilland
Aerodrome, VIC
Yakovlev YAK-18T Latrobe Valley
Aerodrome, VIC
5 Jan
PZL WarszawaOkecie M-18
Nee Nee (ALA),
5 Jan
DG Flugzeugbau
Cessna A185E
Cunderdin (ALA), Minor
Aerodrome, QLD
10 Jan Piper PA-28-140
Mittagong (ALA), Minor
10 Jan Eiriavion OY PIK20-D
13 Jan Cessna R182
Aerodrome, SA
Tyabb (ALA), VIC Minor
14 Jan Cessna 208B
Beagle Bay (ALA), Minor
5 Jan
9 Jan
18 Jan Robinson R22 Beta Rockhampton
Aerodrome, W M
56Km, QLD
20 Jan Hughes
Helicopters 269B Aerodrome, NSW
24 Jan Robinson R22 Beta Collinsville (ALA), Nil
Gold Coast
28 Jan Robinson R44
Aerodrome, QLD
During the landing roll on runway 20, the aircraft struck a wallaby, causing the nose
landing gear to collapse.
On base, the helicopter encountered a stronger downwind component than the pilot
expected. The pilot’s attempt to arrest the high descent rate resulted in low rotor RPM
and the helicopter landed on a raised garden and subsequently rolled off a retaining wall.
While taxiing, the pilot left the aircraft to chase cattle off the runway, leaving the engine
running. The aircraft subsequently rolled forward and hit trees.
During takeoff, the solo student pilot lost control of the helicopter and a skid contacted
the ground before the helicopter rolled onto its side.
The engine failed while the aircraft was flying a geophysical survey line at 200 ft AGL.
The pilot made a forced landing into low scrub.
The helicopter impacted the ground while conducting aerial fire fighting operations,
apparently sustaining a loss of tail rotor pitch control. The investigation is continuing.
The aircraft lost power during the initial climb, and while returning to the aerodrome,
the engine failed. As the aircraft was ditching, the pilot deployed the on-board ballistic
recovery parachute. The aircraft hit the ocean in a nose-down attitude.
During the cruise, the weather deteriorated, so the pilot made a precautionary landing.
The pilot could not control the balloon’s rate of descent and the basket struck a tree and
powerlines before the pilot could activate the smart vent and land the balloon. Several
passengers injured, two seriously.
During the landing roll, the aircraft veered off the runway 35 strip and rolled into a ditch.
During the initial climb, the right main landing gear failed to retract. The pilot recycled the
landing gear and operations returned to normal. During the subsequent landing, the left
main landing gear leg collapsed which resulted in all three landing gear legs collapsing.
During the initial climb, the nose of the aircraft suddenly pitched up and the right wing
stalled. The pilot could not regain control of the aircraft’s attitude, so he jettisoned the
hopper’s load and closed the throttle. The aircraft collided with an irrigation bank.
During the approach, the glider impacted the ground sustaining serious damage. The
pilot suffered minor injuries.
During the take-off run, the pilot noticed vibration and bumps emanating from the right
float. The pilot rejected the takeoff but as the aircraft slowed through 20 kts, it struck a
sandbank and nosed over, coming to rest inverted. The investigation is continuing.
After takeoff, the aircraft encountered an area of sink and clipped a tree. The pilot
retained control, turned away from rising terrain and attempted to land in a paddock, but
during approach struck a second tree and hit the ground.
While turning right base for runway 08 at low level, the glider entered a spin and the
right wing hit trees at the aerodrome perimeter, and then the ground.
During the landing flare, the aircraft encountered a wind gust and the pilot attempted a
go-around. The right wing struck the ground, damaging it, the landing gear, propeller and
The Cessna was en-route from Broome to Koolan island WA at about 9,500 ft when
the pilot noticed a drop in the engine torque indication with a corresponding drop in
the engine oil pressure indication. He increased the power lever setting, but the engine
torque and oil indications continued to reduce. All other engine indications were normal.
He diverted to Beagle Bay WA - the nearest airstrip. When he saw the low oil pressure
light illuminated, he shut down the engine, conducting an engine-out landing at Beagle
Bay airstrip. The aircraft overran the runway, coming to rest upside down after hitting a
mound of dirt. The investigation is continuing.
While conducting low-level cattle mustering operations, the helicopter’s tail rotor struck
the ground. It then rolled onto its right side.
As the helicopter climbed through 300 ft AGL, the engine lost power. The pilot completed
an autorotation landing but during the flare and ground contact, the main rotor severed
the tailboom. Later inspection revealed that the fuel line to number four cylinder had
The helicopter hit the ground during mustering operations.
While hovering over a peak during mountain awareness training, the low-rotor RPM horn
sounded. The pilot could not increase rotor RPM and the helicopter hit terrain and rolled.
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.
11 Dec Robinson R22
During cruise, the engine failed. The pilot conducted a forced landing into a paddock
where the aircraft struck a fence.
While hovering, the helicopter encountered a wind gust that resulted in the helcopter
entering a high nose attitude and the tail rotor striking the ground. The pilot lost control
and the helicopter impacted the ground coming to rest on its left side.
While manoeuvring for fire bombing operations, the engine failed. The pilot conducted a
forced landing. The investigation is continuing.
It was reported that the helicopter collided with terrain. The investigation is continuing.
FSA MAR–APR10 Issue 73
Graeme Rogers, Operations Manager with CASA’s Office of
Airspace Regulation, talks about the transition to Class D airspace.
This change is, arguably, the most significant revision to capital city secondary airport
procedures since the introduction of general aviation airport procedures (GAAP) in 1978. This
transition to Class D can be viewed as an evolutionary progression of procedures at these
secondary airports. Typically, they began life as all-over fields, moved to strip operations in the
1960s and then, in the seventies, to GAAP, with their radical and much-debated contra-circuit/
parallel runway concept.
Just as now, the modifications were made because of the ever-changing aviation environment.
Generally, changes to this environment have been gradual, but sometimes, the pace of change
has accelerated. The aircraft fleet at these locations, for instance, has moved from Tiger
Moths and Chipmunks, through Cessnas and Pipers and the like, to a mix of everything from
ultralights to jet aircraft, therefore incorporating a huge performance spectrum.
Similarly, the nature of operations has changed. From what was almost exclusively fixedwing training activity these airports now accommodate an almost infinite variety of aviation
operations: commuters, joyflighters, helicopter training, charters, even some public transport
services (PTS), together with a continuing high proportion of fixed-wing training. Of particular
significance is the rapid growth in international training organisations at these locations,
something which has added another dimension to an already complex situation.
We need to consider too, the environmental aspects. When these aerodromes were first
established they resided in the ‘country’, in areas relatively free of immediate neighbours. The
gradual, but relentless expansion of suburbia has resulted in these airports, which were once
in the ‘country’, now being surrounded by a built environment, a large proportion of which is
All these factors have placed pressures upon airport operators, service
providers, airspace users and, dare I say it, regulators. It is this relentless
quest for improvement to services, facilities and procedures that drives
the process. This latest change – the transition to Class D – is simply
part of this continuing process of evolution.
The changes to procedures that will come into effect on 3 June 2010 are
in themselves relatively minor. This is testament to the fundamental
integrity of the basic GAAP structure, which has served so well over
three decades. But the changes need to be seen as complementary
to the high-profile and concentrated safety communication program
undertaken by CASA following the two studies of GAAP completed in
2009. These studies, the General Aviation Aerodrome Procedures Review
and the Utility of General Aviation Aerodrome Procedures, identified areas
where safety improvements could be made and action on these items
has already been undertaken.
Following the release of these reports, the Director of Aviation Safety
(DAS), John McCormick, identified an opportunity to implement
a further safety measure by aligning GAAP with Class D airspace
procedures. The replacement of the Australian-specific GAAP with the
internationally recognised Class D procedures was seen as an important
step in standardising procedures. This standardisation is especially
important given the number of overseas students being trained at these
locations around Australia.
The procedures are broadly aligned with the US Federal Aviation
Administration Class D procedures, which were assessed as part of the
National Airspace System project (NAS). NAS still provides the basic
framework for ongoing airspace modelling within Australia.
The transition was originally planned for April 2010, but following
industry discussions, John McCormick agreed to the revised date of 3
June 2010. This aligns with the AIRAC cycle, so that the new charts and
other aeronautical publications will reflect the changes, and also allows
for a more thorough communication campaign regarding the changes.
GAAP to Class D – at a glance
Please note that at the time this issue of Flight Safety Australia went to
press, the Notice of Proposed Changes (NPC) process was not complete.
However, these are the changes proposed in that document.
There is no change to separation responsibilities within Class D
SPC VFR – SPC VFR: ATC separation
provided when visibility less than VMC
IFR–VFR pilot responsibility; no ATC
VFR – VFR pilot responsibility; no ATC
ATC will provide traffic information and/or
sequencing instructions as deemed necessary
to assist with pilot separation/segregation.
ATC will also provide runway separation
between all aircraft.
Class D Airspace Procedures
The procedures following transition GAAP to
Class D are summarised as follows:
1. T
he mandated requirement for instrument
flight rules (IFR) aircraft to proceed visual
flight rules (VFR) in visual meteorological
conditions (VMC) is removed.
IFR flights may elect to operate
2. For a flight to operate VFR (i.e. in VMC)
the ‘below cloud’ criteria changes from
‘clear of cloud’ to 500 feet below cloud.
VMC criteria (minima) below 3000 feet
flight visibility:
5000 metres
distance from cloud:
1000 feet above
500 feet below
600 metres horizontal
3. Amended special VFR minima
flight visibility:
1600 metres (fixed wing)
distance from cloud:
clear of cloud.
4. Clearances
all aircraft require a clearance to enter
Class D airspace
if workload or traffic conditions prevent
immediate entry to the control zone,
the controller will instruct the pilot to
remain outside the controlled airspace
until conditions permit entry
It was also vital to remove any ambiguity from the application of Class
D procedures nationwide. Hence it was determined that the procedures
to be applied at the old GAAP locations would apply in all existing
Class D airspace, again, another action to increase safety through
IFR–IFR: ATC separation provided
IFR–SPC VFR: ATC separation provided
for VFR flights a clearance will be implicit
two-way radio communication with ATC
established and
Takeoff, landing and taxi clearance
an appropriate clearance from ATC is required.
Procedures Summary
ATC instructions are issued.
This information is a brief outline of the practices and procedures
proposed to be adopted at all Class D aerodromes and is designed
to provide insight into the general philosophy behind the procedures.
They are not necessarily definitive and the information should not be
used operationally without first cross-referencing with the appropriate
mandatory inbound points (GAAP approach
points) are deleted and replaced with VFR
approach points–recommended.
Sufficient notice must be provided to ATC
if entry is sought via other than a VFR
approach point
6. Readbacks
FSA MAR–APR10 Issue 73
a departure report is not required for VFR flights
the pilot’s position and intentions are
understood and acknowledged, or
5. CTR entry points
7. Departure reports
for VFR flights no readback is required if:
standard circuit exit/entry procedures
are employed
for VFR flights a readback is required
a specific ATC instruction is issued
varying standard circuit exit/entry
an airways clearance is issued
Pilot information
CASA is currently developing comprehensive information and
communication materials, which will involve a number of activities.
We will provide information/brochures to all licence holders, and
instructional material will be distributed to training organisations.
A series of safety workshops, to be facilitated by a joint Airservices/
CASA team, is planned at a number of locations around the nation.
Both the DAS, John McCormick and the CEO of Airservices Australia,
Greg Russell, have expressed a desire to participate in the briefing
program wherever and whenever possible. (See opposite for details of
these, and how to register.)
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CASA’s aviation safety advisors and flying
operations inspectors will be actively
involved in providing onsite information and
Tuesday 11 May 2010 – BRISBANE
Bardon Conference Centre
The GAAP Q&A page, already available on
the website, will continue to provide updated
information online.
Tuesday 18 May 2010 – PERTH
Mount Pleasant Baptist Church
Additionally, the informative and widely-used
Visual Pilot Guides for each of the former GAAP
locations are being updated and revised, and
will be released to coordinate with the Class
D-day on 3 June. CASA and Airservices are
also developing an interactive online resource,
for pilots flying into Archerfield, Bankstown,
Camden, Jandakot, Moorabbin and Parafield
airports, also to be released on 3 June.
The workshop timetable is as below:
Transition to Class D
Registration for these workshops
is essential.
Log on to www.casa.gov.au/gaap/,
and complete the form online.
Monday 10 May 2010 – SYDNEY
Bankstown Travelodge
Thursday 20 May 2010 – ADELAIDE
The Mawson Centre
In addition to the extensive information on GAAP issues already
available on the CASA website the suite of documents associated
with the draft Notice of Proposed Change (NPC 172/04) were due for
distribution as part of the public consultation process as this issue
of Flight Safety Australia went to print. These documents will also be
available on the CASA website.
As indicated previously, implementation was deferred, in part, to allow
the documentation amendment cycle to capture the changes without
the need to produce extracurricular paperwork, thus reducing the
risk of currency confusion. The amendment process is well underway
with the Aeronautical Information Publication, which includes the
aeronautical charts, to become effective on the June 3 AIRAC date.
This transition project marks another milestone in the evolution of the
provision of services to the aviation industry within Australia. As with
all these steps, the overriding requirement is safety but, importantly,
efficiency, equity and access are extremely high priorities to both
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and the second in the evening. Catering
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Thursday 13 May 2010 – MELBOURNE
Dingley International
Using HF vs SAT phones
Recently, CASA has had a number of queries
along the lines of:
I have been advised that CASA will approve
installation of an ‘approved satellite phone’ in
place of an HF radio on azirliners and charter
aircraft. Do you know anything about this
The AIP [GEN 1.5 (para. 1.4)] does mention
that CASA approval may be given for the use
of SATCOM telephone instead of HF radio.
However, this is only applicable to flights
where the operator has determined they would
need to use HF in the event of emergency and/
or abnormal operations enroute. This could
be, for example, an in-flight depressurisation
requiring lower-level flight where VHF
communication is not possible.
FSA MAR–APR10 Issue 73
There are several conditions relating to routes, systems, and
procedures, that the applicant must meet before gaining SATCOM
However, no approval may be given for the use of SATCOM telephone
in lieu of HF radio, for flights expected to proceed beyond VHF range
during normal operations, including ground ops at the departure and
arrival aerodromes. The reasons for this include:
ICAO does not recognise SATCOM as an alternative to HF for ATS
purposes; and
Airservices Australia does not have the infrastructure or procedures
to accept SATCOM routinely for ATS purposes.
CASA is continuing efforts internationally to advance increased use
of SATCOM equipment for aircraft communications. However, the
current provisions above are unlikely to change for some time.
Both categories allow aircraft to be used for certain specified purposes,
including exhibition and type training. Limited category aircraft can
also be used for commercial adventure flights, without the need for an
air operator’s certificate (AOC).
The history
Under the Civil Aviation Regulations 1988 (Regulation 262AN) limited
category aircraft must be operated under a manual of operations from
a CASA-approved organisation. Until 2009, a dispensation allowed
operations to continue WITHOUT such a manual, but this dispensation
was withdrawn last year.
What does this mean?
The withdrawal of the dispensation means that all limited category
aircraft MUST now operate under an approved operations manual
... something similar to an AOC. Aircraft owners should note that
an individual aircraft’s operating manual IS NOT a limited category
operations manual.
If you operate a limited category aircraft, there are two ways you can
comply with this regulation:
1. Operate under the auspices and operations manual of Australian
Warbirds Association Limited, or
2. Seek CASA approval to operate other than under a manual
produced by an approved organisation. Any such application
would incur CASA assessment charges of $160 per hour. If you
operate a limited category aircraft,
you must do one or the other. No other
approvals exist!
Please note: Australian Warbirds Association
Limited (AWAL) has approval from CASA to
administer the operation of limited category
aircraft, including approval of the required
schedule on maintenance, issuance of special
certificates of airworthiness, continuing
airworthiness and approval of adventure
flight operations,
AWAL is the only organisation currently
approved by CASA for the purpose of CAR
Adventure flight
All operators of adventure-style flights using
limited category aircraft must:
submit an exposition to AWAL on how they
intend to meet the requirements of the
regulation, and
obtain AWAL’s approval before further
operations. Again, the alternative is to apply
to CASA for an exemption, and assessment
will be charged at $160 per hour.
For further information on both limited
category and adventure-style operations,
log on to the CASA website www.casa.
gov.au. Click on ‘operations’, then ‘sport
aviation’, then ‘warbirds’, and follow the
link to www.australianwarbirds.com.au.
More than 200 ex-military, replica, and historic aircraft, generally
known as ‘warbirds’, are currently operating in Australia. While
they appear on CASA’s civil register, these aircraft do not have civil
type certificates, and therefore operate under special certificates of
airworthiness in ‘limited category’, or as experimental aircraft in
‘experimental category’.
12 February 2009
Bombardier Q400
Buffalo, NY, USA
NB. Preliminary
only and full
investigation not
yet complete.
On February 12, 2009, about 10:17 p.m. Eastern Standard Time (EST), a Colgan Air Inc.,
Bombardier Dash 8-Q400, N200WQ, Continental Connection flight 3407, crashed during
an instrument approach to runway 23 at the Buffalo-Niagara International Airport (BUF),
Buffalo, New York. The crash site was approximately five nautical miles northeast of the
airport in Clarence Center, New York, and mostly confined to one residential house. The four
crew members and 45 passengers were fatally injured and the airplane was destroyed by
impact forces and post crash fire. There was one ground fatality. Night visual meteorological
conditions prevailed at the time of the accident. The flight was a Code of Federal Regulations
(CFR) Part 121 scheduled passenger flight from Liberty International Airport (EWR), Newark,
New Jersey to Buffalo.
A preliminary media report stated:
FSA MAR–APR10 Issue 73
The pilots of the Colgan Air Bombardier Q400 involved in the February 12 crash near Buffalo,
New York, that killed 50 people did not observe the so-called sterile cockpit rule and the
captain appears to have violated Colgan Air’s policy prohibiting the use of the crew room to
sleep overnight, according to testimony read this morning during the NTSB’s public hearing
on the crash.
The NTSB has turned much of its attention to fatigue as a possible contributor to the crash.
Records indicate that on the day of the accident, the captain logged into the company’s crew
scheduling computer system at 3am and 7:30am, and that the first officer commuted to
Newark on an overnight flight to Newark and had sent and received text messages on the day
of the accident.
Colgan had scheduled the crew to report at 1:30pm on the day of the accident, but high winds
at the airport forced the cancellation of the first two flights of the day. Schedules called for
Flight 3407 to take off at 7:45pm and arrive in Buffalo at 10:21pm. Although ground crew
pushed back the airplane from the gate at 7:45pm, the crew did not receive taxi instructions
until 8:30pm and the tower cleared the flight for takeoff at 9:18pm.
This morning’s testimony indicated that Colgan had put in place a fatigue policy before the
accident occurred and that it covered the policy during indoctrination training. However,
according to the testimony, by the date of the accident Colgan did not provide specific
guidance to its pilots in fatigue management. On April 29 this year Colgan issued an
operations bulletin that reiterates its fatigue management policy.
Both pilots were based in Newark. The captain commuted from the Tampa, Florida area, and
arrived in Newark on February 9 at 8pm. On February 10 the captain began the first day of a
two-day trip at 5:45am.
The first officer, who previously lived and was based in the Norfolk, Virginia area, recently moved
to Seattle and had changed her base to Newark. On February 11 she awoke between 9 and 10am
PST, and took a jump seat from Seattle to Memphis, Tennessee, on a FedEx flight that departed
just before 8pm PST. The flight arrived at about 2:30am EST on February 12; at about 4:20am the
first officer rode a jump seat from Memphis to Newark and arrived at about 6:30am.
Colgan’s pilot handbook states only that the company expects the pilot to report for duty in
a timely manner. Although a previous edition of the handbook said that flight crewmembers
should not attempt to commute to their base on the same day they are scheduled to work,
that statement does not appear in the current edition, according to today’s testimony.
Colgan requires its Newark-based crewmembers to provide their own sleeping
accommodation, and ‘sleeping in operations or any crew room in Newark is strictly
prohibited and will have severe disciplinary consequences up to and including termination’,
according to a memo issued May 24 last year by Colgan’s Newark chief pilot.
While there are many more aviation case studies in which fatigue was
a contributory factor, the above highlight a broad cross-section from
different sectors of the aviation industry and remain as valuable case
studies for ongoing training. So what lessons can be learned from
these case studies about improving fatigue management?
The Guantanamo Bay accident was a defining moment (particularly
for the US) in highlighting the risks of fatigue. It remains one of the
few accidents in which fatigue was found to be a primary contributing
factor. The valuable personal insights provided by Captain Chapo and his
openness to share his story, even today after all these years, continue to
provide valuable lessons for other pilots regarding the insidious nature of
fatigue and its ability to trap even the most proficient operators. Fatigue
has been on the NTSB ‘most wanted list’ since 1990, and the NTSB
continues to be at the forefront of fatigue accident investigation and
to provide targeted training on fatigue investigation. After many years,
the US Federal Aviation Administration is in the process of updating its
regulations regarding flight and duty times. Copies of the NTSB fatigue
factors course are available from [email protected]
While a more detailed review of the case studies remains the best
option to gain an understanding of the contribution of fatigue, some
broad factors to consider include:
environment, which encourages such open
and honest feedback regarding the system
There are many more lessons to be gleaned
from the case studies and that’s something for
the professional and disciplined crewmember
and aviation shift worker to pursue further. So
where are we at from a regulatory perspective,
and where does Australia stand in comparison
to the rest of the world?
The risk of balancing the desire for experience and flying hours versus
workload and your own human performance capabilities. The Cessna
172 accident highlighted a situation where an inexperienced pilot with
minimal supervisory support pushed himself too hard on the day.
In some sectors of industry, pilots are exposed to longer periods of
standby time followed by ad hoc medical evacuation operations. There
can be significant pressure to fly regardless of fatigue, and it’s not an
easy task to say no to a flight if you’re getting the bare minimum hours
to stay current.
Personal stress resulting in poor sleep contributed to a breakdown in
the 737 crew’s normal procedures. This remains an issue most aircrew
and shift workers deal with on a daily basis. The development of team
training has provided, and continues to provide, processes to identify
those factors and minimise the risk of stress and fatigue.
The Colgan Air accident highlights the risk of long commutes prior
to duty periods. This is relevant in the Australian situation as well.
Consider the suburbs surrounding airports: property prices continue
to rise near major airfields and many pilots are required to live further
away from their main hub. The pressure to balance personal/family
needs, pay the bills and commute remains an ongoing challenge for
the aviation industry.
Finally, it is important that any operator exposed to higher fatigue risks
and/or utilising a fatigue risk management system (FRMS) ensures the
procedures for managing fatigue are clear and unambiguous, and staff
have been trained appropriately. Furthermore, robust quality assurance
activities must be in place to confirm the system is actually managing
the fatigue risk. Formal feedback from operational personnel–those
actually working the rosters–is the best way to achieve this. However,
for this to work, there must be a suitable safety culture: a working
T he G
u an
a y ac
c id e n
The tasks completed to date include:
Review of various FRMS practices and
scientific reports from around the globe
Strategic input to the ICAO fatigue risk
management working paper
Let’s start by defining a fatigue risk management system (FRMS).
An ‘FRMS is a data-driven, flexible alternative to prescriptive flight
and duty time limitations, based on scientifically valid principles and
measurements.’ International Civil Aviation Organization (ICAO)
FRMS involves a continuous process of monitoring and managing
fatigue risk within the context of an operator’s safety management
system (SMS). This process can be embedded within an SMS, or it can
be a stand-alone system integrated with the SMS.
FSA MAR–APR10 Issue 73
As some of you may be aware, the CASA FRMS project was placed on
hold in anticipation of leadership and further direction from the ICAO.
In the interim, Australia has provided a member and advisers to the
ICAO Fatigue Risk Management Systems Task Force (FRMSTF) with
representation from the regulator, an airline and air traffic control. The
CASA member is also serving as the regional facilitator Asia-Pacific to
coordinate the completion of project tasks.
FRMS work to date includes:
2005–Flight Safety Foundation International task force
develops ultra long-range (ULR) guidelines based on fatigue risk
management (FRM)
2006 – ICAO Operations Panel forms FRM Subgroup to develop
guidance material
2008 – Introduction of FRMS to Annex 6 proposed in a working
Need identified for more guidance on how to implement and
oversee FRMS
2009, August – secretariat forms FRMS task force.
The task force was established as an efficient means to respond to an
urgent call for ICAO leadership regarding FRMS. The aim of the ICAO
task force is to:
Achieve joint industry-government consensus on how to best
implement and benefit from the safety and efficiency gains that
FRMS offers, and
Develop detailed guidance material to build upon the current
working paper to provide operationally viable methods so that
operators can readily implement FRMS within the broader context
of safety management systems.
As part of achieving this broader aim, a meeting was held in Montreal
from 3-5 November 2009 for members and advisers. This involved 37
participants from around the world providing representatives from ICAO,
regulators, airlines, aircraft manufacturers, universities, the International
Federation of Airline Pilots’ Association (IFALPA) and the International Air
Transport Association (IATA).
Development of a draft framework for
FRMS standards and recommended
practices and further detailed guidance
Submission of a number of reports/
papers representing good fatigue risk
management (FRM) practice from the
Asia-Pacific for consideration and possible
inclusion in the guidance material.
The work of the task force is progressing well.
As this issue of Flight Safety goes to press,
two milestones are about to be completed:
a preliminary briefing to the Air Navigation
Commission on 24 February 2010; and the
formal ICAO Commission hearing on 12
March. As can be expected, the process,
which includes review and comment by the
190 contracting states, will take some time. All
going well, this process should be completed
by mid 2011.
So from this experience with ICAO, it’s timely
to reflect on where we stand within Australia
with regard to the CASA and industry FRMS
CASA’s involvement has ensured our region
remains abreast of fatigue world best practice
and emerging issues.
Importantly, Australia has a large number
of operators (approximately 70) already
operating within an FRMS framework. While
other airlines (easyJet, Air New Zealand,
Singapore and Delta) and regulators: the
United Kingdom’s Civil Aviation Authority (UK
CAA) and the Canadian CAA, for example, are
further advanced in some areas of FRMS,
Australia remains at the forefront for smaller
operations. The technical and operational
FRMS expertise both within CASA and more
broadly, the Australian aviation industry, is
well advanced and in a very good position to
leverage from the work of ICAO.
FRMS should be considered in reference to
SMS, where applicable. SMS regulations and
the ongoing timetable for their implementation
in low- and high-capacity regular public
transport (RPT) operations were introduced
last year, and remain a priority. For airlines,
the process of implementing SMS is an
opportunity for identifying, implementing and
refining practices to identify hazards, mitigate
and control risks, implement quality assurance
processes to ensure the system is working and
provide necessary training to staff.
Fatigue is just one of the many risks airlines
must manage. And according to a number of
the ICAO fatigue risk management task force
members, managing fatigue risk successfully
and developing and implementing an FRMS
is one of the more difficult and challenging
areas to do well, because it’s an advanced
application of SMS. To build an FRMS on
secure foundations, an organisation needs
a mature understanding of SMS, as well
as a safety culture with open and honest
communication which encourages feedback
from operational personal.
While some operators are well advanced and
managing fatigue to a high standard, recent
observations from the field have highlighted
some ongoing issues with complacency
and overreliance on these biomathematical
models. This was identified some time ago,
and further guidance material has been
developed by CASA human factors on the use
A biomathematical model is a tool just like
any other–a traffic collision avoidance system
(TCAS), for example. If you install a TCAS into
an aircraft it is essential those using the tool
are well trained in the operation of the system
and any limitations to its use. The same is
true of FRMS tools. Those using the tools
(biomathematical models, for example) must
receive appropriate training regarding how to
use the tool and understand any limitations
associated with it.
FRMS requires continuous monitoring,
assessment and improvement. A couple of
key questions any safety manager should
regularly ask (say every 12 months) are:
’What’s changed permanently through the
use of our SMS/FRMS?’ and ‘What are we
doing differently from 12 months ago?’ If you
struggle to answer these questions, it may be
that you are too busy with ‘process’, rather than
implementing permanent changes. If you’re
preoccupied with multiple investigations of
incidents, transferring this information into
a database, quarterly reports, training and
so on, it may be a sign of being so busy with
the formal processes at the front end of the
system, that you’re not actually delivering
any tangible changes or improvements.
Arguably, one good process that closes the
loop and leads to permanent improvements
can be better than multiple processes which
are not fully completed. Ultimately, any
system, whether SMS or FRMS, designed to
improve the management of operational risks
must seek regular feedback from operational
staff (pilots, cabin crew, mechanics, air
traffic controllers etc) as part of the quality
assurance process.
In summary, Australia, through the dedicated
work to date of a number of regulatory and
industry personnel, is well placed in its
ability to implement FRMS for the improved
management of fatigue.
The definition of FRMS above emphasised
the use of ‘scientifically-validated principles
and measurements’. Traditionally, the direct
approach to prevent fatigue has been to
introduce regulations limiting flight and duty
time. But this prescriptive approach does not
take into account the fact that depending on
the time of day–the circadian rhythm–a break
will have different recovery values. So in an
effort to introduce ‘scientifically-validated
principles’, some use biomathematical models
to predict the risk of fatigue associated with
a specific pattern of working hours. Many
operators within Australia and around the
globe are utilising various biomathematical
models to support their FRMS.
and limitations of biomathematical modelling.
This report is available via [email protected]
casa.gov.au and has been reviewed by a
number of fatigue specialists, some of whom
are serving on the ICAO FRMS task force. The
report provides a survey of current capabilities
of various fatigue models and considerations
regarding incorporation into an FRMS.
Guantanamo Bay accident
Information extracted from NTSB Aircraft Accident
Report, NTSB/AAR-94/04; NTSB Fatigue Factors Course
ULR operational guidelines
Flight Safety Foundation, Flight Safety Digest, Vol 24, No.
8-9 August-September 2005
1999 Cessna accident
2007 Boeing 737-476 Swan Hill VIC www.atsb.gov.au/publications/investigation_
FSA MAR–APR10 Issue 73
2009 Bombardier Q400
Also: www.ainonline.com/news/single-news-page/article/
Maintenance Fatigue Focus
FAA publication
Copies of the biomathematical
modelling report & any further
FRMS information
Flight Safety Australia articles
[email protected]
Available for download online: www.casa.gov.au/fsa/
and go to the FSA archive.
‘Dead Tired’ July-August 2001
‘Sleep Inertia’ September-October 2002
‘Are you Getting Enough?’ May-June 2005
‘When the shift hits the fan …’ November-December 2000
Roger Alder looks at
defect reporting from
the other side.
Anyone who has been in the maintenance game for a few years gets to
collect ‘classic’ examples of defect analysis gone wrong. I have to say
that I have done my fair share of misdiagnosing problems and ‘fixing’
the wrong thing–and when I think back to those occasions, I still kick
myself, even today. Experience, they say is the best educator, but I found
the lessons to be very expensive; so, let me share an experience or two,
and hopefully help cut training costs.
Gentle questions about voltage regulator adjustment just brought
blank stares. We found by checking the settings, of course, that they
had drifted to very high values, which explained what had ‘cooked’
the batteries and given the generators a very good workout. When the
regulator was adjusted to the correct values, battery life improved out
of sight, and the generator problems went away as well.
It all looks so very simple looking back years later, but I understand
now, more than ever, that sometimes the pressure of work, of meeting
deadlines, forces you to focus on addressing the problem with everincreasing desperation, and never consider the basic cause.
As your experience grows, you can generally tell if the problem (defect)
seems to be related to, or directly caused by design, manufacture,
operation or maintenance, or a combination of these factors. Might I
Years ago, in another part of the world, I came across an example
of a misdiagnosed electrical system problem. In the corner of this
quite isolated bush hangar, there was a rather large heap of very
dead-looking, badly disfigured lead-acid batteries. The cases of every
battery had melted; some so badly that the tops had collapsed onto
the plates below, and filler caps were missing, or leaning against each
other. Obviously, heat was involved somewhere. When I asked the
maintenance people, they said: ‘They simply don’t make batteries like
they used to. These days they never seem to last more than about 50
hours; sometimes very rarely, 100 hours; then they do this. We keep
topping them up; in fact, we have adjusted the fleet’s maintenance
program to ensure the battery water is kept up to them – but all we
keep getting is … meltdown. We’re starting to see generator problems
now, as well.’
Pull-Out Section
Following the service difficulty report (SDR) competition announcement
in the last issue, we thought that it might help to provide some ongoing encouragement regarding actual defect analysis. Last issue, we
identified some of the legal requirements of defect reporting and how
to fill out the CASA SDR form (another legal requirement in regard to
reporting defects).
also suggest that is also worth considering:
Whether it is a repeating problem and if so,
what are the indicators or other clues that
could tell why this is happening? What are
the common factors?
Pull-Out Section
‘Phoning a friend’ to see if you are the only
person experiencing this type of defect.
FSA MAR–APR10 Issue 73
Whether maintenance has been recently
completed on this system or part and
if so, checking that the manufacturer’s
instructions were properly followed.
If there were any new or overhauled
parts installed, and if the parts really are
approved parts.
If the maintenance manual troubleshooting guide has anything to say about
the problem.
If a service bulletin (SB) or airworthiness
directive (AD) has been issued on this
problem. Apart from the legal aspects,
these documents are usually records of
hard-won experience regarding serious
problems, and often contain advice on how
to avoid the problem altogether, and how
to fix it.
In addition to using the manufacturer’s troubleshooting guides, I can’t say enough about
having good, sound, systems knowledge when
investigating defects. Preferably, this means
having knowledge of more than one category,
and more importantly, how the various
systems interact with each other. This gives
you the ability to imagine the ‘invisible’: to
create a dynamic simulation of the structure,
system or engine in operation, because you
know all the elements that make an engine,
for example, run well. You should be able to
put the basic elements together – air, fire,
coolant and oil – (and noise) to help you come
to a satisfying, well reasoned conclusion.
Here’s another example. The aeroplane in this
case is a classic Cessna 206.
The problem was that the main wing flaps
came down to about the half-way position and
just ‘stuck’ during the approach to land. They
would not retract from that setting in flight –
and yet they worked just fine on the ground.
Up-down, up-down; no fault found.
This was serious, because a safe landing on a
short bush strip at high altitude was simply not
safe without full flaps; and trying a go-round
with more than 10 degrees was definitely not
healthy. Once on the ground, the flaps could
be set and retracted from any setting. As the
long days wore on, I was instructed to change
the flap motor, control relays and control
switch. Which I did of course, but the flaps still
became ‘stuck’ during the approach. As the
new bloke, I was given the problem, I had a bit
of a think, and imagined what was going on
as the flaps came down in flight, and noticed
that on the right side of the fuselage, as they
came down, they passed the cargo doors.
The cargo doors have a microswitch wired
so as to switch the electric flap motor off
and prevent the flaps coming down when
the cargo door is open. In flight, however, as
the flap moves past the door, it introduces
a significant area of low pressure at the
door, trying to pull it open about where the
microswitch is located. I walked up and found
I could stick my fingers in and pull the top
edge of the door open just that little bit and
sure enough, I could hear the micro clicking.
I adjusted the door and fixed the flaps. It was
one of my few ‘wins’.
1 Dec 2009 – 31 Jan 2010
Airbus A320212 Fuel system manifold valve
faulty. Ref 510009863
Wing fuel tanks overfilled and venting. Fuel had been
transferred to the wing tanks at a faster rate than
the engines were using it, causing tanks to overfill
and vent. Further investigation found a faulty fuel
manifold air release valve. Investigation continuing.
P/No: FRH280002.
Airbus A330202 Nose wheel steering faulty.
Ref 510009899
Nose wheel steering system faulty. Green hydraulic
system pressure switch suspect faulty. Investigation
continuing. (4 similar occurrences)
Airbus A330203 ADIRU faulty. Ref 510009624
Attitude direction indicator remote unit (ADIRU)
suspect faulty. Investigation continuing.
P/No: 46502003030316. (7 similar occurrences)
Airbus A380842 Aircraft fuel systems pump
failed. Ref 510009539
Dual fuel boost pump failure. Investigation continuing.
BAC 146RJ70 Autopilot digital flight guidance
computer failed. Ref 510009868
Autopilot digital flight guidance computer (DFGC) failed.
P/No: 4068300905. (1 similar occurrence)
BAG JETSTM4101 Engine starter-generator
terminal block burnt. Ref 510009664
Right-hand engine starter-generator terminal
block burnt. Investigation found the feeder cable
incorrectly installed causing connection to loosen
and overheat.
P/No: 230951180. TSO: 891 hours/468 cycles.
Boeing 717200 Nose landing gear proximity
sensor faulty. Ref 510009540
Nose landing gear proximity sensor faulty.
Boeing 7373YO Aircraft start fuel valve wire
broken. Ref 510009599
Start fuel valve wire broken. Wire is located in righthand wing leading edge at approximately FSS 403.
(1 similar occurrence)
Boeing 737476 Aircraft outflow valve
malfunctioned. Ref 510009508
Aircraft aft outflow valve malfunctioned during climb.
Valve was replaced on the ground and pressurisation
system tested serviceable. Refer to related SDR
Boeing 737476 Co-pilot’s window outer pane
shattered. Ref 510009545
First officer’s outer window (R1) outer pane shattered
in flight.
P/No: 5893543150. (30 similar occurrences)
Boeing 737476 Flight deck oxygen shutoff valve
partially open. Ref 510009551
Flight deck oxygen valve partially open. Investigation
Boeing 737476 Fuselage floor beam straps
cracked. Ref 510009523
Fuselage floor beam straps located at Stn 320 BL0 in
the avionics bay cracked.
P/No: 654583470.
Boeing 737476 Outboard flap carriage spindle
cracked. Ref 510009827
Left-hand outboard flap carriage spindle cracked.
Found during inspection iaw AD/B737/200.
P/No: 6546481105.
Boeing 737476 Weather radar transceiver
failed. Ref 510009818
Weather radar transceiver failed.
P/No: 6225132106. TSN: 534,895 hours. TSO: 37,831
hours. (18 similar occurrences)
Boeing 7374L7 Spoiler outboard actuator
hinges broken. Ref 510009794
No 4 and No 5 spoiler outboard actuator hinges
broken. Investigation continuing.
P/No: 654645262A.
Boeing 73776Q Main landing gear tyre burst.
Ref 510009618
Left-hand main landing gear No 2 main wheel tyre
burst on landing.
TSN: 594 hours/235 cycles. (22 similar occurrences)
Boeing 7377Q8 Captain’s pitot tube blocked.
Ref 510009781
Captain’s pitot probe blocked by insect.
P/No: 0851HT1. TSN: 16,271 hours/11,629 cycles.
(2 similar occurrences)
Boeing 7377Q8 Engine cowl anti-ice valve
stuck. Ref 510009517
No 1 engine cowl anti-ice valve failed to close.
P/No: S332A2392. TSN: 15,471 hours/9,290 cycles.
(11 similar occurrences)
Boeing 7377Q8 Flight management computer
unserviceable. Ref 510009671
No 2 flight management computer (FMC) failed.
P/No: 1762000101. TSN: 25,610 hours/18,583 cycles.
(16 similar occurrences)
Boeing 7377Q8 Lift spoiler mixer
unserviceable. Ref 510009586
Lift spoiler mixer unserviceable.
P/No: 251A17415. TSN: 24,534 hours/17,689 cycles.
Boeing 737838 Cargo smoke detector
unserviceable. Ref 510009592
Forward cargo smoke detector failed.
P/No: 4735975. TSN: 27,081 hours.
TSO: 27,081 hours. (2 similar occurrences)
Boeing 737838 Flap inboard operating
bellcrank broken. Ref 510009600
Right-hand outboard aft flap inboard operating
bellcrank broken.
P/No: 113A39104. (5 similar occurrences)
Boeing 737838 Main and APU battery charger
unserviceable. Ref 510009546
Main and APU battery charger unserviceable. Main
battery changed due to high temperature.
P/No: 893003. TSN: 11,637 hours. TSO: 11,637 hours.
(2 similar occurrences)
Boeing 737838 Standby power control unit
failed. Ref 510009591
Standby power control unit (SPCU) failed.
P/No: 115195214. TSN: 14,081 hours. TSO: 14,081 hours.
Boeing 737838 Weather radar failed.
Ref 510009638
Weather radar failed. Investigation found graphics
generator B defective.
(3 similar occurrences)
Boeing 73786N Air conditioning cabin pressure
control module failed. Ref 510009683
Cabin pressure control module failed.
P/No: 103223111. TSN: 19,697 hours/13,935 cycles.
Boeing 7378BK Engine bleed air pre-cooler
control sense line leaking. Ref 510009537
No 2 engine bleed air system pre-cooler control
pressure sense flexible line leaking.
P/No: 1613580.
Boeing 7378BK Hydraulic system pump
unserviceable. Ref 510009896
Right-hand hydraulic system electric motor-driven
pump (EDMP) failed. Nil contamination of filters.
P/No: 5718610. TSN: 9,032 hours/4,209 cycles.
(20 similar occurrences)
Boeing 747438 Aircraft fuel system override
jettison pump tube separated. Ref 510009770
No 2 main outboard override/jettison pump housing
discharge tube flange separated in area beneath
Wiggins coupling. Tube is part of pump housing P/No
60-703200. Investigation continuing. P/No: 6070330.
Boeing 747438 APU unserviceable – oil fumes
in cockpit. Ref 510009826
Oil fumes in cockpit. Suspect faulty APU.
Investigation continuing.
Boeing 747438 Ground power receptacle
caught fire. Ref 510009696
No 2 ground power receptacle caught fire. Damage
caused to power status lights. External power was
connected at the time. Investigation continuing.
Boeing 747438 Moisture barrier leaking.
Ref 510009656
Moisture barrier above radio altimeter transceivers
leaking. Radio altimeter transceiver water
contamination. Investigation continuing.
Boeing 767336 Aircraft fuel systems wire
corroded. Ref 510009621
Right-hand auxiliary fuel tank quantity indicating
system wire W448 failed resistance check due to
corroded shield between D5880p and D2812.
BAC 146200 Door escape slide unserviceable.
Ref 510009811
Door R1 escape slide unserviceable. Slide failed to
deploy automatically.
P/No: D31050105SN0298. TSN: 289 months.
TSO: 11 months.
Boeing 737476 Flap position indicating
connector short circuit. Ref 510009735
Flap position indicating system connector D275 pin 11
and pin 3 short-circuited. Suspect resistance problem
with wire W802-209-22R. TSN: 63,262 hours.
TSO: 63,262 hours.
Boeing 737838 Elevator feel and centering
spring broken. Ref 510009526
Elevator feel and centering unit inner spring broken.
P/No: 251A21843. (3 similar occurrences)
Pull-Out Section
Airbus A330202 Aircraft oxygen system PSU
doors nil clearance. Ref 510009549
Numerous passenger oxygen system passenger
service units (PSU) doors had insufficient clearance.
(4 similar occurrences)
Boeing 737476 Escape slide failed to deploy
during test. Ref 510009740
Escape slide failed to fully inflate during test.
Approximately 20 per cent inflation achieved.
P/No: 737M25651017. TSN: 61,048 hours.
TSO: 1,876 hours. (9 similar occurrences)
Boeing 767336 Electrical utility buses tripped.
Ref 510009844
Left-hand and right-hand utility buses tripped off on
takeoff. Investigation continuing.
Boeing 767336 Equipment rack drip shield
cracked. Ref 510009628
E1/E2 equipment rack drip shield cracked.
Investigation continuing.
Pull-Out Section
Boeing 767338ER Aircraft fuel systems wiring
failed test. Ref 510009764
RH auxiliary fuel tank fuel quantity indicating system
wiring failed loop resistance check.
FSA MAR–APR10 Issue 73
Boeing 767338ER EICAS computer water
contamination. Ref 510009571
Right-hand EICAS computer contaminated with water
due to faulty forward drain mast heater. Investigation
continuing. P/No: 8221033100. (1 similar occurrences)
Boeing 767338ER EICAS screen failed.
Ref 510009512
Lower EICAS screen failed. Investigation found
capacitor A5C117 on the A5 deflection card had
failed. P/No: 622799003.
Boeing 767338ER Trailing edge flap control rod
nut missing. Ref 510009623
Left-hand inboard trailing edge flap control rod nut
missing, allowing torque tube to contact and break off
forward and aft fairing doors. Investigation continuing.
Bombardier DHC8102 Air conditioning system
outflow valve venturi blocked. Ref 510009813
Pressurisation system outflow valve venturi blocked
and venturi supply line leaking. P/No: 1314101.
Bombardier DHC8202 Antenna coaxial cable
damaged. Ref 510009722
Coaxial cable located between antenna and rear
pressure bulkhead disconnect heat damaged.
Investigation continuing. P/No: 83455436001.
(1 similar occurrence)
Bombardier DHC8202 Elevator trim chain
disconnected at servo motor. Ref 510009688
Elevator trim chain disconnected at servo motor.
Investigation found the chain link/circlip had failed.
Bombardier DHC8202 Elevator upper bumper
stop missing. Ref 510009751
Left-hand elevator upper bumper stop missing,
allowing elevator to catch on rudder.
P/No: 85520271003. TSN: 2,483 hours/594 cycles.
Bombardier DHC8402 Engine fuel flow
transmitter wiring chafed. Ref 510009556
No 2 engine fuel flow transmitter wiring insulation
chaffing inside connector.
TSN: 8,248 hours/9,508 cycles. (2 similar occurrences)
Embraer EMB120 Elevator cable incorrectly
fitted. Ref 510009677 (photo below)
Elevator cable not routed over pulley. Cable was outside
of the keeper and rubbing on the side of the pulley.
Elevator Pitch Cable
out of the keeper
& rubbing against
keeper side.
Elevator Flight
Control Cable
Embraer EMB120 Landing gear anti-skid
control box failed. Ref 510009734
Anti-skid system control box failed. P/No: 426871.
Embraer ERJ170100 Hydraulic system firewall
shutoff valve unserviceable. Ref 510009516
RH engine nacelle firewall mounted hydraulic shutoff
valve unserviceable. Valve is Post SB 170-29-0024.
P/No: 9752877. TSN: 9 hours/10 landings.
(5 similar occurrences)
Embraer ERJ190100 Aileron cable worn.
Ref 510009519
Left-hand aft inboard aileron cable worn beyond
limits. Found during aileron cable inspection.
P/No: 19004209401. (9 similar occurrences)
Embraer ERJ190100 Aircycle machine seized.
Ref 510009636
Air cycle machine seized. Investigation continuing.
P/No: 10007004.
Fokker F28MK0100 Seat belts detached from
seat bases. Ref 510009783
Two seat belts separated from seat bases. Further
investigation found another seven belts incorrectly
fitted. (1 similar occurrence)
Fokker F28MK0100 Speed brake actuator
unserviceable. Ref 510009625
Speed brake actuator unserviceable. Investigation
(1 similar occurrence)
Lear 45 Engine isolation bolt failed.
Ref 510009669 (photo below)
Aft engine isolator bolt sheared at waisted threaded
area. Bolt remained in position due to lockwire and
anchor nut. Suspect bolt had failed prior to engine
removal for vibration.
P/No: 4571408525001. TSN: 7,665 hours/13,831 cycles.
Embraer ERJ190100 Landing gear system
suspect faulty. Ref 510009520
Suspected landing gear activation in flight. Flight
data recorder indicated gear position did not change.
Extensive investigation could find no fault, although
selector panel was changed as a precaution.
Embraer ERJ190100 Nose wheel steering
control module unserviceable. Ref 510009847
Nose wheel steering control module unserviceable.
P/No: 1855A000004. TSN: 1,927 hours/1,312 cycles.
Fokker F28MK0100 Air conditioning system
main riser distribution duct split. Ref 510009640
Plastic-type odour in forward cabin. Investigation
found the main riser distribution duct split.
Investigation also found a blank separating the ACM
bay from the avionics bay had come adrift.
TSN: 26,104 hours/19,845 cycles.
(1 similar occurrence)
Fokker F28MK0100 Aircraft fuel vent line
disconnected. Ref 510009555
Fuel vent line located in right-hand wing
disconnected from flexible coupling. Fuel leaking.
Investigation continuing.
Fokker F28MK0100 Flight control lift dumper
bellcrank dry. Ref 510009886
Inboard lift dumper bellcranks dry, with nil
Fokker F28MK0100 Hydraulic pump leaking.
Ref 510009717
No 2 engine driven hydraulic pump leaking. Loss of
No 2 hydraulic system fluid.
P/No: 42047. TSN: 15,674 hours.
Fokker F28MK0100 Main landing gear brake
separated. Ref 510009742
No 4 main landing gear brake assembly broken up
with rotor and stators separated. Wheel assembly
scored by brake debris. Found during removal of
brake assembly due to worn to limits.
P/No: 50118091. TSN: 7,641 cycles/7,641 landings.
TSO: 1,613 cycles/1,613 landings.
Fokker F28MK0100 Nose landing gear steering
bath vent plug leaking. Ref 510009514
Hydraulic oil leak from nose landing gear steering bath
vent plug. Investigation could not determine the source
of the leak, but suspected that the fault was internal
leakage at the steering pistons. Investigation continuing.
TSN: 24,733 hours/23,875 cycles.
TSO: 1,871 hours/4,080 cycles.
Raytheon 800XP Stall vane heating system
wiring loom rubbing/short circuiting.
Ref 510009593
Right-hand stall vane heating-system wiring loom
chafed, and short-circuiting on fire extinguisher
bottle located in rear equipment bay.
TSN: 1,670 hours/1,055 cycles.
Saab SF340B Aircraft oxygen system fitting
contaminated. Ref 510009880
During removal of interconnect line fittings at
right-hand oxygen cylinder manifold assembly,
white powder was found in and around the O-ring
and mating surfaces. As the interconnect line was
removed, sparking occurred at the manifold port. Nil
external power was applied and battery had been
Saab SF340B Cockpit overhead panel wires
burnt. Ref 510009617
Cockpit overhead panel wires LS67 and LS68 had
burnt insulation and wires were melted.
P/No: LS67.
Saab SF340B Tail pipe fire detection loom
damaged. Ref 510009851
Right-hand tailpipe fire detection system loom
damaged between WG616-20 and WG609-20 and
sealant deteriorated.
Beech 200 Main landing gear actuator support
bracket angle cracked. Ref 510009887
Right-hand main landing gear actuator support
bracket attachment angle cracked.
P/No: 10112012216.
Beech 200 Fuselage skin cracked.
Ref 510009684
Lower fuselage skin cracked. Crack located at
approximately FS 127 half-way between stringer 15L
and stringer 16. Crack length approximately 30.48mm
(1.2 in).
P/No: 10140001027. (4 similar occurrences)
Beech 58 Aircraft fuel system gauge pressure
tube corroded. Ref 510009700
Fuel gauge pressure tube assembly corroded and
leaking. Tube had corroded in area of contact with
Scat hose.
P/No: 96324128121. TSN: 5,793 hours/360 months.
Beech 58 Landing gear drive rod shear pin
failed. Ref 510009879
Left-hand main landing gear drive rod shear pin
failed. Right-hand drive rod shear pin replaced as a
precaution, and was found to be worn.
P/No: 608100823.
Beech 76 Hydraulic power pack valve body
leaking. Ref 510009691
Hydraulic power pack leaking from valve body.
Investigation found pump manifold plug missing due to
failure of the retaining roll pin. Investigation also found
one of the roll pin holes in the housing elongated.
P/No: HYC2056C1. TSO: 5,748 hours/117 months.
Britten Norman BN2B20 Autopilot roll servo
failed. Ref 510009855
Autopilot roll servo failed causing wiring to smoke.
(1 similar occurrence)
Cessna 172S Aileron cable worn.
Ref 510009542
Left-hand and right-hand aileron cables worn.
P/No: 051015360. TSN: 1,198 hours. (1 similar occurrence)
Cessna 208 Rudder hinge bracket corroded.
Ref 510009750
Lower rudder hinge attachment bracket contained
exfoliation corrosion.
P/No: 26310461. TSN: 1,753 hours/4,808 cycles/4,808
landings/33 months.
Cessna 402C Aircraft fuel sensor wire rubbing.
Ref 510009536
Left-hand and right-hand fuel tank low-fuel sensor
wire chaffing through insulation at Stn 133.29.
Cessna P206E Trim cable failed. Ref 510009850
Left-hand forward trim cable failed. P/No:
DHAV DH82A Landing gear axle collar broken.
Ref 510009877
Right-hand main landing gear axle collar failed.
Landing gear collapsed causing aircraft to nose
over and damage outer wing leading edge and two
forward exhaust stacks. P/No: H21583.
Piper PA25235 Flap cable frayed at pulley
position. Ref 510009699
Flap cable frayed at pulley position. Eyelets at either
end of the cable also had broken cable strands.
Swearingen SA227AC Main landing gear
retraction hose ruptured. Ref 510009757
Right-hand (RH) outboard main landing gear
retraction system flexible hose ruptured/detached.
Loss of hydraulic fluid. During investigation it was
noted that the RH main landing gear door actuator
shear bolt was sheared, and the RH outboard gear
Swearingen SA227AC Park brake system
faulty. Ref 510009860
Park brake system faulty. Problem with park brake
valve release system prevents proper release of park
brake, resulting in dragging and overheated brakes.
TSN: 33,929 hours/44,600 cycles.
TSO: 33,929 hours/44,600 cycles.
Agusta-Bell A109E Tail rotor head trunnion
galled. Ref 510009527
Tail rotor hub Teflon bushings badly worn, causing
galling of tail rotor trunnion.
P/No: 109813133101. TSN: 344 hours/27 months.
TSO: 344 hours.
Eurocopter AS332L Autopilot trim servo valve
faulty. Ref 510009749
Autopilot hydraulic pitch trim servo valve faulty. P/
No: 677702. TSN: 19,909 hours. TSO: 2,031 hours.
Eurocopter AS350B2 Hydraulic pump drive
pulley worn. Ref 510009753
Hydraulic pump drive pulley inner bearing excessively
loose and spinning on pulley shaft. Spalling of shaft
evident. P/No: 350A35109222. TSN: 1,815 hours.
Eurocopter AS350B2 Tail rotor blades spar
cracked. Ref 510009866
Tail rotor blade spar cracked beyond limits. Found
during inspection iaw AS350 Service Bulletin
SB05.11R5 and AD/Ecureuil/22. P/No: 355A12004008.
TSN: 3,291 hours/21,431 landings.
TSN: 3,291 hours/21,431 landings/84 months.
Eurocopter SA365C1 Autopilot trim motor
suspect faulty. Ref 510009861
Autopilot system causing binding in lateral cyclic
controls. Investigation found that the autopilot trim
motor (P/No 418-00302-000) and the roll auxiliary
servo (P/No 30302-410) were the cause of the
binding. P/No: 41800302000.
MDHC 369E Main rotor blade delaminated.
Ref 510009567 (photo below)
Main rotor blade delaminated. Approximately 100mm
(4in) of the top leading edge affected.
P/No: 500P2100105. TSN: 121 hours. TSO: 121 hours.
(1 similar occurrence)
Sikorsky S76A Tail rotor blade cracked.
Ref 510009809
Tail rotor blade cracked in area of spar trailing edge.
P/No: 7610105101041. TSN: 13,934 hours.
Continental GTSIO520 Engine exhaust coupling
bolts failed. Ref 510009797
Right-hand engine, left-hand exhaust coupling bolts
failed, allowing coupling to separate. Recovered
bolts found thread stripped. Slip joint partially seized.
P/No: AN3.
Continental IO360E Magneto flange cracked.
Ref 510009882
Right-hand magneto mating flange cracked in area of
holding washer.
P/No: 6314. TSN: 1,234 hours/59 months.
Continental IO520L Engine crankshaft bearing
failed. Ref 510009710
Rear crankshaft bearing failed. Bearing appears
to have been spinning and had migrated causing
bearing metal to delaminate. Metal contamination
of oil filter and sump.
P/No: SA642720. TSN: 1,106 hours. (3 similar occurrences)
Continental IO520L Magneto cracked/leaking
oil. Ref 510009741
Left-hand magneto cracked and leaking oil from base
at lower hold-down point.
P/No: 6310. TSN: 814 hours. TSO: 814 hours.
Continental IO550N Exhaust turbocharger
bearings worn. Ref 510009569
Left-hand engine turbocharger bearings worn,
allowing oil to leak into cabin heater vent.
Investigation also found the cabin heat control
incorrectly rigged from the factory being still
partially open when selected ‘Off’.
P/No: 4663040003. TSN: 340 hours/30 months.
Jabiru JABIRU2200B Engine crankcase/
cylinder through bolt failed. Ref 510009870
Engine crankcase/cylinder through bolt head snapped
of flush with the cylinder base flange.
TSO: 301 hours.
Jabiru JABIRU2200B Engine cylinder barrel
cracked. Ref 510009848 (photo below)
Engine cylinder cracked for approximately 50 per cent
of circumference of barrel. Rear upper stud snapped
off at flange. TSO: 106 hours. (1 similar occurrence)
Robinson R22BETA Tail rotor control pitch link
failed. Ref 510009575
Tail rotor control pitch link snapped in area adjacent
to the ball joint. The ball joint was found worn to
limits, but it could not be established whether this
happened before or after the pitch link failure.
P/No: B3453. TSN: 563 hours. TSO: 563 hours.
Cessna 172C Wing spar angle corroded.
Ref 510009634
Right-hand wing forward spar angle contained severe
exfoliation corrosion in two places in area of wing
strut attachment. P/No: 05230202.
Swearingen SA227AC Main landing gear
retraction tube cracked. Ref 510009859
Left-hand main landing gear ‘up’ hydraulic tube
cracked and leaking at formed bend. Loss of main
hydraulic system fluid. P/No: 2781006021.
Robinson R44 Main rotor drive scissor arm
worn. Ref 510009532 (photo below)
Main rotor drive scissor levers worn. Caused by
incorrect shimming. P/No: C2043. TSN: 1,156 hours.
Pull-Out Section
Beech 58 Landing gear gearbox arm failed.
Ref 510009874
Landing gear gearbox arm failed. P/No: 1048200503.
door had minor damage, possibly caused by contact
with the RH main landing gear drag brace. P/No:
94F0800004F0204. (2 similar occurrences)
Pull-Out Section
FSA MAR–APR10 Issue 73
Lycoming LTIO540J2BD Engine turbocharger
shaft bearing collapsed. Ref 510009604
Right-hand engine turbocharger shaft bearing
collapsed. Impeller tip damaged.
P/No: 4091709001. TSO: 9 hours. (10 similar occurrences)
GE CF680E1 Thrust reverser duct ruptured.
Ref 510009657
No 2 engine thrust reverser HP duct ruptured at
clamp attachment. Numerous adjacent wiring looms
burnt. Investigation continuing. P/No: 1849M16G01.
Lycoming O320D3G Engine cylinder cracked/
failed. Ref 510009893 (photo below)
No 3 cylinder cracked and eventually failed in area
between seventh and eighth fins. Investigation found
corrosion to be a contributing factor. P/No: LW12416.
TSO: 1,752 hours. (6 similar occurrences)
GE CFM563C Turbine engine turbine section
turbine damaged. Ref 510009557
No 2 engine high EGT and vibration. EGT 940 degrees
for four seconds and four units of vibration. Engine
change carried out. Damage to tailplane. Preliminary
investigation found damage to the low pressure
turbine. Investigation continuing.
P/No: CFM563C1. TSN: 36,087 hours.
TSO: 36,087 hours. (1 similar occurrence)
Lycoming O360A4M Spark plug unserviceable.
Ref 510009713
No 4 cylinder upper and lower spark plugs worn and
damaged. Detonation then caused failure of No 4
big-end bearing and destruction of the engine. P/No:
REM40E. TSO: 684 hours. (2 similar occurrences)
Thielert TAE12502 Engine low power/
fluctuates – suspect electrical connection. Ref
Left-hand engine low power and fluctuations due to
suspected fuel pressure fluctuations. Investigation
could find no definitive cause, but following
disconnection/reconnection of the plug from the
wiring loom to the rail pressure sensor, the fault was
cleared. Suspect poor electrical connection in plug
connecting harness to rail pressure sensor.
P/No: TAE12502. TSN: 308 hours. TSO: 308 hours.
(4 similar occurrences)
Garrett TFE73120R Engine failed. Ref 510009646
(photo below)
RH engine failed. Initial investigation found damage
to the turbine and other areas. Investigation
continuing. P/No: 30600823. TSN: 7,124 hours/12,777
cycles. TSO: 2,030 hours/3,663 cycles.
(2 similar occurrences)
IAE V2527A5 Engine HP turbine disc cracked.
Ref 510009873
Engine high pressure turbine Stage 1 disc contained
45 linear crack indications in fir tree roots.
Investigation continuing.
P/No: 2A5001. TSN: 18,118 hours/11,362 cycles.
TSO: 18,118 hours/11,362 cycles.
IAE V2533A5 Engine variable stator vane
actuator faulty. Ref 510009792
No 2 engine variable stator vane actuator (VSVA) faulty.
P/No: 2607MK2. (1 similar occurrence)
PWA PT6A114A Engine FCU to fuel flow
transducer pipe leaking. Ref 510009644
Engine FCU to fuel flow transducer pipe leaking from
brazed joint. Suspect pipe damaged during FCU change
0.4 hours previously. No leaks were evident during
post FCU engine run.
P/No: 3034789. TSN: 684 hours. (2 similar occurrences)
PWA PT6A114A Engine flamed out.
Ref 510009798
Engine flamed out and lost power. Aircraft landed
with engine shut down. Investigation continuing.
P/No: PT6A114SNPCE17154. (2 similar occurrences)
PWA PT6A67B Engine fuel pump leaking.
Ref 510009597
Engine low pressure fuel pump leaking.
P/No: 9688451108. TSN: 6,531 hours. TSO: 1,675
hours/2,256 cycles/2,256 landings/19 months.
PWA PT6A67D Engine propeller shaft
magnetised. Ref 510009650
Right-hand engine propeller shaft magnetised.
Aircraft was undergoing a special inspection
following a lightning strike.
PWA PT6A67D Engine reduction gearbox
failed. Ref 510009733
LH engine reduction gearbox failed. Gearbox
partially seized. Metal contamination of oil system.
Investigation continuing.
P/No: PT6A67D. TSN: 15,530 hours. TSO: 719 hours.
Garrett TPE33111U611 Engine FCU drive
bearing failed. Ref 510009729 (photo below)
Right-hand engine fuel control unit drive train system
bearing failed. Metal contamination of oil system.
TSO: 2,476 hours/2,991 cycles. (2 similar occurrences)
PWA PT6A67P Engine accessory gearbox
starter/generator pad seal damaged.
Ref 510009857
Starter/generator pad seal located in the accessory
gearbox damaged and leaking. Investigation found
the seal runner had three broken locating tangs, one
of which had passed through the carbon seal.
P/No: 307396601. TSN: 44 hours/18 cycles/18
landings/1 months. (2 similar occurrences)
PWA PW119C Engine compressor bleed valve
faulty. Ref 510009831
Left-hand engine inter-compressor bleed valve (IBV)
faulty. P/No: 311995704. (4 similar occurrences)
PWA PW119C Engines HMU faulty.
Ref 510009805
Right-hand engine hydro-mechanical unit (HMU)
faulty. During fault-finding, oil contamination was
also found in the PCU/CSU connectors.
P/No: 8110995L28. (3 similar occurrences)
PWA PW119C Engine power fluctuates with
torque drop. Ref 510009801
Left-hand engine power fluctuations with a torque
drop of 30 per cent. During fault-finding ground
runs the inter-compressor bleed valve (IBV) failed.
IBV replaced but fault still present. Investigation
continuing. (2 similar occurrences)
PWA PW119C Engine torque and fuel flow
fluctuating. Ref 510009802
Right-hand engine torque and fuel flow fluctuating up
to 40 per cent. Ground runs could not reproduce fault
and nil problems reported since.
(2 similar occurrences)
PWA PW119C Engine wiring connector
contaminated. Ref 510009799
Right-hand engine electrical harness connectors
contaminated. (2 similar occurrences)
Rolls Royce RB211524G Engine high oil
consumption. Ref 510009791
No 4 engine high oil consumption. Investigation
could find no obvious leaks, and engine was changed.
Investigation continuing. (1 similar occurrence)
Rolls Royce TAY65015 Engine outer combustion
case ruptured. Ref 510009603
Right-hand engine outer combustion case ruptured
at approximately 11 o’clock position. Damage to case
approximately 50.8mm by 25.4mm (2in by 1in). Hole
burnt through bypass duct.
TSN: 27,425 hours/25,966 cycles.
TSO: 2,567 hours/1,861 cycles.
McCauley 3FF32C501 Propeller latch screw
sheared. Ref 510009643
During engine start, the propeller went straight to
feather shearing the latch screw. Propeller had been
inspected iaw AD/Prop/2A3. P/No: B4324. TSO: 1,492
hours. (2 similar occurrences)
McCauley 3GFR34C703 Propeller governor
suspect faulty. Ref 510009810
Nil response to power lever following first start.
Suspect insufficient P3 air due to excessive bleed
air use caused FCU scheduling problems. Propeller
governor changed as a precaution.
P/No: 3033926. TSN: 4,173 hours/5,795 cycles.
Magneto corroded. Ref 510009670
During inspection prior to fitment, the magneto rotor
was found to be seized. Further investigation found
the rotor and stator corroded (rusted). Magneto had
been overhauled by the manufacturer. The magneto
had been stored at Cairns and the tropical conditions
may have contributed to the corrosion.
P/No: BL3493101. TSO: 1,501 hours.
Note: occurrence figures based on data
received over the past five years.
Pull-Out Section
The Federal Aviation Administration’s (FAA)
maintenance fatigue resources
Dr Bill Johnson, the chief scientific and technical adviser for human
factors in aircraft maintenance systems and his team from the FAA
continue to deliver quality resources to support the integration of
human factors and consideration to improved fatigue management
within maintenance organisations. If you’ve not yet accessed the
website, the FAA has developed an aircraft maintenance human
factors web portal, which provides a wealth of information regarding
maintenance human factors. The web portal can be accessed via:
A recent publication titled Maintenance Fatigue Focus provides some upto-date information regarding fatigue management. While regulators
around the world are turning their attention to fatigue management
for aviation shift workers, Dr Johnson states:
‘The idea that employers are waiting for regulations before taking steps
to address worker fatigue reminds me of lyrics from Bob Dylan …
“you don’t need a weather man to know which way the wind blows.”
Anyone who has worked a night shift well understands the challenges
of maintaining vigilance as the clock moves into the early hours of
the morning. Even more challenging is the role of aircraft mechanics
who are regularly required to manage fatigue risks while performing
maintenance tasks. In many respects, these are the personnel within
the aviation industry who have developed very sound and robust
strategies for managing these fatigue risks, and the track record within
the Australian aviation industry is exceptional. But we cannot afford
to become complacent about our record and must strive to further
formalise good fatigue management strategies, share lessons learned
and continue to improve workplace practices for our shift workers.
Some new resources available from the American FAA provide further
support for this process.
ed a
you do man to
weath hich way
the w
It seems fitting doesn’t it? It seems to suggest that we don’t need a lot
of rules and regulations to address fatigue in aviation; instead, we can
come to reasonable solutions simply with some common sense and
applied science.’
Pull-Out Section
Dr Johnson provides four examples where common sense and basic
applied science are utilised for positive change within the maintenance
workplace, which can be accessed from the web link below.
FSA MAR–APR10 Issue 73
Amongst other practical information provided within the publication,
one article highlights the benefits of fatigue countermeasures
training. As extracted from the publication, a study conducted
with mining shift workers found that six weeks following fatigue
countermeasures training:
Workers’ sleep increased by an hour on average
Workers reported a reduction in excessive caffeine use
Workers made changes in their sleeping environment to make it
more conducive to sleep
Fewer workers reported difficulty fulfilling domestic responsibilities
Fewer workers reported difficulty finding time for entertainment
and recreational activities
Fewer workers reported believing that their health would improve
with a different schedule
Reports of gastrointestinal symptoms declined.
This supports the substantial cost-benefits that can be achieved across
other industries through targeted training on fatigue management.
For access to the FAA Maintenance Fatigue Focus publication:
1-22 October 2009
Embraer ERJ-190 Series Aeroplanes
AD/ERJ-190/24 - Ram Air Turbine
Part 39 - Rotorcraft
Fokker F100 (F28 Mk 100) Series Aeroplanes
AD/F100/86 - Flight Controls - Horizontal Stabilizer
Control Unit - CANCELLED
2009-0220 - Landing Gear - Parking Brake Shut-off
Valve (PBSOV) - Replacement
2009-0221 - Landing Gear - Main Landing Gear (MLG)
Piston - Inspection/Replacement
2009-0222 - Doors - Passenger Door Actuator Replacement
Eurocopter EC 135 Series Helicopters
AD/EC 135/23 - Time Limits / Maintenance Checks
Part 39 - Below 5700 kgs
Aerospatiale (Socata) TBM 700 Series
AD/TBM 700/41 Amdt 1 - Pilot Door Locking
Fittings - CANCELLED
2009-0214 - Pilot Door Locking Fittings
Airbus Industrie A330 Series Aeroplanes
2009-0223-E - Hydraulic Power - High Pressure
Manifold Check Valve - Inspection
AMD Falcon 50 and 900 Series Aeroplanes
2009-0209 - Fuselage Structure - Cockpit Window
Frames - Modification
Boeing 727 Series Aeroplanes
2009-20-08 - Fuel Boost Pump Wiring
Boeing 737 Series Aeroplanes
AD/B737/339 Amdt 1 - Elevator Tab Pushrod Ends
2009-21-01 - Fuselage Aft Skin between BS 727
and BS 1016
Boeing 767 Series Aeroplanes
2009-20-09 - Nacelle Strut Upper Link Fuse Pin
Bombardier (Canadair) CL-600 (Challenger)
Series Aeroplanes
AD/CL-600/78 Amdt 1 - Engine Throttle Control
AD/CL-600/123 - Wing Anti-Ice System - Outboard
Low-Heat Detection Switches
British Aerospace BAe 146 Series Aeroplanes
2009-0215 - Airworthiness Limitations
AD/BAe 146/133 Amdt 1 - Airworthiness Limitations
AD/BAe 146/140 Airbrake Lever Detent Mechanism
Part 39 - Piston Engines
Part 39 - Below 5700 kgs
Thielert Piston Engines
AD/THIELERT/13 - Engine/Propeller - Constant Speed
Unit - Propeller Control Valve - CANCELLED
2009-0224 - Engine/Propeller - Constant Speed
Unit - Propeller Control Valve - Vibration Isolator Installation
Aerospatiale (Socata) TBM 700 Series
2009-0238-E - Towing - Towing Bar Foam Pads
Part 39 - Equipment
Reims Aviation F406 Series Aeroplanes
AD/F406/19 - Flap Push Rod Assemblies CANCELLED
2009-0127R1 - Flaps - Push Rod Assemblies Replacement
Auxiliary Power Units
2009-21-03 - Hamilton Sundstrand T-62T-46C12 APU
Software Upgrade
American Champion (Aeronca, Bellanca)
Series Aeroplanes
2009-22-02 - Rear Seat Frame
23 October 5 November 2009
TECNAM P92, P96, and P2002 Series
2009-0229 - Retractable Landing Gear System –
Part 39 - Rotorcraft
Part 39 - Above 5700 kgs
Agusta A109 Series Helicopters
2009-0231-E - Rotors Flight Control - Tail Rotor
(T/R) Adjustable Rod Assembly - Identification/
2009-0232-E - Rotors Flight Control - Tail Rotor
(T/R) Adjustable Rod Assembly - Identification/
Airbus Industrie A319, A320 and A321 Series
2009-0235 - Electrical Power - AC and DC ESS BUS
Power Supply - Modification
Beechcraft 1900 Series Aeroplanes
2009-23-01 - Main Landing Gear Actuators
Agusta AB119 Series Helicopters
2009-0231-E - Rotors Flight Control - Tail Rotor
(T/R) Adjustable Rod Asembly - Identification/
Agusta AB139 and AW139 Series Helicopters
2009-0234-E R1 - Fuselage - Tail Boom - Inspection
Boeing 747 Series Aeroplanes
2009-22-14 - MEC Electrical/Electronic Units
Moisture Protection
2009-22-08 - Control Switches - Forward, Aft
and Nose Cargo Doors
2008-10-07 R1 - Airworthiness Limitations
& Inspections - Fuel Tank Systems
Service Difficulty Reports
CALL: 131
02 6217 1920
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
Boeing 747 Series Aeroplanes
2009-20-12 - Trailing Edge Flap Transmission
Carbon Disk
Sikorsky S-92 Series Helicopters
2009-23-51 - MGB Mounting Foot Pads and
Foot Ribs
Pull-Out Section
Part 39 - Above 5700 kgs
Bell Helicopter Textron Canada (BHTC) 206
and Agusta Bell 206 Series Helicopters
2009-0226 - Rotors Flight Control - Cyclic Lever
Bearing - Inspection
Eurocopter AS 332 (Super Puma) Series
2009-0227-E - Equipment/Furnishings - Pilot and
Co-pilot Seat Rails - Modification
Pull-Out Section
Boeing 767 Series Aeroplanes
2009-22-13 - Fuel Tank Motor Operated
Valve Actuators
Boeing 747 Series Aeroplanes
AD/B747/379 - Airworthiness Limitations &
Inspections - Fuel Tank Systems - CANCELLED
British Aerospace BAe 146 Series Aeroplanes
AD/BAe 146/79 - Nose Landing Gear Oleo CANCELLED
Boeing 767 Series Aeroplanes
2009-23-04 - Main Tank Fuel Boost Pump
Feed-Through Electrical Connector
Fokker F50 (F27 Mk 50) Series Aeroplanes
AD/F50/101 - Engine Controls - Automatic Flight-Idle
Stop Control Unit - CANCELLED
2009-0049R1 - Engine Controls - Automatic FlightIdle Stop Control Unit - Installation
Bombardier (Boeing Canada/De Havilland)
DHC-8 Series Aeroplanes
CF-2009-40 - Fuel Tank - Removal of NonConforming Springs from the Collector Tank
Flapper Valves
Part 39 - Turbine Engines
Bombardier (Canadair) CL-600 (Challenger)
Series Aeroplanes
CF-2009-39 - Hydraulic Accumulators - Screw
Cap/End Cap Failure
International Aero Engines AG V2500 Series
2009-22-06 - High Pressure Compressor (HPC)
Stage 9-12 Disc Assemblies
Turbomeca Turbine Engines - Arriel Series
AD/ARRIEL/17 Amdt 3 - Engine - Gas Generator
Second Stage Turbine - CANCELLED
2009-0236 - Engine - Gas Generator Second
Stage Turbine
6–19 November 2009
FSA MAR–APR10 Issue 73
Part 39 - Rotorcraft
Bell Helicopter Textron Canada (BHTC) 206
and Agusta Bell 206 Series Helicopters
CF-2007-13 R2 - Power Turbine RPM Steady State
Operation Avoidance
CF-2009-41 - Tailboom Attachment Fitting
Eurocopter SA 360 and SA 365 (Dauphin)
Series Helicopters
AD/DAUPHIN/98 - Vertical Gyro Unit Data Output Operational Limitation/Procedure - CANCELLED
2009-0247 - Time Limits / Maintenance Checks, Tail
Rotor Drive - Tail Gearbox (TGB) Oil Level and Tail
Rotor Pitch Control Rod Bearing
Part 39 - Below 5700 kgs
Cessna 150, F150, 152 & F152 Series Aeroplanes
AD/CESSNA 150/50 - Rudder Limit Stops CANCELLED
2009-10-09 R1 - Rudder Limit Stops
Part 39 - Above 5700 kgs
Airbus Industrie A330 Series Aeroplanes
2009-0240 - Power Plant - Forward and Aft ward
Mount Pylon Bolts - Inspection / Replacement
Avions de Transport Regional ATR 42 Series
AD/ATR 42/2 Amdt 1 - Fuel Tank Safety - Electrical
2007-0226 R1 - Fuel - Fuel Tank System Wiring &
Sensors - Modification/Replacement - Fuel Tank Safety
Beechcraft 1900 Series Aeroplanes
AD/BEECH 1900/49 Amdt 1 - Wing Rear Spar Lower
Cap Inspection - 2 - CANCELLED
2009-23-03 - Wing Rear Spar Lower Cap Inspection - 2
Boeing 737 Series Aeroplanes
AD/B737/340 - Outboard Trailing Edge Flap
Carriage Spindles - CANCELLED
2009-23-10 - Outboard Trailing Edge Flap
Carriage Spindles
Part 39 - Piston Engines
Teledyne Continental Motors Piston Engines
2009-24-51 - TCM Engine Hydraulic Lifters CANCELLED
2009-24-52 - TCM Engine Hydraulic Lifters
Part 39 - Turbine Engines
Rolls Royce Turbine Engines - RB211 Series
2009-0244 - Low Pressure Turbine Stage 1, 2
and 3 Discs
Turbomeca Turbine Engines - Arriel Series
AD/ARRIEL/19 Amdt 1 - Fuel Metering Unit
Acceleration Controller Axle - CANCELLED
AD/ARRIEL/27 - HP Turbine (Module M03) Turbine Blade Displacement - CANCELLED
AD/ARRIEL/34 - Module M05 - Lubrication
2007-0109R1 - Engine - Module M03 (Gas
Generator) - Turbine Blade Borescope Inspection/
2009-0245-E - Engine - Module M05 (Reduction
Gear Box) Lubrication Duct - Inspection / Repair
2009-0246 - Engine Fuel & Control - Hydro HMU
Acceleration Control Axle - Inspection and
Part 39 - Equipment
Propellers - Variable Pitch - Hartzell
2009-22-03 - Propeller Hub Cracks
20 November 2009 3 December 2009
Part 39 - Rotorcraft
Bell Helicopter Textron Canada (BHTC)
206 and Agusta Bell 206 Series Helicopters
AD/BELL 206/172 Amdt 1 - Power Turbine RPM
Steady State Operation Avoidance - CANCELLED
Eurocopter SA 360 and SA 365 (Dauphin)
Series Helicopters
AD/DAUPHIN/83 Amdt 2 - Tail Rotor Gearbox Oil
Level and Pitch Control Rod Bearing - CANCELLED
Part 39 - Below 5700 kgs
Cessna 525 Series Aeroplanes
2009-24-13 - Thrust Attenuator Paddle Assemblies
Pilatus PC-12 Series Aeroplanes
2009-0249 - Navigation - Air Data, Attitude
and Heading Reference System (ADAHRS) Modification/Replacement
AD/PC-12/58 - Air Data Attitude & Heading
Reference System - CANCELLED
Part 39 - Above 5700 kgs
Boeing 737 Series Aeroplanes
2009-24-07 - MLG Forward Trunnion Pins
Embraer ERJ-170 Series Aeroplanes
2009-11-01 - Escape Slides P/N 4A4030-2
and 4A3030-4
Embraer ERJ-190 Series Aeroplanes
AD/ERJ-190/15 Amdt 2 - Low Pressure
Check Valves
SAAB SF340 Series Aeroplanes
AD/SF340/2 Amdt 1 - Rudder Limiter High
Speed Stop
AD/SF340/5 Amdt 1 - Installation of Tail De-Icer
Valve Heater Blanket
AD/SF340/9 Amdt 2 - Power Control Cable
AD/SF340/12 Amdt 1 - Air Conditioning System
AD/SF340/16 Amdt 1 - AC Generator P/N 31342-001
AD/SF340/26 Amdt 2 - Modification of Exit and Dome
Light Assemblies
AD/SF340/41 Amdt 1 - Elevator and Aileron Coves
AD/SF340/44 Amdt 1 - Propeller Brake Valve
Part 39 - Turbine Engines
AlliedSignal (Lycoming) Turbine Engines - LTS
101 Series
2009-24-12 - Gas Generator Turbine Disc
General Electric Turbine Engines - CF6 Series
2007-11-18R1 - Uncontained Fan Blade Failure
General Electric Turbine Engines - CF34 Series
AD/CF34/16 - FADEC Software Version 8Ev5.40 CANCELLED
2009-24-06 - CF34-8E Series Engines - Full Authority
Digital Electronic Control
2009-24-11 - Fan Blades and Aft Actuator Head
Hose Fitting
Pratt and Whitney Turbine Engines - JT8D
2009-24-01 - Second Stage Fan Blades
Rolls Royce (Allison) Turbine Engines - AE 3007
2009-24-04 - Fan Spinner
Rolls Royce Turbine Engines - RB211 Series
2009-0243 - Engine - Front Combustion Liner Inner
Wall - Inspection - CANCELLED
2009-0243R1 - Engine - Front Combustion Liner Inner
Wall - Inspection
Part 39 - Equipment
Fire Protection Equipment
2009-0251-E - Portable Halon 1211
Fire Extinguishers
4 December–
17 December 2009
Part 39 - Rotorcraft
Agusta A109 Series Helicopters
2009-0264 - Electrical Power - Battery Bus
Circuit Breaker - Modification
Bell Helicopter Textron Canada (BHTC) 206
and Agusta Bell 206 Series Helicopters
CF-2009-43 - Hydraulic System
Eurocopter AS 350 (Ecureuil) Series
2009-0256 - Engine Controls - Contactors 53Ka
and 53Kb - Check
Eurocopter EC 225 Series Helicopters
2009-0263 - Equipment & Furnishings - Emergency
Flotation Gear - Inspection / Repair / Replacement
Eurocopter SA 360 and SA 365 (Dauphin)
Series Helicopters
2009-0241-E (Correction) - Navigation - Vertical
Gyro Unit Data Output - Operational Limitation/
Operational procedure
Part 39 - Below 5700 kgs
Beechcraft 33 and 35-33 (Debonair/Bonanza)
Series Aeroplanes
AD/BEECH 33/38 - Pilot and Co-pilot Shoulder
2009-25-01 - Pilot and Co-pilot Shoulder Harness
Beechcraft 35 (Bonanza) Series Aeroplanes
AD/BEECH 35/64 - Pilot and Co-pilot Shoulder
2009-25-01 - Pilot and Co-pilot Shoulder Harness
Beechcraft 36 (Bonanza) Series Aeroplanes
AD/BEECH 36/38 - Pilot and Co-Pilot Shoulder
2009-25-01 - Pilot and Copilot Shoulder Harness
Beechcraft 55, 58 and 95-55 (Baron) Series
AD/BEECH 55/75 - Pilot and Co-pilot Shoulder
2009-25-01 - Pilot and Co-pilot Shoulder Harness
Cirrus Design SR20 and SR22 Series
2009-26-01 - Anti-Ice Fluid Distribution Lines
Grob G115 Series Aeroplanes
D-2009-324 - Canopy - Canopy Jettison
Pilatus Britten-Norman BN-2 Series
AD/BN-2/85 Amdt 1 - Elevator Tip Assemblies CANCELLED
2009-0105R1 - Elevator Tip Assemblies
Airbus Industrie A319, A320 and A321 Series
2009-0259 - Hydraulic Power - Ram Air Turbine
(RAT) Balance Weight Screws - Inspection /
Airbus Industrie A330 Series Aeroplanes
AD/A330/39 Amdt 1 - Elevator Structure CANCELLED
2009-0260 (Correction) - Hydraulic Power Ram Air Turbine (RAT) Balance Weight Screws Inspection / Replacement
Airbus Industrie A380 Series Aeroplanes
2009-0213 - Wings - Inner Leading Edge Droop
Nose 1 Sidestay Bracket - Inspection / Replacement
2009-0265 - Pneumatic - Overheat Detection
System - Inspection
Boeing 727 Series Aeroplanes
2008-04-10R1 - Fuel System Airworthiness
Boeing 747 Series Aeroplanes
2009-25-11 - Body Frame at Fuselage Station
1800 on left side between Stringers 39 and 40
2009-24-17 - Stringer-to-Stringer Clip Joints at
STA 760 through STA 940 Frames
AD/B747/322 Amdt 1 - Strut Front Spar Chord
Cessna 550 (Citation II) Series Aeroplanes
AD/CESSNA 550/16 Amdt 1 - Fuel Flow Transmitter
Gulfstream (Grumman) G1159 and G-IV Series
AD/G1159/35 Amdt 1 - Takeoff Warning System
Learjet 45 Series Aeroplanes
2009-24-22 - External Baggage Door Seal
and Sealant
Part 39 - Piston Engines
Thielert Piston Engines
AD/THIELERT/11 Amdt 3 - Propeller Control Valve CANCELLED
2009-193R1 - Propellers/Propulsion - Vibration
Isolator of the Propeller’s Constant Speed Unit Inspection/Replacement
Part 39 - Turbine Engines
General Electric Turbine Engines - CF6 Series
2009-21-07 (Correction) - Thrust Reverser Ballscrew
AD/CF6/66 - Uncontained Fan Blade Failure CANCELLED
Pratt and Whitney Turbine Engines - JT8D
AD/JT8D/16 Amdt 2 - Second Stage Fan Blades CANCELLED
Rolls Royce Turbine Engines - RB211 Series
AD/RB211/41 - Engine - Thrust Reverser Unit CANCELLED
2009-0253 - Engine - Thrust Reverser Unit (TRU) Replacement of Damaged Rivets on Thrust Reverser
Fixed Structure
2009-0257 - Engine - Fuel System, Fuel-to-oil Heat
Exchanger (FOHE) - Replacement
Part 39 - Equipment
Radio Communication and Navigation
CF-2009-44 - Honeywell ASCa / Allied Sinal
Aerospace Canada RESCU 406S Emergency Locator
Oxygen Systems
2009-21-10 - AVOX Systems and B/E Aerospace
Oxygen Cylinder Assemblies, as Installed on Various
Transport Airplanes
Sikorsky S-92 Series Helicopters
2009-25-10 - Main Gearbox Lube System Filter
Part 39 - Above 5700 kgs
Part 39 - Turbine Engines (Cont.)
Pull-Out Section
Eurocopter AS 332 (Super Puma) Series
2009-0263 - Equipment & Furnishings - Emergency
Flotation Gear - Inspection / Repair / Replacement
Twin Commander (Gulfstream/Rockwell/
Aerocommander 500, 600 and 700) Series
2009-25-02 - Wing Upper Skin Surface and Engine
Mount Beam Support Straps
FSA MAR–APR10 Issue 73
WIN tools of your choice, to the value of $1000,
courtesy of
or one of 3 pairs of Ray-Ban aviator sunglasses for runners-up.
Competition outline
The winning reports will be those which are judged as being the most accurate and comprehensive.
To enter the competition, simply submit your SDR via the CASA website. Visit http://casa.gov.au/airworth/sdr/index.htm
and click on the ‘SDR and SUP online form’.
Fill out the form noting carefully that you have provided all the required information above. In the description field of
the SDR enter the word ‘FSA competition’ to be in the running to win.
Remember to fill in the submitter’s details so that we can contact you if verification of any detail is required.
A valid entry MUST
Be submitted online.
Be received on or before the closing
date of 09 April 2010.
NOT be from employees, associated agencies or families of CASA or Snap-on Industrial
Include some pictures of your example to illustrate the defect finding.
(Pictures and movies can be attached after submitting the SDR, but note files are limited to 2MB for each attachment.)
Points may be awarded for good pictures.
There is no limit to the number of times a participant can enter, but each entry must relate to a separate defect.
CASA reserves the right to verify and investigate information submitted via the SDR system.
The winner will be judged by a panel of CASA Airworthiness experts and their decision will be final.
The best entries will be published in the May-June 2010 issue of Flight Safety with any pictures and description of
aircraft, owner’s or operator’s details removed for privacy reasons.
Ever had a
Write to us about an aviation
incident or accident that you’ve
been involved in. If we publish
your story, you’ll receive
Write about a real-life incident that you’ve been
involved in, and send it to us via email: [email protected]
gov.au. 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.
by Roger Schulz
In 1992, I was a brave new ag pilot (AG2) and
FSA MAR–APR10 Issue 73
had just landed my first flying job. I’d spent the
previous year crop marking in Narrabri just to
gain some industry experience, and I was more
than ready to do some flying myself.
But I soon discovered that not all aerial agriculture companies are
created equal. The aerial ag operator I worked for in Narrabri had
been highly professional, placing a high importance on safety and
maintenance. This was in complete contrast to the operator I was with
now—he was definitely of the ‘fencing wire and baling twine’ variety.
To illustrate: on one occasion one of our Piper Pawnees flew into a
flock of ducks, badly denting the leading edge of the left wing, and
smashing the windscreen. The pilot, who was very experienced, only
just made it back to the airport under full power. Unbelievably, the
aircraft was back in service the next day. The dented leading edge
was reshaped with stiff cardboard and secured with gaffer tape. The
now open-cockpit Pawnee stayed that way for two weeks until the
pilot threatened to go to the then Civil Aviation Authority (CAA, now
Why would I stay with an outfit which operated in that way? I still ask
myself that question. But at the time I felt that I needed to. As a brand
new AG2, I had to be supervised directly by an experienced ag pilot
for 250 hours. This is a big overhead for a busy ag operator and not
many operators are willing to do it. I’d already shelled out the price of
a small house on training and worked very hard to get to this point. I
really felt I had no choice but to stick with it: I needed this job and the
operator knew it.
d e
The d ing ed th
leadreshaped wrdi
stif f c ured with
f fer
Although I had started off with high ideals, after
a few months immersed in this environment
I found myself starting to compromise on
safety. I cut corners to get things done more
quickly, but mainly to keep the bosses happy.
But there was one incident which snapped me
firmly back into reality. I had been spraying
rice in a Pawnee about 70nm south west of our
base at Deniliquin airport. The job took much
longer than I would have liked and I was feeling
pressured. The weather was deteriorating and
a front bringing thunderstorms with it was
forecast to come from the northwest. I needed
to fly north east to get back to Deniliquin.
As I would be flying away from the weather,
I felt confident I would make it back without
any problems. Besides, at the time I felt I
had little choice. The loader and I had been
operating from a public road, and he was now
on his way back to the airport. It would be
very embarrassing to have to leave one of our
planes out on a road overnight.
Big mistake! Five minutes into the flight I was
down to 100 feet AGL, following a back road
that I knew would take me all the way home
if need be. If all else failed, I could always land
on it. The Pawnee has only basic instruments:
an airspeed indicator, altimeter, compass and
a turn-and-bank indicator. At this point I was
able to maintain straight and level easily by
reference to the ground. But the rain was getting
heavier and eventually I was down to treetop
When I was flying aerobatics, I used to get this
feeling halfway through a manoeuvre that told
me that things weren’t going to work out right.
I was getting that same sinking feeling now.
I was starting to lose control of the aircraft.
Incredibly, just at that moment, I popped out
into brilliant light and smooth air. Looking over
my shoulder a wall of white water stretched
for miles, and at least to 10,000 ft. In a few
minutes I was back at the airport, refuelling
and pushing the aircraft back into its hangar.
No one was any the wiser, except for me.
It was a happy ending to
what could have
been a tragic tale.
The accident report
would have read
‘pilot error’, which it
most definitely was. The
operator would have been cursing
me because they were now one plane down;
and my mother would have been cursing the
operator because she was now one son down.
Faced with the same choice if I was taking the
family for a cross-country flight there would
be no way I would have risked it. But on this
occasion I did. It’s a common story – one I
am sure which is still being told. Young pilots
who get their first big break, only to be taken
advantage of by shonky operators. The pilots
are only too keen to be exploited if it means
getting those all-important hours.
My advice to any young aviator starting out is
to stand your ground. By all means, be flexible,
but not at the expense of safety. If the operator
is working outside the law, or outside the bounds
of what’s reasonable, just say no. You only have
your job to lose. You can, and you will, get
another one of those. Death is for keeps.
Once airborne, I found heavy rain to the north
east and east blocking the shortest route
back to Deniliquin. It was then I should have
contacted someone letting them know what
was happening and what I was going to do. But
because of my ego, and fear of ridicule from
my employer, I decided to say nothing and go
around the weather. So I travelled northwest
towards Wakool hoping to go around it. The
further I flew, however, the worse the weather
became. Commonsense still prevailed at this
point, and so I landed on a farmer’s strip to
wait out the worst of the weather. After an
hour of waiting, I was getting very anxious
about getting back before I was missed. On the
ground I couldn’t make radio contact with either
our base or my loader. So when the weather
improved slightly, I took the opportunity to
make a break for it.
height. Finally, I lost complete sight of the
ground. I was now flying by instruments alone.
I tried to increase the distance between me and
the ground, but even at full throttle I couldn’t
gain any altitude. Outside was a total white out:
there was just no way of telling which way was
up. The roar of the rain and turbulence was
horrific even from under my helmet. I was being
knocked around so badly I was having great
difficulty maintaining straight-and-level flight.
The bat and ball on the turn-and-bank indicator
were just flopping from one side to another.
I wasting to
star control
loshee aircraft.
of t
Fickle fate
Anne Shaw describes an
historic close call
FSA MAR–APR10 Issue 73
If hostess Miss Wise had not wanted
to be back in Sydney so badly that day,
I would not have lived to be 88.
I had been an air hostess with ANA (Australian National
Airways) since March 1946. After my initial training
in Melbourne, I was transferred to my home state to
Brisbane. I flew mainly the coastal route to Cairns and
the gulf country.
On 2 September 1948, I was rostered for ground duty
at Archerfield (in those days, Eagle Farm was not yet a
licensed aerodrome. Archerfield was a grass paddock with
no defined runways. The terminal buildings were built for
the American air force.) The day had been uneventful and
I was now packing up to go home when the captain of
the 5pm Flight 331 Lutana, a DC3 bound for Sydney, told
me the scheduled hostess hadn’t turned up for the flight.
‘Anne, it looks as though you will have to come with us,’
he said. ‘Could you put the passengers on board please?’
After ushering the 10 passengers onto the aircraft, I gave
them barley sugar and the daily paper, checked their
seatbelts and strapped myself into the hostess seat at
the back. It was apparent by now the hostess was not
going to show, so I was designated to hostess the flight.
Captain John Drummond and co-pilot John Atkinson, two
exceptionally experienced pilots, taxied Lutana VH-ANK
out to the southwest corner of the paddock.
The captain exercised his prefight checks, and we were
now ready for takeoff. As the aircraft started to roll into
wind, the throttle was closed just before lift off.
We were all wondering what the problem was, when the
captain called me to the cockpit to explain.
He had sighted the scheduled hostess running her hardest
towards the aircraft. ‘Would you mind jumping down
and giving her a leg up, please?’ he asked. ‘And do you
mind walking back to the terminal building?’ The tail of
the DC3 is not far from the ground, so the exchange was
fairly easy.
Within minutes, Lutana VH-ANK was airborne, flying into
the northeast wind headed for Sydney, and so I went
home. But the aircraft did not reach its destination.
For several days, there was an intensive search. The
Lutana had crashed into the peak of Mt Crawney, south
of Tamworth. All 10 passengers and three crew members
Today, in a little town called Nundle, not far from Mt
Crawney, there is a monument with the propeller of the
ill-fated aircraft and a plaque dedicated to all on board. To
this day, I will never forget the moment I heard the news
of the demise of the Lutana.
After my five years as an air hostess I married a country
GP and have lived in Kingaroy since 1953. In 1976, I
learnt to fly at the age of 55. My husband had been in
the air force and regained his licence in the 1960s. My
son is a jumbo captain and one of my daughters was an
air hostess with Qantas. When recounting this story to a
friend of my son’s, he said, ‘It’s a great story Anne, but in
this day and age no-one will ever believe you!’ I assure
you this is a true story.
The Nundle plaque,
dedicated to the victims
of Flight 331
The Lutana VH–ANK
propeller at Nundle, NSW
Anne with Captain John
Drummond in 1947
in Townsville
All this changed on 2 September 1948. Flying from Brisbane to Sydney
in thunderstorm conditions, the DC-3 VH-ANK Lutana simply vanished.
Thought to have ditched at sea, its burnt wreckage was found several
days later on the main ridge of the Liverpool Ranges, NSW – 90nm
northwest of its last reported position. The aircraft crashed into Mt
Crawney (4744ft), 16nm due east of Quirindi at approximately 2015.
Source: Flight Safety
Australia articles, NovDec 1998 & July-Aug
1999. A full account of
this crash appears in Air
Crash Vol 2 written by
well-known air accident
investigator, and Flight
Safety contributor,
Macarthur Job.
There was heavy cloud and rain in the area. The crash site was
4,570ft ASL.
The Lutana was found on 4 September at 1245 by an East West
Airlines Avro Anson (VH-ASM) on a scheduled flight from Tamworth
to Sydney.
All 13 occupants were killed instantly. The pilot, Captain JA Drummond
was found to be a ‘pilot of more than ordinary ability’. An inquiry into
the cause of the crash was carried out, the findings of which were
released on 17 November, 1948.
For ANA and the Department of Civil Aviation’s newly established air
traffic control (ATC) system, the accident was a major setback. The
Air Court of Inquiry savagely attacked the ATC system for alleged
shortcomings, with a number of changes resulting – an improved
ATC organisation and the development of the Australian distance
measuring equipment (DME) system, a world first.
To this day, I will never
forget the moment I
heard the news of the
demise of the Lutana.
It was a black final quarter in 1948 for the giant Australian National
Airways (ANA). Having expanded rapidly to become the nation’s
major airline, ANA controlled a route network extending from Perth
to the Cape York Peninsula. Business was booming and, for many
Australians, the slogan ‘Wing your way with ANA’ was synonymous
with state-of-the-art air travel.
by Luke Considine
FSA MAR–APR10 Issue 73
I had just received my private pilot’s licence,
and along with a small group of similarly
qualified students, had been organised to go
on a three-day ‘navex, cross-country flight
through Victoria–up to Mildura and back. We
were working towards our commercial pilots’
licences. The idea of the exercise was to
increase our familiarity with different aircraft
(the flying school had both Cessna 172s and
Piper Warriors); improve our navigational
skills over unfamiliar territory, both solo and
accompanied by an instructor; and maybe enjoy
a beer or two and a barbie away from home.
To this end, there were two 172s and one Piper
Warrior, five students and one instructor. We
were all looking forward to the adventure and
getting away from our home airport and the
humdrum of daily routine.
The trip up was both enjoyable and challenging,
involving a two stint navex up to Mildura,
through some very mixed weather (a cold front
was moving through Victoria with embedded
thunderstorms). We all got there safely
and were enjoying the feeling of increased
confidence that comes with experience and
handling new situations well.
For the next day we used Mildura as a base
to launch several different navex and various
training exercises, including endorsement
on our ‘unfamiliar’ aircraft. The weather was
magnificent, and the experience worthwhile,
especially with the arrival of several RPT
services into the airport. That tested our
radio communication skills and navigation
positioning. We also squeezed those beers
in as well on the final night of our stay.
The day of our departure dawned, another
perfect Mildura day, with clear skies and
perfect visibility. It is difficult to recall who
was in charge of checking the met forecast;
however, I believe the gist of it was CAVOK
all the way to Melbourne. The conditions at
Mildura certainly didn’t give cause for anyone
to give it a second glance.
Things were fine until about 10 miles out of
Mildura, and I might add, all flying completely
VFR, our course took us directly over 8/8’s of
fog. Initially, there was little cause for panic.
The day of our departure
dawned, another perfect
Mildura day, with clear skies
and perfect visibility.
The conditions were still perfect above the
fog, and surely it wouldn’t extend all the way
to Melbourne? It would burn off soon enough.
However, about 20 minutes later, the situation
had not changed – there was now fog in every
direction, and as far as the eye could see. Our
instructor kept calm, suggesting (by radio) that
we all do fuel calculations and compute a ‘point
of no return’ where we would turn around if the
fog was still thick. Well, more accurately, a ‘time
of no return’ since we had no visual reference.
But we felt it was most likely the fog would
break up soon.
It helped that there was little wind, and above
the low cloud it was completely clear. The
fog, however, continued. By ded* reckoning
(my instructor once told me it was ‘ded’ as in
‘deduced’ reckoning), we had a rough idea of
our position, but had now been flying for an
hour without a visual checkpoint on the ground.
There was no guarantee we would be where we
thought we were. What if the fog had moved in
around Mildura? Were those fuel calculations
correct? The airfield we had scheduled to land
at for re-fuel came and went, completely out of
view under the fog … if we were even over it.
Looking back on this incident I see several
holes in our approach. Did we attempt to
contact the authorities by radio and check
weather conditions en-route? Did we get
caught up in the idea that everything would
be fine just as long as we pushed on, given the
actually extremely pleasant flying conditions
over the fog? There are a lot of tales of doom
in the aviation industry about pushing on into
In the end the fog began to clear and there was
a frenzied examination of the WACs to try to
establish and confirm positions–it turned out
we were in the vicinity of Ararat with a suitable
airfield not too far off, so a landing was in
order to sort out the details. The fog was still
lifting, so the landing was by no means straightforward, with vision heavily obscured in several
quarters, yet in our predicament the safest
option was to take the opening and try and nut
it out from there. I flew a ‘low-and-close’ circuit
by necessity and within a few minutes we were
on the ground and worrying about our mates.
Radio communication confirmed they were
OK, and had landed at an airfield relatively
nearby. Again, analysis of our predicament
leads me to question the thoroughness of
ourapproach to the flight that day. At our stage
of instruction (bordering on, or only recently,
PPL) it is a cop-out to blame instructors. It was
an incident which taught me one of the most
basic and important rules of aviation. Always
check the forecast and never get a wing in the
air unless you are satisfied you have every bit
of information relating to the route you intend
to fly. Flying VFR is fine so long as you have
VISION. Take that away, and it becomes very
hard, very quickly. In the end, we laughed about
it. I’m glad we got the chance.
*E ditor’s note: ‘Ded’ reckoning as in ‘ deduced
reckoning’ tends to be more a US aviation
usage, popularised during World War II.
The first usage of ‘ dead reckoning’, the more
common English and Australian spelling,
according to the Oxford English Dictionary,
appeared in 1613. Here, ‘ dead’ means
absolute(ly) or complete(ly), as in ‘ dead
ahead’ or dead last’.
This was the major problem for all of us,
particularly the one student flying alone. We
had all been trained to fly under VFR; that is,
continually referencing our position to visual
cues from the ground
we had a rough idea of our
and comparison to the
WAC. That was how
position, but had now been
we navigated. We had
minimal instrument
flying for an hour without a
training (a couple of
visual checkpoint on the ground. hours under the hood
at best), and so IFR navigational techniques
were really out of the question. In some cases,
a bit of panic began to creep in. We were
not flying within visual range of one another.
There were some strained words over the ‘chat’
channel on the radio.
marginal conditions when flying under VFR,
yet we seemed to have uncovered a whole
new troublesome situation when the conditions
were almost too prefect. I’m a keen surfer, and
it really is a pain in the proverbial when fog
moves in over the coast and the surf is invisible.
This was our situation, although with more
significant consequences.
M urphy
his u g ly
FSA MAR–APR10 Issue 73
describes a
‘near miss’
I was working as a licensed aircraft engineer (LAE) contracting in Asia for a
well-known airline MRO (maintenance repair & overhaul). We were carrying
out a heavy maintenance ‘D check’ on a Boeing 747-300 belonging to a Middle
Eastern airline. The aircraft was approximately half way through its check
when I was asked to take over an ‘area’, as the engineer, who had completed
the inspection phase of the check, was being transferred to night shift.
This area was locally known as ‘nose-to-tail’
and included the inspection, rectification and
testing of the main and nose undercarriage
The engineer who had gone to nightshift
had completed and signed off on this task,
leaving only the operational and leak check
to carry out.
As the department did not have a shift
system, there was no handover required.
The areas were generally looked after by the
same engineer, on a daily basis, throughout
the check. Nightshift was usually formed near
the end of a check and was used for critical
path work. In these instances there was a
handover log: of work required, and actions
taken by the nightshift.
The undercarriage operational tests were
usually scheduled quite near the end of the
check, as the hangar preparation and the
lowering of the hangar floor (retraction) pits
relied on numerous other factors being in
place first.
One of the maintenance tasks of this particular
airline was to locate three critical hydraulic
lines for the nose undercarriage system and
have them removed, inspected and cleaned
These hydraulic lines comprised the pressure
undercarriage-down line, the pressure
undercarriage-up line and a common return
line. These lines are approximately 18 to
20 feet long, and run externally from the
left-hand fuselage where the lines enter the
forward cargo hold, back under the wing
fairings and connect back into the system at
the left-hand wing landing-gear wheel well.
Before carrying out the undercarriage
operational test the ‘D’ check scheduling
required the aircraft to undergo refuelling
and initial engine ground runs. This was a
common practice for heavy maintenance
checks, and allowed early detection of faults
in major assemblies, and time to fix them.
As the LAE in charge of the ‘nose-to-tail’ I
was responsible for the towing of the aircraft
from the hangar to the refuel area on to the
engine ground running bay, and then back
to the hangar. I carried out the towing tasks
for the refuel and engine run. To do this I
had to operate the no.1 and no. 4 hydraulic
systems: the no. 1 to facilitate the aircraft
body steering system and the no. 4 to give
me brake pressure. Any time we moved the
aircraft, these two systems were pressurised
and operated.
engineer and asked why he had selected
undercarriage up without waiting for my
instructions. He replied that he had only
switched the hydraulic system on, and that
the undercarriage lever was still selected
in the down position! With all the other
undercarriages ‘safe tied’ (down and locked
with safety pins installed) I instructed the
cockpit to select undercarriage up. The nose
undercarriage then extended and locked
down normally.
We carried on with the full operational check
of the undercarriage, eventually having all
five gears operating at the same time. The
airlines representative was quite puzzled by
the sight of the nose gear operating opposite
the main gears.
Again the operational checks involved
pressurising the no.1 and no.4 hydraulic
systems. The nose undercarriage ‘downlock’
safety pin is hard to get to and has to be
removed for the test. For safety, I decided that
all systems be turned off while a mechanic
removed the nose undercarriage ground lock
pin (safety pin).
With the pin removed, and the areas clear
of personnel and equipment, we started the
operational test. As the nose undercarriage
is operated by the no.1 hydraulic system, I
instructed the cockpit engineer to pressurise
this system. I heard the pump operate, and
then witnessed the nose undercarriage
retract. A bit annoyed, I spoke to the cockpit
We carried out the rectification and completed
the operational checks for the undercarriage
to the airline rep’s satisfaction. I reflected on
the previous few days where we had towed
the aircraft numerous times with the system
no.1 hydraulics pressurised, carried out
engine runs and realised all that time, the
nose undercarriage was trying to retract.
Next time you see a B747 jumbo being towed,
have a look at the engineer in charge of that
towing. You will see he is positioned right
under the nose of the aircraft and that if the
nose undercarriage collapsed (or retracted)
with him in that position he could be severely
injured or even killed.
As part of the maintenance, I replaced the
small nose undercarriage ground lock pin
(safety pin) as it had been under so much
pressure for many days. These devices are
critical to safety in all operational phases
of aircraft maintenance. I have kept that
safety pin as a reminder of what a close call
I had. It was all that stood between me and
possible death.
The airlines
was quite
puzzled by
the sight of
the nose gear
opposite the
main gears.
I guess the aircraft was moved around six times
in the time leading up to the undercarriage
operational test. On that day the aircraft
was placed on jacks and the hangar floor
retraction pits were lowered. Following major
work on an aircraft I always take extra care.
In this instance, I decided I would operate
each of the five undercarriages individually,
working on the theory that if something was
incorrectly installed or assembled, it would
limit the damage if the other landing gears
had the same problem.
Investigation revealed the ‘pressure-up’ and
‘pressure-down’ lines had been crossed
over at their connection points in the lefthand wheel well. This was a classic case of
Murphy’s Law: both lines had the same size
unions and were only inches apart. During
the cleaning process, any identifying marks
applied to the hydraulic lines on removal had
been washed away.
The Australian
Chief Commissioner’s
In the last issue, I invited readers
to provide their feedback
and suggestions on how the
Australian Transport Safety
Bureau could best respond to
the Statement of Expectations
provided by the Minister for
Infrastructure, Transport,
Regional Development and Local Government. Our
response, the Statement of Intent, has been completed,
and is now available on the ATSB website. It provides a
useful explanation of our mission and goals.
I would like to thank all those members of the aviation
community who provided feedback, sharing their
concerns and ideas about aviation safety, and their
thoughts and expectations regarding the ATSB. The level
of input from the public proved extremely useful to us
when composing the Statement of Intent, and I encourage
you to continue providing feedback to us. Your perspective
and insight are invaluable.
In addition, the ATSB has recently signed a Memorandum
of Understanding (MoU) with CASA, which you will be
able to find on the ATSB website. This MoU serves to
outline and clarify the relationship between our two
organisations, and we anticipate that our separate but
complementary roles will make a great deal of difference
in aviation safety in Australia, through cooperation,
collaboration and the sharing of information.
Finally, I am pleased to report that the ATSB is continuing
to augment its pool of expertise. Inevitably, as members
of our organisation retire or leave for new challenges,
we need to replace them. Recently, the Bureau has
welcomed an Investigator with experience as an Air
Traffic Controller, as well as two new Licensed Aircraft
Maintenance Engineers, and two new Human Factors
Investigators. If you are interested in joining the ATSB,
you can view our current vacancies at the employment
page of the ATSB website.
Martin Dolan
Chief Commissioner
Avoidable accidents: Low-level
he ATSB has published the first report in
an educational series on avoidable
accidents. This report focused on
accidents involving unnecessary and
unauthorised low-level flying; that
is, flying lower than 1,000 ft (for
a populous area) or 500 ft (for
any other area) above ground
level without approval from the
Civil Aviation Safety Authority
(CASA). Recognising that there
are obstacles to avoid and a lower
margin of error when flying low,
CASA requires pilots to have special
training and endorsements before they
can legally conduct low-level flying. In the
accidents described in the report, most of the
pilots had neither of these.
Seven accidents investigated by the ATSB are documented. Of those
seven accidents, six were fatal. They were chosen by aviation safety
investigators to highlight the inherent dangers of low flying and to offer
some lessons learnt from each case. Three accidents involved ‘buzzing’,
two accidents occurred during sight-seeing tours, and two occurred
en-route to family celebrations. The tragic thing about those accidents is
that they were all avoidable.
All aircraft impacted the ground or water after either striking
powerlines below 500 ft (five accidents) or losing control of the aircraft
at low height. It is important to keep in mind that powerlines are
difficult to see, exist in remote places where you least expect them,
and research by the ATSB has shown that 63 per cent of pilots knew
the location of the powerline they struck. In addition, low-level flying
presents fewer opportunities to recover from a loss of control compared
to flight at higher altitudes. The closer you are to the ground, the
less time and distance you have to regain control. Low-level flying
is inherently dangerous and should be avoided when there is no
operational reason to fly low.
This short report has been designed as an educational brochure for both
learning and experienced general aviation pilots. It is hoped that these
lessons learnt will help pilots make more accurate risk assessments and
more informed decisions before flying close to the ground. ■
Aviation Safety Investigator
V-belt failure contributes to helicopter accident
n 25 September 2007 at about
0600 WST, a Robinson Helicopter
Company R22 Beta II helicopter,
registered VH-HCN, departed under the
visual flight rules from Doongan Station
in the Kimberley region of Western
Australia. The purpose of the flight was to
conduct a stock survey in the vicinity of
the station. On board the helicopter were
the pilot and one passenger.
The passenger watched the helicopter take
off and, owing to the calm conditions,
continued to hear the engine noise of the
helicopter for some time. The passenger
reported hearing variation in the engine
noise before it ceased abruptly. In
response, the passenger began walking
along the road in the direction of the
station and discovered the wreckage of
the helicopter adjacent to the road. The
The investigation determined that the
helicopter’s main rotor system drive
belts probably failed or were dislodged,
resulting in a loss of drive to the rotor
system that necessitated an autorotative
landing over inhospitable terrain. The
helicopter manufacturer’s maintenance
documentation advised that a burning
rubber smell may be indicative of
impending V-belt failure as a result of belt
or actuator bearing damage. Examination
of the clutch actuator and sprag clutch
bearings found no evidence of damage
that would account for the reported smell.
Therefore, V-belt damage was isolated
as the likely source of the burning smell.
That was consistent with the findings
from a number of other Australian V-belt
failure or dislodgement events. The pilot’s
decision to return the helicopter to the
station without shutting down to visually
inspect the V-belts probably contributed
to the development of the accident. The
investigation also identified a number of
safety factors relating to unsafe decision
making. During the flight immediately
preceding the accident flight, operation
of the helicopter outside of the centre
of gravity limits, and at a gross weight
that exceeded the maximum allowable
for the helicopter, increased the risk of
controllability issues, component fatigue
and V-belt damage.
In addition, there was
evidence of the recent
use of cannabis by the
pilot, which would have
increased the risk of
impaired motor skills and
reduced cognitive capacity;
in particular, in response to
in-flight problems, such as
an engine or rotor system
drive failure.
As a result of this accident,
and a number of other
similar events that were
identified during this
investigation, the ATSB has
commenced a Safety Issue investigation
to determine if there are any design,
manufacture, maintenance or operational
issues that increase the risk of a failure
of the rotor system drive belt in the R22
V-belt failure or dislodgement was
identified as a factor in a number of
overseas and Australian R22 accidents.
In response, the Civil Aviation Safety
Authority issued airworthiness bulletin,
AWB 63-006 Issues related to the
Robinson Helicopter Corporation (RHC)
R22 main rotor drive system. ■
ATSB investigation report AO-2007-046,
released on 22 December 2009, is available on
the website.
About 5 to 10 minutes into
the flight, the passenger
detected a rubber-like
burning smell, combined
with a smell he associated
with hot metal. The
passenger informed the pilot
who immediately landed
the helicopter in a clear area
adjacent to a nearby road.
The pilot visually inspected
the helicopter with the
engine and rotor turning,
and remarked that one
of the rotor system drive
belts appeared to be damaged, though he
assessed that the helicopter was capable
of conducting the short return flight to
Doongan Station. The pilot decided to
return the helicopter to the station, while
the passenger elected to remain at the
landing site and await recovery by motor
helicopter had been destroyed by impact
forces and fire and the pilot had been
fatally injured.
Investigation briefs
Wake turbulence buffets aircraft
ATSB Investigation AO-2008-077
FSA MAR–APR10 Issue 73
On 3 November 2008, a SAAB Aircraft
Company 340B-229, registered VH-ORX,
was conducting a regular public transport
flight from Orange, NSW to Sydney.
At about 0724 AEST, when tracking to
join a 7 NM final for runway 34R and
descending through an altitude of about
2,400 ft above mean sea level, the aircraft
experienced an uncommanded 52° roll to
the left, in conjunction with an 8º nosedown pitching motion. Immediately after,
the aircraft rolled through wings level to
a 21° right bank angle. The aircraft also
experienced an altitude loss of 300 to
400 ft. The aircraft was about 259 m to
the right of the 34R centreline.
As a result of exceeding its operational
parameters, the Command Cutout feature
ceased giving steering commands to
the autopilot. The crew disengaged the
autopilot, regained control and manually
flew the remainder of the approach. A
passenger sustained minor injuries.
Examination of the available radar,
meteorological and aircraft operational
data identified that the upset probably
resulted from wake turbulence, generated
by an Airbus Industrie A380-800 (A380)
that was conducting a parallel approach
to runway 34L. There was a
35 kt left crosswind affecting both
aircraft’s approaches.
Airservices Australia (Airservices)
reported that, as a result of this incident,
they had introduced a number of interim
minor changes to Sydney parallel
runway operational procedures. Those
minor changes would have effect while
Airservices carried out a review of A380
operations. In addition, CASA has opened
a regulatory change project to review
and update wake turbulence separation
information in the Manual of Standards
for CASR Part 172. ■
Incorrect data entry leads to
Microburst event
ATSB Investigation AO-2009-012 Interim
On 15 April 2007, a Boeing Company
747-438 aircraft, registered VH-OJR, was
being operated on a scheduled passenger
flight from Singapore to Sydney, NSW.
On board the aircraft were 19 crew and
355 passengers. At 1923 EST, the aircraft
was about 100 ft above ground level
prior to landing on runway 16 Right
(16R) when it encountered a significant
and rapid change in wind conditions.
The aircraft touched down heavily and
the crew received a windshear warning
in the cockpit. The crew conducted
the windshear escape manoeuvre and
returned for a normal landing.
On 20 March 2009, at 2230 AEDST, an
Airbus A340-541 aircraft, registered
A6-ERG, commenced the take-off roll at
Melbourne Airport, Vic. on a passenger
flight to Dubai, United Arab Emirates.
During the reduced thrust takeoff, the
aircraft’s tail made contact with the
runway surface, but the aircraft did not
climb. The captain commanded and
selected take-off and go-around engine
thrust and the aircraft commenced a
climb. After jettisoning fuel to reduce the
landing weight, the flight crew returned
the aircraft to Melbourne for landing.
The investigation has identified that
the pre-flight take-off performance
calculations were based on an incorrect
take-off weight that was inadvertently
entered into the take-off performance
software on a laptop computer used by
the flight crew. Subsequent crosschecks
did not detect the incorrect entry and its
effect on aircraft performance.
As a result of this accident, the aircraft
operator has undertaken a number of
initiatives across its operations with
a view to minimising the risk of a
recurrence. In addition, the aircraft
manufacturer has released a modified
version of its performance planning tool
and is developing a software package that
automatically checks the consistency
of the flight data being entered into the
aircraft’s flight computers by flight crews.
The investigation has found a number
of similar take-off performance-related
incidents and accidents around the
world. As a result, the ATSB has initiated
a safety research project to examine
those events. The ATSB has drawn the
interim report to the attention of relevant
Australian operators to highlight the
risks when calculating and checking
take-off performance information. The
investigation is continuing. ■
ATSB Investigation AO-2007-001
Investigation revealed that the airport
was under the influence of a line of
high-based thunderstorms. Outflow
descending from one of the storm cells led
to the formation of a dry microburst that
resulted in rapidly changing surface wind
conditions. Moderate windshear had
been reported by aircraft operating on the
reciprocal runway. However, ATC had
not effectively communicated the wind
information to the occurrence aircraft.
The airport did not have an automatic
windshear warning system and the
windshear warning system fitted to the
aircraft was reactive and not predictive.
As a result of this occurrence, the
Bureau of Meteorology commenced a
Sydney Airport Wind Shear Study to
assess options for providing the aviation
industry with low altitude windshear
alerts. That study is scheduled for
completion in April 2010.
The ATSB database includes 194 reported
occurrences of high capacity aircraft
encountering windshear during the
approach or take-off phases of flight at
Australian capital city airports between
1 July 1998 and 30 June 2008. ■
Engine failure
ATSB Investigation AO-2007-008
On 24 May 2007, at about 1530 WST,
a Raytheon Beechcraft B200 King Air
aircraft, registered VH-IWO, was cruising
at flight level 290 on an aero-medical
flight from Newman to Fitzroy Crossing,
WA. On board the aircraft were the pilot,
a doctor and a flight nurse. Approximately
259 km south-south-east of Broome,
the aircraft’s right engine inter-turbine
temperature indication (ITT) increased
without any engine control input by the
pilot. The ITT rise was accompanied by
a slight fluctuation in the right engine’s
torque, fuel flow, ITT and N1 indications.
In response, the pilot reduced power
on the engine, and the ITT appeared to
return to within the normal operating
range, although the fluctuations persisted.
Shortly after the power reduction, there
was a slight right engine surge with an
accompanying rise in ITT, and a wisp of
smoke was observed coming from the
right engine.
The operator’s maintenance personnel
examined the aircraft and engine at
Broome and found that they were unable
to rotate the right engine compressor.
The engine was removed and sent to
the engine manufacturer’s authorised
overhaul facility for examination under
ATSB supervision. It was determined
that there had been a major internal
failure of the right engine. Examination
revealed extensive damage caused by
the separation of one of the compressor
turbine blades at mid span.
As a result of this occurrence, the engine
manufacturer has modified the alerting
feature in the case of the interruption of
the supply of electronic trend monitoring
(ECTM) information to customers from
its automated ECTM program. ■
Rotor blade injury
ATSB Investigation AO-2009-002
On 2 April 2009, a flight instructor and
a student pilot were conducting normal
circuit and autorotation training at
Proserpine/Whitsunday Coast Airport,
Qld. At 1400 EST the helicopter collided
with terrain on the grass at the side of the
departure end of runway 11, impacting
with a high rate of descent and significant
forward speed. The helicopter was
seriously damaged and the instructor was
seriously injured.
While conducting a survey flight at
Ambalindum Station (approximately
135 km north-east of Alice Springs,
NT), the pilot of a Robinson R22 Beta
helicopter, registered VH-HZB, noticed
severe vibration of the main rotor
assembly and cyclic controls. The pilot
landed the helicopter immediately, and
a subsequent inspection revealed that a
length of aerofoil skin had peeled back
from the leading edge on the underside of
one of the main rotor blades.
The main rotor blades were subsequently
removed from the helicopter and the tips
sent to the ATSB’s Canberra laboratories
for examination. Initial inspection
revealed extensive erosion of the paint on
the leading edge, and debonding of the
stainless steel skin along the bond line
on the underside of one of the main rotor
blades. The debonding was considered
to have been influenced by the extensive
surface erosion observed.
A review of the current information
surrounding Robinson helicopter blade
debonds found a number of previous
incidents involving a similar failure
mechanism. Additionally, the issue of
main rotor debond had been addressed
by a number of airworthiness directives
(ADs) issued by the Civil Aviation Safety
Authority (CASA) and the Federal
Aviation Administration, along with a
number of safety alerts and service letters
issued by the manufacturer.
The investigation also found no evidence
to suggest that the actions contained
within the current CASA Airworthiness
Directive addressing blade debonding
issues (AD/R22/54) had been integrated
into the helicopter’s maintenance routine.
The logbooks and maintenance release
documents for the helicopter have since
been updated to include reference to
AD/R22/54 Amdt 3. ■
ATSB Investigation AO-2009-010
The instructor received a laceration of the
rear section of the scalp, with exposure of
the skull, requiring about 60 stitches. The
injury was consistent with the instructor
being struck by a rotating main rotor
blade during the accident sequence. That
was supported by the instructor’s headset
cable being found wound around the
main rotor mast and hub.
Afterwards, neither pilot could recall any
of the flight sequence immediately before
the impact. There were no witnesses to
the accident and no relevant recorded
data. An examination of the helicopter
wreckage indicated that there were no preimpact defects. Both main rotor blades
were still attached to the main rotor mast,
with no evidence of delamination or
The R22 Pilot Operating Handbook stated
that door-off operation was approved with
doors removed. The helicopter was found
with the left cabin door removed. The
pilots were not wearing safety helmets,
and were not required to do so. The
helicopter was about 11 kg over its gross
weight limit during takeoff and in the
initial part of the flight, increasing the risk
of structural fatigue, underperformance,
and control instability. While the effect
of overweight operations may not be
immediately apparent, the cumulative
effect of such operations can, over time, be
catastrophic. Due to a lack of information,
the investigation was unable to determine
why the helicopter collided with terrain.
The investigation found, however,
that the use of safety helmets would
reduce the risk of pilot injury during
door(s)-off operations. ■
The pilot shut down the right engine and
decided to divert to Broome Airport.
He also contacted his operations centre
to ensure the availability of appropriate
support at Broome. The pilot shut down
and secured the right engine, briefed
the passengers on the situation and they
prepared for landing. The remainder of
the flight and subsequent single-engine
landing was uneventful.
Skin peels away from main rotor
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.
FSA MAR–APR10 Issue 73
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
raised by reporters.
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
Control of Licensed Aircraft
Maintenance Engineer licences
Report narrative:
The reporter expressed safety concerns
that although the operator was physically
checking all LAME (Licensed Aircraft
Maintenance Engineer) licences, those
checking them were having difficulties
in verifying the licences as valid and
Action taken by REPCON:
REPCON supplied CASA with the deidentified report and a version of the
operator’s response. CASA advised that
it had reviewed the report, and noted
that the operator had indicated it had
carried out an in-depth review of all
licensed engineers, along with aircraft
maintenance engineers not yet licensed.
All of the records were verified by CASA
and only very minor, insignificant
discrepancies were found. CASA reported
that it will not be pursuing this matter
The use of electronic devices
during descent
Report narrative:
The reporter expressed safety concerns
that a passenger continued to use a
portable electronic device (i-phone)
even after an announcement over the
cabin Passenger Address (PA) system
that required all electronic devices to be
switched off. The reporter approached a
cabin crew member to inform them of
the situation. The cabin crew approached
the user of the i-phone, but the user
was observed to continue to use the
i-phone while the aircraft conducted
an Instrument Landing System (ILS)
approach at night in Instrument
Meteorological Conditions (IMC) and
during the landing.
Reporter comment: The cabin crew
should have monitored the passenger
more closely and, if necessary, should
have removed the i-phone for the
remainder of the flight.
Action taken by REPCON:
REPCON supplied the operator
with the de-identified report and the
operator advised that it had reviewed its
procedures for the monitoring of portable
electronic device use during all phases
of flight. The review identified that the
existing procedures provide adequate
measures for confirming portable
electronic devices are switched off during
applicable stages of flight. In addition,
the system for reporting passengers
who fail to follow crew instructions has
been reviewed. The operator is satisfied
with the integrity of these procedures.
Notwithstanding, a reminder has been
sent to all cabin crew reaffirming the
existing procedures.
REPCON supplied CASA with the deidentified report and a version of the
operator’s response. CASA provided the
following response:
CASA has reviewed the Report and is
satisfied with the operator’s response.
The operator investigated the matter with
a review of existing procedures and has
further demonstrated their commitment to
a positive safety culture within the organisation in reaffirming these procedures with
cabin crew.
Restroom visits
Report narrative:
The reporter expressed safety concerns
about flight deck procedures for the
Airbus A320 aircraft with two flight crew,
when a restroom visit is required. The
reporter was very concerned that during
restroom visits, one flight crew member
was alone on the flight deck with the
access door locked.
Aircraft Landing Area (ALA)
Report narrative:
The reporter expressed safety concerns
that some aircraft operating at an Aircraft
Landing Area (ALA) in Western Australia
were only making radio calls on the
Melbourne Centre frequency (120.3),
whereas the reporter believes calls should
also be made on the ALA frequency and a
local aerodrome frequency in accordance
with the Aeronautical Information
Publication (AIP).
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;
Total 2007
Total 2008
Total 2009
Total 2010 a
Information briefs and alert bulletins issued
Total 2007
Total 2008
Total 2009
Total 2010 a
Who is reporting to REPCON? b
Aircraft maintenance personnel
Reporter comment: The ALA is within
a busy training area and there is a high
volume of traffic in the area of the ALA,
and effective communication is vital for
the safety of those aircraft operating at
the ALA and in the vicinity of the ALA.
Cabin crew
Facilities maintenance personnel
/ground crew
Flight crew
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
How do I get further
information on REPCON?
(c) industrial relations matters;
Reporters can submit a REPCON report
online via the ATSB website. Reporters
can also submit via a dedicated REPCON
telephone number: 1800 020 505;
a. as of 19 January 2010
b. 29 January 2007 to 31 December 2009
c. examples include residents, property owners, general
by email: [email protected];
by facsimile: 02 6274 6461 or by mail:
Freepost 600, PO Box 600,
Civic Square ACT 2608.
How can I report to
Air Traffic controller
Note 1: REPCON is not an alternative
to complying with reporting obligations
under the Transport Safety Investigation
Regulations 2003 (see <www.atsb.gov.au>).
(b) acts of unlawful interference with
an aircraft;
(d) conduct that may constitute a
serious crime.
REPCON reports received
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.
What is not a reportable safety
CASA has reviewed the issues raised in the
Report but can find no evidence of aviation
operators at the [name] Aircraft Landing
Area (ALA) making radio calls on inappropriate frequencies.
What happens to my report?
Action taken by REPCON:
REPCON supplied CASA with the deidentified report and CASA provided the
following response:
All operators of the Airbus A320 aircraft
have approved procedures to handle situations such as restroom visits for the flight
crew. Procedures include monitoring the
status in the flight deck and access in an
Action taken by REPCON:
REPCON supplied CASA with the deidentified report and CASA provided the
following response:
Taking off at 4:43am Eastern European Time from Runway 22R for Paris via Cairo,
the aircraft, operating the company s Flight 604, was cleared to make a
climbing left turn at the crew s discretion to intercept the 306 radial
of the Sharm el-Sheikh VOR. The climb was then to be continued to flight
level 140, placing the aircraft on the designated air corridor to
Cairo. The night weather was fine, with a wind of eight knots from 280
degrees, resulting in a cross-wind component of seven knots.
When the first officer reported the Boeing was passing through 1000ft,
the tower confirmed its departure time and flight clearance. But the
first officer’s acknowledgement proved to be its final transmission. Two
minutes later, because another aircraft was inbound to Sharm el-Sheikh,
the tower controller asked the Boeing for its position. There was no
reply. When a further seven tower transmissions also failed to gain a
response, the controller asked the inbound aircraft to call the Boeing.
Again the call was in vain, as were numerous further calls to the Boeing
from the controller after the inbound aircraft landed.
Minutes afterwards, when it was seen that the Boeing’s radar target had
vanished from the tower controller’s radar screen, a rescue vessel
FSA MAR–APR10 Issue 73
was dispatched to the area where the aircraft disappeared, just off
the coast. Initially searching for survivors, its crew found only
small fragmented floating wreckage. It was all too obvious that a major
catastrophe had overtaken the aircraft with the loss of all on board. Most
of the passengers were French tourists from the Paris area.
Flight Safety Australia writer, Macarthur Job,
The Boeing 737’s captain, aged 54, was one of Egypt’s more experienced
pilots, with almost 7500 hours flying experience including a
examines the worst aircraft accident in Egyptian
distinguished career in the Egyptian Air Force. In the military, he had
flown Russian Mig17 and Mig21 fighter jets, had been an instructor Taking
history and the worst for a Boeing 737-300 anywhere
off at 4:43am Eastern European Time from Runway 22R for Paris via Cairo, the
aircraft, operating the company s Flight 604, was cleared to make a climbing
in the world.
left turn at the crew s discretion to intercept the 306 radial of the
Sharm el-Sheikh VOR. The climb was then to be continued to flight level
a night take-off
Egypt’s Sharm el-Sheikh
airport onto Cairo. The
140, placing
on the
air corridor
3 January 2004,
a Boeing
by theknots
night weather
was fine,
a wind
of eight
280 degrees,
Flash Airlines,
plunged into component
the Red Sea at
speed. All
in a cross-wind
seven knots.
142 passengers and the six crew were killed.
When the first officer reported the Boeing was passing through 1000ft,
el-Sheikh is its
a tourist
resort ontime
the Red
close clearance.
to the
the tower
and Sea,
But the
tip of the Sinai Peninsula.
first officer’s
proved Its
to international
be its final
transmission. Two
of theanother
city and 140ft
AMSL, was
has two
Sharm el-Sheikh,
04-22, each 3080m
the tower
Boeing for its position. There was no
reply. When a further seven tower transmissions also failed to gain a
response, the controller asked the inbound aircraft to call the Boeing.
Again the call was in vain, as were numerous further calls to the Boeing
from the controller after the inbound aircraft landed.
flight saf w ty australia
Minutes afterwards, when it was seen that the Boeing’s radar target had
vanished from the tower controller’s radar screen, a rescue vessel was
dispatched to the area where the aircraft disappeared, just off
Taking off at 4:43am Eastern European Time
from Runway 22R for Paris via Cairo, the
aircraft, operating the company’s Flight 604,
was cleared to make a climbing left turn at the
crew’s discretion to intercept the 306 radial of
the Sharm el-Sheikh VOR. The climb was then
to be continued to flight level 140, placing
the aircraft on the designated air corridor to
Cairo. The night weather was fine, with a wind
of eight knots from 280 degrees, resulting in a
cross-wind component of seven knots.
When the first officer reported the Boeing was
passing through 1000ft, the tower confirmed
its departure time and flight clearance. But
the first officer’s acknowledgement proved to
be its final transmission.
Minutes afterwards, when it was seen that
the Boeing’s radar target had vanished from
the tower controller’s radar screen, a rescue
vessel was dispatched to the area where the
aircraft disappeared, just off the coast. Initially
searching for survivors, its crew found only
small fragmented floating wreckage. It was
all too obvious that a major catastrophe had
overtaken the aircraft with the loss of all on
board. Most of the passengers were French
tourists from the Paris area.
The Boeing 737’s captain, aged 54, was one of
Egypt’s more experienced pilots, with almost
7500 hours flying experience including a
distinguished career in the Egyptian Air Force.
In the military, he had flown Russian Mig17
and Mig21 fighter jets, had been an instructor,
and a C130 Hercules transport pilot. But he
had slightly fewer than 500 hours on Boeing
737s. The Egyptian first officer, 25, who had
Investigating the accident, including recovering
the flight data recorder (FDR) and cockpit voice
recorder (CVR), proved extremely difficult. In
the area of impact, the sea was 3300ft deep,
and two French deep sea salvage vessels, both
equipped with submersible, remotely operated
vehicles (ROV), were contracted for the task.
Investigators from the Egyptian Ministry
of Civil Aviation were joined by air safety
experts from the US National Transportation
Safety Board (NTSB) and the French Bureau
d’Enquêtes et d’Analyses pour la Sécurité de
l’Aviation Civile (BEA). After a highly-skilled
underwater operation, assisted by the French
Navy, both the FDR and the CVR were located
and recovered by a ROV two weeks after the
accident, together with critical components
of the aircraft’s hydraulically powered aileron
control system.
It was thought at first that terrorists might
have been responsible for
the disaster, a group in
Yemen actually claiming it
had destroyed the aircraft
as a protest against a French
law banning Muslim head
scarves in schools. But
the investigation dismissed
terrorism as the cause when
the salvage effort found the
wreckage lay in a tight debris
field, only 440m long and
275m wide. This showed that
the aircraft struck the water
intact, whereas destruction
by a bomb would have left
scattered debris.
tow troller
coned the
ask ing for
Boe osition.
its pre was
The eply ’
no r
Two minutes later, because another aircraft
was inbound to Sharm el-Sheikh, the tower
controller asked the Boeing for its position.
There was no reply. When a further seven
tower transmissions also failed to gain a
response, the controller asked the inbound
aircraft to call the Boeing. Again the call was
in vain, as were numerous further calls to the
Boeing from the controller after the inbound
aircraft landed.
undergone his flying training in the USA, held
an FAA commercial pilot’s licence with almost
800 hours experience, fewer than 250 of
which were on Boeing 737s. Also on the flight
deck was a third pilot, a mature Egyptian
completing his training as a B737 first officer.
Holding dual Canadian and U.S. citizenship,
he had 4000 hours flying experience in North
America, including time on corporate jets.
In Cairo, readouts of the FDR and CVR showed that, as the Boeing was
climbing through 440 feet, the captain requested the ‘heading select’
mode on the autopilot. The first officer confirmed the command
and the heading mode was engaged. Shortly after the first officer
acknowledged the controller’s transmission of the departure time
and clearance, the Boeing banked 20 degrees to the left and began a
climbing turn. The captain called for the after-take-off checklist, but
the first officer did not respond, and eight seconds later the captain
called ‘Autopilot!’.
FSA MAR–APR10 Issue 73
Again, thr
was no
the firs
officr or
, but loss
Again, there was no immediate response from the first officer or
autopilot mode change, but the captain then said, ‘Not yet’. Almost at
once the autopilot was engaged, the transition to control wheel steeringroll (CWS-R) mode resulting in the loss of the heading mode, and the
first officer reported, ‘Autopilot in command, Sir’. But a second later the
captain uttered a sharp Arabic exclamation of surprise, and at the same
time the FDR recorded a momentary aileron movement. The autopilot
disengaged, the aircraft’s pitch increased and the airspeed decayed a
little. Six seconds later, the aircraft began banking to the right, prompting
the captain to exclaim, ‘See what the aircraft
did!’ With the aircraft now banked 12 degrees
to the right, the first officer called, ‘Turning
right, Sir!’. The captain exclaimed ‘What!’.
As the right bank increased to 17 degrees,
and still in night IMC, with the FDR recording
the ailerons increasing the bank, the captain
wondered aloud, ‘How (is it) turning right?’.
The bank increased to just under 40 degrees,
and there was a momentary left roll before the
right bank continued increasing.
As the bank reached 50 degrees, the first officer
called ‘Overbank!’ and at the same time the
aircraft reached its maximum height of 5460
feet. The captain called, ‘Autopilot! Autopilot!’,
the first officer answering, ‘Autopilot in
command’. But the FDR recorded no autopilot engagement.
With the bank angle now reaching 60 degrees, the aircraft’s nose-up
pitch fell to zero, and again the captain called, ‘Autopilot!’. But the first
officer’s alarmed response was, ‘Overbank! Overbank! Overbank’, as
this increased to 70 degrees. As the aircraft’s nose began dropping, the
first officer urgently repeated ‘Overbank!’. The bank became vertical,
the nose-down attitude steepened to nearly 40 degrees, and with
1300ft of altitude lost and the bank increasing beyond the vertical, the
first officer cried out, ‘No autopilot, Commander!’.
The bank was now 111 degrees and the aircraft was diving through
3500ft. With the nose now down more than 40 degrees, the captain
again called urgently ‘Autopilot!’. Three seconds later, the trainee
first officer in the jump seat shouted, ‘Retard power! Retard power!
Retard power!’.
Both throttles were closed to idle; the vertical g loading on the aircraft
increased, and the captain appeared to be regaining control, reducing
the bank to 50 degrees and the nose attitude to 40 degrees as the
Boeing dived through 2470ft. But its speed continued to increase,
the overspeed warning sounding as it passed 307kt as he succeeded
in reducing the dive to 30 degrees and the bank to14 degrees at an
airspeed 407 knots. Now only 760ft above the sea, and obviously still
struggling with the controls, the captain exclaimed, ‘Come out!’.
But it was too late. Three seconds later the Boeing plunged into the
Red Sea, still diving 24 degrees nose-down and banked the same
amount to the right at an airspeed of 416kt while pulling 3.9 g. All on
board were killed instantly. The impact point was eight nm south of
the airport.
The Egyptian report said the cause of the aircraft’s dive into the Red
Sea remained uncertain. ‘No conclusive evidence could be found …
to determine a probable cause’, it read. ‘Although the crew at the
last stage of the accident attempted to correctly recover, the gravity
of the upset condition ... made this attempt insufficient to achieve a
successful recovery.’ Findings listed as ‘possible causes’ included an
aileron trim runaway and a hard over autopilot actuator.
Both the BEA and the NTSB took issue with the Egyptian findings.
The BEA conceded that the ‘two hypotheses were not eliminated’,
but insisted that even if these occurred, the simulations undertaken
during the investigation showed that ‘the crew would still have been
able to control the airplane’s track’.
The French comment continued, ‘It is necessary to examine why the
crew, when confronted with an abnormal and unusual situation, did
not seem to have either analysed this situation or to have mobilized all
available resources to deal with it. The CVR readout shows an absence
of dialogue aimed at identifying a possible problem or proposing a
solution to it.
‘It is necessary to examine the knowledge the captain possessed to
enable him to identify and manage the crisis situation encountered
during this flight, which implies studying the successive training
Neither the BEA nor the NTSB believed there
was evidence of technical failure that could
have led to the upset. The NTSB, in a letter
to the Egyptian Ministry of Civil Aviation,
maintained there was ‘no evidence that
an airplane-related malfunction or failure
caused or contributed to the accident’. Both
the French and US investigators concluded
that the cockpit voice recorder script and
the flight profile indicated that the captain
became spatially disorientated during the
night departure and the first officer ‘did not
assume timely control of the aircraft’ because
he was unwilling to challenge his far more
experienced superior.
After a long investigation, with full participation by technical officers
from both French BEA and the American NTSB, the Egyptian Ministry
of Civil Aviation prepared the draft report, forwarded to the two
national authorities for comment.
programmes he had followed. His activity
for several years showed no evidence of
any structured training in this area, nor
more generally for the role of captain. On
the technical level, his type rating had been
carried out on a B737-500 and not on a B737300, without any training on the specifics
of the fleet’s aircraft being included in the
operator’s documentation.’
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FSA MAR–APR10 Issue 73
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Furthermore, according to the BEA and the NTSB, both officers were
insufficiently trained. The NTSB said that the CVR showed 24 seconds
elapsed after the aircraft began banking to the right before the captain
began correcting manoeuvres. The NTSB continued. ‘A few seconds
before the captain called for the autopilot to be engaged, the airplane’s
pitch began increasing and airspeed decreasing. These deviations
continued during and after the autopilot engagement/disengagement
sequence. The captain ultimately allowed the airspeed to decrease to
35 knots below his commanded target airspeed of 220 knots and the
climb pitch to reach 22 degrees, 10 degrees more than the standard
climb pitch of about 12 degrees. During this time, the captain allowed
the airplane to enter a gradually steepening right bank. The pitch,
airspeed, and bank angle deviations indicated that the captain directed
his attention away from monitoring the attitude indications during and
after the autopilot disengagement process.
‘Changes in the autoflight system’s mode status offer the best explanation
for the captain’s distraction. The following changes occurred in the
autoflight system shortly before the initiation of the right roll:
2. Automatic transition of roll guidance from heading select to
control wheel steering-roll (CWS-R mode)
3. Manual disengagement of the autopilot
4. Manual re-engagement of heading select for roll guidance.
5. ‘The transition to the CWS-R mode occurred in accordance with
nominal system operation because the captain was not closely
following the flight director guidance at the time of the autopilot
engagement. The captain might not have expected the transition,
and might not have understood why it occurred. The captain was
probably referring to the mode change from command mode to
CWS-R when he stated, “See what the aircraft did?”, shortly after
it occurred. The evidence indicates the unexpected mode change
and the crew’s subsequent focus of attention on re-establishing roll
guidance for the autoflight system were the most likely reasons for
the captain’s distraction from monitoring the attitude.’
Accident investigation experience has shown numerous instances
where pilot control problems can arise from the very complexity of
modern autopilot systems. During this investigation the suggestion
was made that differences in the ADI instrument presentation of the
MiG-21 jet fighter, which the captain had flown extensively in the
past, and the conventional Boeing 737 instrumentation, could have
contributed to the loss of control.
There is no shortage of evidence from
similar types of accidents that the
current emphasis by aircraft operators
on the use of automation for all but takeoffs and landings has inevitably led to a
steady decline in pure flying skills on the
part of crews—and indeed to a reticence
to attempt to fly an aircraft manually
when the situation demands it.
This particular accident is a tragic
example. The captain’s almost frantic
demands for the autopilot to be
engaged give the impression he was
reluctant to revert to normal manual flight
when that action was the most appropriate
for correcting the aircraft’s deviation from
the intended flight path.
The first officer’s reluctance to take control
immediately after it became obvious that
the captain was seriously disoriented,
is another example of where ‘cockpit
gradient’–the relationship or command
structure between the captain and the first
officer – is implicated as a causal factor
in an aircraft accident. In this case there
was a ‘steep cockpit gradient’, where the
co-pilot felt unable to question any of the
captain’s actions or decisions. This has
become something of an impediment to
global aviation safety today, with numerous
accidents in recent years demonstrating
the fact. It is because of cockpit gradient,
and the reluctance of aircrew often to
manage these command relationships,
that crew resource management (CRM)
was introduced. Whether flight crew
share the same country of origin, as in
the Flash Airlines case, or comprise a
national mix, when the captain and first
officer fail to communicate, there are
major safety implications, often with tragic
consequences. Again, t=hrk
1. Manual engagement of the autopilot
An Australian comment
Changes – operating at
non-towered aerodromes
FSA MAR–APR10 Issue 73
The date of 3 June, 2010 is significant for aviation
in Australia for several reasons, not the least
of which are the transition from GAAP to Class
D airspace, covered elsewhere in this issue of
Flight Safety, and planned changes to operating
in the vicinity of non-towered aerodromes. Most
aerodromes in Australia fall into this category,
that is they are ‘non-towered’.
CASA is finalising changes to Civil Aviation Regulation 166 (CAR
166) planned to come into effect on 3 June 2010. Several changes to
operating procedures are proposed for all non-towered aerodromes,
but the primary one which may affect some aircraft operators is the
necessity for them to carry an aircraft radio (the mandatory carriage of
radio) at all registered, certified and military non-towered aerodromes.
Across Australia there are approximately 295 certified or registered
aerodromes, as well as a number of military aerodromes, where
it will be mandatory to carry an aircraft radio. There are a further
approximately 285 uncertified or unregistered aerodromes which will
not require the mandatory carriage of a radio.
Non-towered aerodrome
An aerodrome at which air traffic control
(ATC) is not operating. This can be either:
An aerodrome that is always in Class
G airspace
An aerodrome with a control tower
where no ATC service is currently
provided, or
An aerodrome which would normally
have ATC services, but such services
presently unavailable.
You must also remember that ‘nontowered aerodromes’ include those with
Class C and D air traffic control services
at times when these services are not
available. It is critical that you consult
the current ERSA and the latest NOTAMs
for times of ATC operation at these
Certified aerodrome
An aerodrome with runway suitable for
aircraft with more than 30 passengerseats, or able to carry 3400kg, and is
available for regular public transport
or charter operations by such aircraft.
Certified aerodromes have higher
operating standards than registered
aerodromes. (Certified by CASA under
CASR subpart 139.B)
Registered aerodrome
An aerodrome which meets certain
operating standards, and is regularly
inspected. (Registered by CASA under
CASR subpart 139.C)
Military aerodrome
An aerodrome under the control of
any part of the defence force. The En
Route Supplement Australia (ERSA)
contains criteria for military aerodrome
operations. You must carry radio at
military aerodromes at all times.
Operations at non-towered aerodromes can
present many challenges to pilots, which
may include:
fitting into the circuit traffic, and
dealing with threats and hazards which
may be encountered.
These proposed changes came about as a
result of the post-implementation review
of the new National Airspace System 2C
(NAS2C) implemented in November 2005. At
that time, the review, and the ATSB report: the
‘Limitations of the see-and-avoid principle’
suggested that changes were necessary,
based on the known and improved collision
avoidance that ‘alerted see-and-avoid’
provides, and the value of radio in enhancing
separation and situational awareness.
Through making these changes to CAR 166,
CASA has undertaken to put these into effect.
A notice of proposed rule making was issued
last year, and by the closing date in January
this year, following an extensive consultation
period, CASA had received 212 submissions.
The majority of this feedback was extremely
positive, and has informed the details of the
proposed new regulation, as well as being
incorporated into the advisory material to
support the revised regulation.
Changes at a glance
Carriage of radio is mandatory at all
certified, registered or military nontowered aerodromes.
Two new CAAPs to be released. These
CAAPs support the changes to legislation
and provide guidance on a code of conduct/
airmanship, which when followed, will
provide improved situational awareness
and safety for all pilots when flying at, or in
the vicinity of, non-towered aerodromes.
Changes to traffic circuit procedures at all
non-towered aerodromes
Standard traffic circuit procedures
Circuit heights
Arriving and departing the circuit area.
Operating and handling the traffic mix
Radio broadcasts – standard broadcast
Handling various hazards including:
Aircraft size & performance
Wake turbulence & windshear
Collision avoidance – maintaining
Details of the new regulations are
being finalised as this issue of Flight
Safety went to press, but there will be a
further article explaining the changes
in the May-June issue of the magazine.
Look out too, for the communications
campaign and industry seminars to
support the implementation. Check
the website: www.casa.gov.au/car166/
for more details.
The majority of
this feedback
was extremely
Non-towered aerodromes can provide a
challenge too, because of the differences in
capacity and performance arising from the
mix of aircraft which can be seen at nontowered aerodromes. These can range from
passenger-carrying aircraft, IFR/VFR, smaller
general aviation aircraft, those involved in
aerial work/agriculture, to the various VFR
sport and recreational aircraft – all of which
can operate in the vicinity of a non-towered
aerodrome at any one time.
There are two civil aviation advisory
publications (CAAPs) on the new regulation
CAAP 166-1(0) and CAAP 166-2 (0), which
are expected to become effective in June.
It is envisaged that the two CAAPs will
become an authoritative benchmark of
operating procedures at these non-towered
With operations from a non-towered aerodrome (other than
one designated CTAF[R]) where the elevation is less than
3000FT AMSL and the visibility is 5000M or more, an aircraft
without radio may
(a) operate without restriction.
(b) not operate under any circumstances.
(c) operate, provided it can remain clear of cloud by 1000ft
vertically and 1500m horizontally.
(d) operate, provided it remains clear of cloud and in sight of
the ground or water.
The most likely consequence resulting from the somatogravic
illusion would be
(a) collision with the ground during a night takeoff.
(b) stalling during a night takeoff.
(c) perceiving an undershoot on a down-sloping runway.
FSA MAR–APR10 Issue 73
(a) higher than it actually is (due to diffraction).
(d) perceiving an overshoot on an up-sloping runway.
Water on a windscreen during an approach may produce an
illusion that, with reference to the runway, the aircraft is
(b) lower than it actually is (due to diffraction).
When experiencing the somatogravic illusion, there is a
tendency for a pilot to further increase the false sensation by
(c) lower than it actually is (due to refraction).
(d) higher than it actually is (due to refraction).
(a) raising the nose and approaching the stall.
(b) lowering the nose and increasing the acceleration of the
(c) reducing power in order to reduce acceleration.
(d) increasing power in order to increase acceleration.
(a) if the incoming fuel is hotter, it will immediately sink to the
bottom of the tank.
A terminal area forecast containing ‘PROB30 INTER 3105/3110
VRB25G45KT 3000 ...’ would probably be associated with a
(b) if the incoming fuel is colder, it will immediately sink to the
bottom of the tank.
(a) cold front.
(c) the water may have dissolved into the fuel by agitation that
occurs during the refuelling process.
(b) warm front.
(d) the water may have diffused into the fuel by the agitation
that occurs during the refuelling process.
(c) thunderstorm.
(d) a col.
An attitude indicator indicates the angle of bank with a pointer
against a scale. When the bank angle scale indication occurs
on the same side as the bank is occurring, (i.e. banking leftpointer left) the pointer is
(a) attached to the aircraft reference (instrument case) and the
scale is attached to the vertical gyro.
(b) attached to the vertical gyro and the scale is attached to the
instrument case.
(c) aligned with the gyro spin axis.
(d) aligned with the gyro lateral gimbal axis.
Unless a suitable settling time is allowed, water in fuel tanks
prior to refuelling may not be detected on a subsequent fuel
drain because
When making an approach to a runway that is sloping upwards
from the threshold, the runway will appear
During a crosswind landing, an aircraft may ‘weathercock’
into wind
(a) only when a wheel is on the ground.
(b) only when all wheels are on the ground.
(c) only when airborne.
(d) at any time during the approach and landing.
10. An electrical system which has the ammeter installed
between the battery and electrical bus will, under normal
operation, show the
(a) total generator output.
(b) sum of the electrical loads and the charge to the battery.
(a) longer and the approach will appear low.
(c) charge into the battery.
(b) longer and the approach will appear high.
(d) total electrical load.
(c) shorter and the approach will appear low.
(d) shorter and the approach will appear high.
In normal flight a wing is upward bending and the top spar cap
will be
(a) the currents in each output phase compared with those
between each phase winding and the star point or ground.
(a) in tension, and the lower spar cap, and if fitted, a wing strut,
will be in compression.
(b) the currents in each phase winding and the star point.
(b) in compression, and the lower spar cap, and if fitted, a wing
strut, will be in tension.
(d) the average currents in the output phases compared to that
from any other generator feeding the same bus.
(c) in tension, together with the lower spar cap, and if fitted, a
wing strut.
(c) the currents in each of the three output phases.
(d) in compression, together with the lower spar cap, and if
fitted, a wing strut.
(b) the pitot pressure minus the static pressure.
In a jet engine, a compressor stall occurs when:
(c) the pitot pressure minus the static pressure, divided by the
pitot pressure.
(d) the pitot pressure minus the static pressure, all divided by
the static pressure.
(b) in a centrifugal compressor, the angle of attack of the air
reaching the stator guide vanes exceeds the stalling angle.
(c) in an axial flow compressor, the angle of attack of the air
reaching the rotor aerofoils exceeds the stalling angle.
(d) in a centrifugal compressor, the angle of attack of the air
reaching the rotor aerofoils exceeds the stalling angle.
(c) oil flow from the hub, to cause an increase in blade angle.
(b) lower voltage DC source from a higher voltage DC input.
(d) oil flow to the hub, to cause an increase in blade angle.
(b) closed due to the higher pressure below the wing.
(c) open due to the flow of fuel from the tank.
(d) open due to the action of the fuel pumps.
One disadvantage of a fuel system that gravity feeds to the
carburettor without the use of pumps, is that
(a) it is not possible to incorporate a vapour return feature.
(b) the system is more prone to vapour locks.
(c) the fuel pressure at the carburettor varies with the level of
fuel in the tank.
(d) aerobatics are not possible.
In an AC generating system, differential current protection is
provided to
(a) detect extreme load unbalance between the three phases.
(b) detect ground faults within the generator.
(c) detect ground faults on the load side of the generator.
(d) detect faults between the star point and ground.
10. A capacitance fuel quantity indicator system operates by
(a) applying an AC voltage to the capacitance probe in the tank,
and measuring the increase in probe capacitance due to the
increased dielectric constant of fuel compared to air.
(b) applying an AC voltage to the capacitance probe in the tank,
and measuring the decrease in probe capacitance due to
the decreased dielectric constant of fuel compared to air.
(c) applying a DC voltage to the capacitance probe in the tank,
and measuring the increase in probe capacitance due to the
increased dielectric constant of fuel compared to air.
(d) applying an DC voltage to the capacitance probe in the tank,
and measuring the decrease in probe capacitance due to
the decreased dielectric constant of fuel compared to air.
Where a conventional vented fuel cap, containing a one-way
valve, is used in a fuel system as an auxiliary to the main
venting system, the valve, under normal operation, will be
(a) oil pressure increasing in the hub, to cause a reduction in
blade angle.
(a) higher voltage AC source from a lower voltage DC input.
(a) closed due to the lower pressure above the wing.
On an aircraft with a constant speed propeller, a reduction of
power results in
(b) oil flowing either into or out of the hub (depending on the
system design), to cause a reduction in blade angle.
(d) lower voltage DC source from a higher voltage AC input.
The role of a TRU (transformer-rectifier unit) in aircraft with an
AC electrical system is to provide a
(c) higher voltage DC source from a lower voltage AC input.
A mechanical Machmeter operates by comparing the pitot and
static pressures and responding to
(a) the static pressure minus the pitot pressure.
(a) in an axial flow compressor, the angle of attack of the air
reaching the stator guide vanes exceeds the stalling angle.
Differential current protection is best described as
automatically tripping a generator off line when there is a
significant imbalance between
An IMC arrival
You are the pilot in command of a Beech 58 Baron operating as a
category B aircraft and equipped with ADF, VOR, ILS with marker
beacons, DME and TSO’D GNSS. You are endorsed on all these
Navaids, but only for GNSS enroute. You are tracking from Hobart
(YMHB) to Strahan (YSRN) at A080 in cloud. You plan top-ofdescent. You have conducted a GPS RAIM prediction and found
that RAIM is available. The GPS currently reads 30SRN.
Questions 1 to 7 refer to this enroute descent and arrival at YSRN.
Assuming continuing IMC, what is the lowest height you may
descend to enroute at this time?
(a) The LSALT of 6200.
(b) The MSA of 6000.
(c) The MSA of 5100.
(d) The MSA of 3600.
FSA MAR–APR10 Issue 73
Passing 6500, descending and still in cloud, the GPS now reads
24 SRN. No RAIM warning active.
What height may you now descend to?
(a) Still only LSALT of 6200.
(b) The MSA of 3600.
(c) The MSA of 6000.
(d) The MSA of 5100.
You now consider the GPS arrival for further descent.
What is the recency requirement for you to fly this arrival?
Passing 4 GPS and descending through 4700 a RAIM warning
Which of the following is the correct action to take?
(a) Flown specifically a GPS arrival, either in flight or category
B simulator within the last 90 days.
(a) Discontinue the GPS arrival maintaining 4700 to the NDB.
(b) Discontinue the GPS arrival, climbing back to the (positive
fix) MSA within 10nm of 5100 and tracking to the NDB.
(b) Flown specifically a GPS arrival, either in flight or category
B simulator within the last 35 days.
(c) Continue descent to the MDA, since the RAIM loss occurred
after the FAF at 5 GPS.
(c) Flown either a DME or GPS arrival (aircraft or approved
simulator) within the last 90 days.
(d) Discontinue the GPS arrival, climbing back to the LSALT of
6200 and dead reckoning the missed approach track of 270.
(d) Flown either a DME or GPS arrival (aircraft or approved
simulator) within the last 35 days.
Which of the following is correct concerning the GPS arrival
‘steps’ enroute to SRN?
(a) Maintain 6000 until after passing 7.5 GPS then maintain a
steady 3.39° profile, checking not below 5100 until after
passing 5nm, then MDA of 3300 (no known QNH).
(b) After passing the IAF at 15 GPS descend to 5100, then after
passing the FAF at 5 GPS descend to MDA of 3300 (no
known QNH).
(c) After passing 18 GPS you may descend to 5100, then after
passing 5 GPS descend to MDA of 3300 (no known QNH) or
3200 (known QNH from telephone AWIS).
(d) Both (a) and (c) are correct.
You are now approaching overhead the NDB, still IMC and still
with the RAIM warning active.
What actions will you now take?
(a) Divert to a suitable alternate.
(b) Conduct a Sector 3 entry to the holding pattern, descending
to 3600, then fly the NDB approach.
(c) Conduct a Sector 3 entry to the holding pattern, descending
to 3600 only when established inbound in the hold, then fly
the NDB approach.
(d) Conduct a Sector 1 entry to the holding pattern descending
to 3600, then fly the NDB approach.
O verhead the NDB at 3600 tracking 198 you commence the
If you were to establish visual reference by day on the initial
approach track, whilst descending to 1400 and can maintain
this reference to the aerodrome, the instrument approach may
be discontinued at this time. True or false?
(a) True.
If the aircraft in the previous question were to establish VMC
this time by night and with a GPS arrival not being possible due
to RAIM loss, when can further descent be made?
(a) You can modify the published LSALT of 2700 to allow further
descent inbound.
(b) You can descend to the MSA of 2000 having used GPS to
obtain the positive fix.
(c) You can only descend below the LSALT of 2700 once
established within the circling area for the aircraft
(b) False.
Refer to ERC L2
You are tracking along W887 by day, inbound for a landing at
Swan Hill (SWH). Overhead position ‘FRANZ’ and passing through
7000 on descent you establish VMC and ascertain that this can be
maintained to the circuit area.
Whilst electing to remain IFR category, when can the visual
descent be made?
(a) Not until passing the 25nm MSA of 2000.
(b) Not until achieving the LSALT of 2700 and within the circling
(c) Since remaining IFR category you can only descend visually
in accordance with the GPS arrival steps.
(d) Once established within 30nm, i.e. 1nm past ‘FRANZ’.
(d) You can descend to the MSA of 2000 having used deduced
reckoning (DR) navigation to fix the position within 25nm.
Refer to the Melbourne TAC
You have been tracking along W495 from ‘WAREN’ to Plenty in
cloud when ATC give you the instruction to ‘Turn right heading 350,
radar vectors for the Essendon runway 26 ILS, descend to 3000’.
10. Why is it acceptable to descend below the LSALT of 4000?
(a) The MSA in this area is 2900.
(b) The ILS commencement altitude is 3000.
(c) You are being radar vectored so ATC take on terrain separation
responsibilities (with the pilot still maintaining awareness!).
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Calendar 2010
Organiser & More info
Professional Development Program
Bankstown Trotting
Recreational Club
CASA Flight Training & Testing Office
[email protected]
Airtourer Association Convention & AGM
Cowra, NSW
Airtourer Co-operative
International Air Safety Seminar
Lisbon, Portugal
Flight Safety Foundation, European
Regions Airline Association & Eurocontrol
[email protected]
Professional Development Program
CASA Flight Training & Testing Office
Professional Development Program
CASA Flight Training & Testing Office
[email protected]
Professional Development Program
CASA Flight Training & Testing Office
[email protected]
3 Jun
Transition to Class D airspace
3 Jun
Implementation of new CAR 166
regulations regarding operations
at non-towered aerodromes
AAAA Convention 2010
Holiday Inn,
Surfers Paradise
Aerial Agricultural Association Australia
Australian Centenary of Powered Flight
Mia Mia, VIC
Australian Centenary of Powered Flight
Mia Mia Inc.
Jill James secretary:
M - 0418 388 919.
E: [email protected]
The Australian Aircraft Airworthiness &
Sustainment Conference
Brisbane Convention &
Exhibition Centre, QLD
AASC/Ageing Aircraft - chairman
Richard Gauntlett
[email protected]
Regional Aviation Association Australia
annual conference
Hyatt Regency Resert
Coolum, QLD
Sixth Triennial Int’l Aircraft Fire & Cabin
Safety Research Conference
Atlantic City, New
Various civil avation authorities, including
FAA, CAA-UK, Transport Canada, CASA
and CAAS
Register online at
or email [email protected]
FSA MAR–APR10 Issue 73
for more information.
Please note: AvSafety Seminar calendar subject to change, please confirm date
and venue with your regional AvSafety Advisor
CASA events
Other organisations’ events
Have you got the latest copy
of the AOPA magazine?
Out now!
Look out for the March/April issue of
Australian Pilot
For pilots and aircraft owners.
In this months issue:
>> Helicopter special
>> Flying. Your legal rights
>> Challenge in the desert
Support AOPA - working for YOU
On sale early March
Flying Ops
IFR Operations
1. (c) ENR 1.2 Para. 2.6.
2. (a) Acceleration is perceived as pitching-up.
3. (b) The false sensation of pitching-up is
increased by further acceleration if the pilot
lowers the nose.
4. (c) Such a strong wind from a variable
direction is the key.
5. (a) There are two conventions for presentation
of the banka angle and these depend on the
instrument design. (b) is the earliest version.
6. (b)
7. (d)
8. d) This can be a trap; suitable settling time
allows the water to accumulate again on the
bottom of the tank.
9. (a)
10. (c)
1. (a) AIP GEN 3.3. – 16 Para 3.6
2. (c) AIP ENR 1.5 – 2 Para 1.4; ENR 1.5
– 14 Para 2.2.1
3. (c) C.A.O. 40.2.1
4. (d) DAP EAST YSRN/GPS arrival plate;
AIP ENR 1.5-30 Para 5.3.2
5. (b) AIP ENR 1.5-44 Para 13.2.2f
1.5. – 2 Para 1.5
7. (a) AIP ENR 1.5. – 9 Para 1.14a
8. (d) AIP ENR 1.5 - 9 Para 1.14a
9. (c) AIP ENR 1.5 – 10 Para 1.14b
10.(c) AIP ENR 1.6. – 1 Para 3.5. Terrain
awareness is obviously critical - in some
countries, a minimum vectoring altitude
plate can be very useful.
(d) There are two capsules in a Machmeter.
(b) Single-engined aircraft tend to use oil flow
from the hub to fine the propeller, but there are
10.(a) AC is used for capacitive measurement and
a rising fuel level increases the capacity of the
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Did I register my ELT ?
Since February 2009, most aircraft have been required to carry a digital 406MHz emergency
locator transmitter (ELT) on flights in Australia. To work effectively when activated during an
accident, these beacons need to be registered with the Australian Maritime Safety Authority
(AMSA). Under CASA regulations, registering your beacon is mandatory.
FSA MAR–APR10 Issue 73
Ensure you register your 406 MHz beacon with AMSA. This is a free service
and is available through the AMSA website at http://beacons.amsa.gov.au,
or call the AMSA hotline on 1800 406 406 for other registration options.
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Inside next issue
The transition to Class D - making sure you’re On Track
Operating at non-towered aerodromes
The results of our latest SDR competition, and
More of the ever-popular quiz and readers’ close calls.
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