Flight safety starts... May–June 2009 Issue 68 Military restricted areas VCAs What if you had to ditch? And ... more ‘close calls’ on the ground UAS – the story continues ERROR MANAGEMENT ROADSHOW coming to a city near you ‘Practical error management for pilots and LAMEs’ – a nationwide road show in June – brought to you by CASA’s human factors’ team, and featuring: Keynote speaker - Dr. Tony Kern multiple award-winning aviation safety expert and the author of ﬁ ve books on aviation professionalism, including Redeﬁning Airmanship and Flight Discipline. The full-day seminars are practically-focused for pilots & LAMEs, and cover: background to human error: physiology and psychology violation and error-producing conditions & countermeasures for LAMEs & pilots developing a personal safety management system (PSMS) to integrate seamlessly with organisational safety management systems ﬂight discipline & compliance: the cornerstone of professionalism practical error management – tips & strategies for individuals. Each seminar participant will also receive: Blue Threat Fieldbook – tailored to Australian conditions, so that you can track your own errors & develop personal countermeasures A year’s free subscription to online assessment tools ERROR MANAGEMENT ROADSHOW JUNE 2009 Date City Venue Wednesday 10 June 2009 Brisbane Comfort Inn & Suites, Kessels Road Robertson Gardens Friday 12 June 2009 Cairns Holiday Inn 123 Esplanade, Cairns Monday 15 June 2009 Darwin Darwin Airport Inn cnr. Henry Wrigley & Sir Norman Brearley Drives, Marrara Wednesday 17 June 2009 Adelaide The Mawson Centre Mawson Lakes Boulevard, Mawson Lakes Friday 19 June 2009 Monday 22 June 2009 Perth Runway Bar & Café Eagle Drive, Jandakot Dingley International Hotel Boundary Road, Dingley Wednesday 24 June 2009 Hobart Mercure Hotel Bathurst Street, Hobart Friday 26 June 2009 Sydney Bankstown Sports Club Greenﬁeld Parade, Bankstown Melbourne Places are limited, and on a ‘ﬁrst-in, best-dressed’ basis. So to secure your place, please register: E: firstname.lastname@example.org or P: CASA human factors via 131 757 CONTENTS Features ISSUE NO. 68, MAY-JUNE 2009 8. CHIEF EXECUTIVE OFFICER, CASA John McCormick MANAGER, SAFETY COMMUNICATIONS & MARKETING Gail Sambidge-Mitchell Flight Safety looks at this arguably often-neglected area of aviation safety. 20 ‘UAS … the story continues’ UAS researcher, Dr Rod Walker, & three UAS operators talk to Flight Safety. EDITOR, FLIGHT SAFETY AUSTRALIA Margo Marchbank ADVERTISING SALES P: 131 757 or E: email@example.com CORRESPONDENCE Flight Safety Australia GPO Box 2005 Canberra ACT 2601 P: 131 757 F: 02 6217 1950 E: firstname.lastname@example.org W: www.casa.gov.au/fsa/index.asp CHANGED YOUR ADDRESS? To change your address online, go to http://casa.gov.au/change For address-change enquiries, call CASA on 1300 737 032 24 DESIGN & PRODUCTION Spectrum Graphics – www.sg.com.au PRINTING IPMG (Independent Print Media Group) NOTICE ON ADVERTISING Advertising appearing in Flight Safety Australia does not imply endorsement by the Civil Aviation Safety Authority. Warning: This educational publication does not replace ERSA, AIP, airworthiness regulatory documents, manufacturers’ advice, or NOTAMs. Operational information in Flight Safety Australia should only be used in conjunction with current operational documents. Information contained herein is subject to change. The views expressed in this publication are those of the authors, and do not necessarily represent the views of the Civil Aviation Safety Authority. © Copyright 2009, 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: CASA photo library Military restricted areas’ Why it’s important to avoid such areas. 26 ‘Baby, it’s cold outside’ The dangers of upper-wing icing. 30 Winner of the Snap-on tool kit! Corrosion defect SDR competition results. 31 DISTRIBUTION Bi-monthly to 85,000 aviation licence holders and cabin crew in Australia and internationally. CONTRIBUTIONS Stories and photos are welcome. Please discuss your ideas with editorial staff before submission. Note that CASA cannot accept responsibility for unsolicited material. All efforts are made to ensure that the correct copyright notice accompanies each published photograph. If you believe any to be in error, please notify us at email@example.com ‘Flight safety starts on the ground’ ‘High G manoeuvring’ Darren Morris on the need for additional record-keeping on aerobatics aircraft. 58 ‘What if you had to ditch?’ Flight Safety looks at surviving a deliberate emergency landing on water. 62 www.skybrary.aero The aviation safety ‘one-stop-info-shop’. 64 ‘Error management roadshow’ Dr Tony Kern’s Australian visit in June. 65 ‘Human factors & TEM training’ Resources to help instructors meet the new day-VFR syllabus requirements. Regulars 2 5 16 18 18 31 AirMail Flight Bytes–aviation safety news ATC Notes– news from Airservices Australia Accident reports– International Accident reports– Australian Airworthiness pull-out section 33. SDRs 37. Directives 39. Channel squeeze update 44 Close Call 44. 46. 47. 50. ‘Cockpit complacency’ ‘A very real simulation’ ‘Magnetic mix-up’ ‘See Gull?’ 52 ATSB supplement 66 Av Quiz 71. Quiz answers 70 Calendar A IR M A IL PAR AVION PAUL COUVRET EMAILED ABOUT THE EDITOR’S ‘GROSS ERROR IN THE ARTICLE ON ERROR’ GUSTAVO DE LEON, AN ICAO TECHNICAL OFFICER, EMAILED FROM MONTREAL, CANADA Re Icarus’ ‘classical CFIT’ – it was no I would like to refer to the article ‘Making incursions into runway safety’ published in Flight Safety Australia, No 62, May-June 2008. such thing! His wings came off – a catastrophic inflight structural failure – and he fell to earth. The report may well have been written up in the classical era, but there was nothing controlled about it! To which this editor contritely replied: ‘I’d like to say it was a deliberate ploy to pick the error, but the error’s all mine - Icarus’ fall from grace, and indeed the heavens, was, 2 as you rightly point out, a classical UFIT, not CFIT. The growing incidence of UFIT FSA MAY–JUNE09 accidents will be a topic for future issues, since it sadly seems to have surpassed CFIT.’ Your article provided excellent information related to the subject of the prevention of runway incursions and it’s very well aligned with the objectives of ICAO to reduce these incidents worldwide, except that on page nine your definition of runway incursion differs from ICAO’s definition. The ICAO definition in PANS-ATM (Doc 4444) does not include ‘animal’ and the footnote under the published definition could lead one to interpret that the published definition is the ICAO definition. The ICAO definition for runway incursion is as follows: Any occurrence at an aerodrome involving the incorrect presence of an aircraft, vehicle or person on the protected area of a surface designated for the landing and take-off of aircraft. HENRY LESCHEN EMAILED I find your magazine Flight Safety Australia a very enjoyable read in its level of technical expression, especially the latest March - April 2009 issue 67 where on page number four the first article entitled, ‘I was relieved to tuck the aircraft away that afternoon etc ‘. I should like to commend the thoughtful readerr who noted the pilot’s lack of responsibility and basic airmanship in failing to record in the technical log of the aircraft that pilot’s mismanagement of the engine, as well as his total lack of responsibility in informing the owner of the aircraft of his engine mismanagement, likely to lead to a severe incident or accident to the next person or persons to fly this aircraft in the future. PATRICIA NIXON-SMITH EMAILED A ‘BOUQUET’ FOR HER LOCAL COUNCIL Some issues ago in Flight Safety mag. you showed all those poor, neglected windsocks on lonely airfields. Not long afterwards, Rockhampton Regional Council replaced our windsock with a nice bright new one on EMU PARK Airfield, on the Capricorn Coast in central coastal Queensland. The strip is 800m grass, less than one kilometre from the town and beaches. Hope you might like to show that some councils still do care for their aviators. credit for the first solo return trip from Perth to Sydney. See http://www. pioneerwomen.com.au/highflyers.htm. ACCORDING TO READER M. ROGERS, Nancy de Loew Bird (later Walton) SEVERAL READERS, INCLUDING THE EDITOR OF THE AUSTRALIAN WOMEN PILOT’S MAGAZINE AIR NEWS, CAROL KITCHING, EMAILED ABOUT NANCYBIRD WALTON. On page 5, the mag states Nancy Bird was the first woman in Australia to gain a commercial licence. This is not strictly correct. Nancy was the first woman pilot to use a pilot’s licence to earn a living. The first commercial licence went to a woman called Irene Dean-Williams in WA, who also takes was female commercial pilot no.8, and taught to fly not by Charles Kingsford Smith, but by instructor, Pat Hall. Kingsford Smith gave her the first flying lesson, and it was Pat Hall who continued with lessons until Nancy-Bird’s first solo flight. The letter goes on to say: ‘There have been many inaccuracies that have been perpetuated over the years with poor research … including newspapers, 3 encyclopaedias and even aviation websites. This seemed a good time to make comment following your article, ‘The war on error’. There can also be errors in history! AIRMAIL The heading on page five: ‘All safe as US plane crashes into the Hudson River’ is very misleading, for a crash is very different to a ‘forced landing’. In a crash the reader may reasonably expect serious injury or loss of life to occur to crew and passengers. This did not happen and all souls were miraculously saved, due to the expert skill and professionalism of the captain and all his officers and cabin staff. As a pilot who has flown light aircraft - general aviation and (sailplanes) for over forty eight years, I feel a more accurate title could read as, ‘All safe aboard, after a forced landing in Hudson River.’ A IR M A IL PAR AVION MAX ERSKINE EMAILED: 4 How surprised I was to read the article ‘To boldly go where no man can’ FSA Mar-Apr edition and find that no reference was made to one of Australia’s greatest manufacturing and technological achievements, developed in the early 1950’s and continued through to the late 1990’s. I refer to the Government Aircraft Factory Jindivik: remotely piloted drone aircraft. This aircraft was developed during the late 1940s for a high and fast flying drone that was capable of recording the flight proximity and performance of missiles that at the time were in the early stages of development. Jindivik was such a success story that it generated many millions of dollars and was exported to Sweden, the United Kingdom and the USA. It served to develop weapons and systems at Woomera and later to exercise the Royal Australian Navy’s guided missile warships off the east coast of Australia. Keep up the great work. I always look forward to reading FSA. It gave me a job which I enjoyed greatly for 27 years. Thus was I surprised at its omission in the UAS article. Alan Paterson, a member of the SA Civil Aviation Historical Society responded to the Newark Air Museum’s call for help in restoring their General Aircraft Monospar ST12, which spent its flying years in Australia (Jan-Feb 2009 issue). Alan forwarded contact details for the Narromine Aviation Museum, which has a Monospar, to Newark curator, Mike Smith. Newark and Narromine have corresponded, with a productive exchange of information. AND IN RESPONSE TO THE EDITOR’S EMAIL REPLY, MAX SAID FURTHER: FSA MAY–JUNE09 You are quite correct in defining Jindivik as a target drone, however they became that expensive it was deemed necessary to develop radar-enhanced tows so that the aircraft would be far less likely to suffer a hit from a missile. The original tows were called ‘tonic tows’ and in fact in the photo [above] of the Jindivik taking off from Jervis Bay range facility, you can see these tows stowed in their launcher under both wings. They were called ‘tonic tows’ because some bright spark thought that went well with Jindivik … Jin & tonic. I kid you not. MONOSPAR VH-UTH RESTORATION State of the Art, Two Place, Touring and Training Aircraft – Certiﬁed IFR (FAR Part 23) • Safety – robust modular design with incredible visibility • Performance – advanced aerodynamics with high manoeuverability • Comfort – 48” wide cockpit with huge baggage space • Utility – Useful load after full fuel 192 kg • Simplicity – FADEC Engine with digital engine monitoring display • Economy – 132 knots cruise at 23 litres per hour, up to 500 nm range plus reserves • Affordability – low purchase price and low operating costs Book a demonstration ﬂight now! Call 0419 355 303 Contact Nigel Hutchinson–Brooks Liberty Aircraft Company Pty Ltd A.C.N. 118 727 889 Tel 03 5662 5658 Fax 03 5662 5179 Email firstname.lastname@example.org Details at www.libertyaircraft.com ‘As the economy gets worse, will the safety record get worse?’ That’s the question Bill Voss, the president and CEO of the US-headquartered Flight Safety Foundation posed at the launch of the Australian regional office of the Flight Safety Foundation. The launch took place during the Avalon airshow in March. Presenting an industry briefing at the launch, Bill Voss indicated that the recent spate of accidents he had detailed earlier were ‘almost certainly not related’ to the global economic downturn, as there were ‘no common threads, but in each case, there should have been data that provided a warning, and that data was missed.’ He went on to say, that aviation safety is facing some challenges, and economic pressures will make it more difficult. While an economic downturn does not have to result in a safety downturn, we do have to get some difficult things right. He was optimistic about the resilience of the aviation industry, pointing to the potential for growth posed by the growth of the middle class. Citing July 2008 figures from Goldman Sachs, he said, ‘we are in the middle of an explosion of the world’s middle class: about 70 million people a year globally are entering this wealth group, expected to accelerate to 90 million a year by 2030. By that time, two billion people will have joined the ranks of the middle class,’ he argued. So ‘the future will come, and it will be hard to explain why we are not ready for it this time,’ he concluded. Showing that the flow of safety information is not just one-way, the launch was also the occasion for Daniel Warring, Aircrew Chief with CareFlight, to present Bill Voss with the procedures/ operations manual developed by CareFlight for night-vision goggles. a series of advisory committees, such as the ‘Asia Pacific Advisory Committee’ (modelled on existing FSF ‘International, ‘European and ‘Corporate’ advisory committees), and a number of nationally-based advisory groups. Much greater activity by the Foundation within the region, addressing issues and risks identified through its advisory committee/group structure and other regionally specific research undertaken by the regional office. EUROPEAN HELICOPTER SAFETY TEAM RELEASES RESULTS Paul Fox is the regional director for the Foundation, which has its Australian offices in Melbourne. He can be reached via email: email@example.com . For more information, go to the Foundation’s website: www.flightsafety.org On 22 April, the European Helicopter Safety Team (EHEST) released its preliminary analysis report on helicopter accidents in EASA member states between 2000 and 2005. Analysis is the first step towards reducing the helicopter accident rate by 80 per cent by 2016, an objective stated by the International Helicopter Safety Team. The report presents the results of 186 accidents where a final investigation report has been issued by the responsible accident investigation board. Paul Fox says the increased regional focus through the new Melbournebased office will bring significant industry benefits including: Of the accidents analysed so far, 72 involve general aviation operations, 66 aerial Work, 40 commercial air transport, and eight state flights. Increased access to the Foundation’s substantial range of technical programs and expertise. Sixty-eight per cent of the fatal accidents and 34 per cent of all accidents analysed by the European safety analysis team occurred during the en route phase of flight. In 33 per cent of the accidents, the pilot had less than 1,000 hours total helicopter experience. In 26 per cent of the accidents, the pilot had less The opportunity for industry in the region to provide direct input into the Foundation’s global information-gathering network via 5 FLIGHT BYTES FLIGHT SAFETY FOUNDATION REGIONAL LAUNCH S c h g o n o i y l l to of f F t s r i F er th e PROFLITE AUSTRALIA FLIGHT TRAINING CENTRE Has a large ﬂeet of modern aircraft and simulators We can meet your ﬂying training needs • All ﬂying training commencing from trial instructional ﬂights up to and including CPL and M/E CIR, FIR A320 FBT • A320 ﬁxed base sim with fully functioning avionics FMC’s, auto pilots and auto throttles with 180˚ external visuals • Airline jet transition course • Overseas conversion course • Airline training on the B737, including uding the endorsement and line training and time on type with a respected overseas airline • CASA approved BATD simulator and all associated ﬂight theory courses Coming soon Multi-crew course preparation • VETAB and Cert IV approved Proﬂite Australia Flight Training Centre Hangar 15, Drover Rd, Bankstown Airport NSW 2200 T: 02 9791 0006 F: 02 9791 0426 E: info@proﬂite.com.au W: www.proﬂite.com.au The top three identified areas are ‘pilot judgment and actions’, ‘safety management and safety culture’, and ‘pilot situational awareness’. Different patterns were observed for commercial air transport, aerial work and general aviation. Michael John, who ﬂies with the Rockhampton Aero Club, combines his twin passions, ﬂying and writing. To tackle the variety of languages used in accident reports and optimise the use of resources, EHSAT has established nine regional analysis teams across Europe. Anticipation. A light cross-wind stirs the wind sock. RED BULL ROOKIE HOLDS HIS OWN A clean white shirt – with epaulettes, Matt Hall, featured in last issue’s ‘War on error’ article, competed in the Red Bull Air Race season opener in Abu Dhabi on 17 and 18 April. The race was won by last year’s champion, Hannes Arch, but Hall acquitted himself very well, gaining fifth place behind the UK’s Nigel Lamb. The next race is due to take place in San Diego on 9 and 10 May. The 150, tethered; indents and wear from years of training, Grime from the windshield wiped to paper towel. Seat locked forward, headset plugged in; plane and pilot are one. Mixture rich, mags on both, engine to 1000, Line-up, full throttle, Slight rudder, sliiight rudder, Squeeze back, climb away. Scan instruments, scan outside, radio call, turn away, Climb to 3000; level out, throttle back and trim. Training area five miles, CASACOMS CASAComs is an extension of our previous ATComs for high-capacity RPT operators, and delivers safety-related information promptly to a broader audience of AOC holders. New CASAComs topics such as ‘Renewal of instruments/approvals within time’, ‘International operator requirements under CAR 223’, and ‘Pilot in command under supervision’ appeared on 1 April 2009, while previous ATComs have been re-published in the new format. For more information, and all current CASAComs, go to www.casa.gov.au/aoc/ casacom/index.htm or call 131 757. 7 Relax now (bump), scan (bump), respond (bump), scan (bump) … Sooo happy; 150 and student. Haiku is a Japanese form of poetry; 7 the best examples describe everyday experience in a way which gives the reader a new understanding of that situation. Traditional Japanese haiku consist of three lines of 5, and 5 syllables, but in English, there is greater variation, as in these ‘haiku threads’. FLIGHT BYTES than 100 hours flight experience on the helicopter type involved in the accident. Haikuds for threa o Zulu Romember Nove 8 FLIGHT SAFETY STARTS ON THE FSA MAY–JUNE09 It’s timely with phase one of SMS implementation on 1 July this year, to consider all aspects of safety management, and this includes ground operations. Flight Safety editor, Margo Marchbank, gives an overview of this often-neglected area of aviation safety. The second occurred on 18 May 2007 in Syracuse, New York. The Douglas DC-9-31, operated by Northwest Airlines, with 99 people on board, was climbing through approximately 20,000ft, when the flight crew heard a ‘loud pop’ and the cabin depressurised. After an ‘uneventful landing’, postflight inspection revealed a ‘12-inch by five-inch fuselage skin tear, approximately six feet forward of the forward cargo door’. After a belt loader malfunction, the senior ground agent had attempted to move the belt loader away from the aircraft by pushing it with a luggage tug, but the tug’s cab hit the fuselage. He had advised fellow workers not to say anything. The NTSB determined that the probable cause of the accident was the ‘the senior ground agent’s failure to follow written procedures and directives’. The third and most recent – took place on 1 February 2008, and involved a UK night cargo flight from Edinburgh to Coventry. The Fokker F27 was undergoing de-icing at a wintry Edinburgh Airport, with both engines started. The commander (captain) signalled the marshaller to remove the ground power unit (GPU) from the aircraft, which was facing nose out from its stand, down a tight slope. As the marshaller went to assist his colleague to remove the GPU to a safe distance prior to the aircraft taxiing off the stand, the aircraft started to move forward slowly, forcing them to run to safety. The flight crew, who were looking into the cockpit, were unaware that the aircraft was moving. It continued to move forward until its right propeller struck the GPU, causing substantial damage to the GPU, the propeller and the engine. The ground crew were uninjured. Accidents and incidents involving ground crew, who include: cargo/baggage handlers, refuellers, potable water/ toilet system servicers, catering support, cleaners, aircraft and equipment servicers, maintenance and security, have received little attention historically. However, as the diagram on the next page of a [B747 on the tarmac surrounded by ground crew 9 GROUND SAFETY Three accidents which have occurred in the past four years demonstrate the potential human and hull cost of ground operations accidents. The first took place on 28 December 2005 on Alaskan Airlines Flight 536, where an MD-80, 20 minutes out of Seattle, bound for California with 142 people on board, was rocked by a ‘thunderous blast’, and dropped from 26,000ft. According to the National Transportation Safety Board (NTSB) senior investigator, baggage handlers at Seattle had creased the side of the aircraft with loading equipment. This crease, 20 minutes after takeoff, developed into a ‘one foot by six inch hole’, causing depressurisation of the aircraft. The aircraft returned to Seattle, and was landed safely without injury to crew or passengers. 10 and vehicles] illustrates, the number of personnel servicing an aircraft, and getting it into the air safely, is significant, especially in comparison to flight and cabin crew numbers. And while the UK accident did not result in fatality or injury, studies confirm that the ramp is a dangerous and potentially lethal place – a congested and pressured environment where humans interface with large aircraft and multiple vehicles and ground support equipment. According to a 2005 UK Health and Safety Executive (HSE) analysis of data, the ‘causes of accidents (affecting ground crew) at airports have remained fairly constant over recent years, with around 50 per cent related to musculoskeletal disorders (baggage and cargo handling); 25 per cent slips, trips and falls; 15 per cent related to moving vehicles or ramp equipment; and 12 per cent falls from heights (maintenance, aircraft access steps, catering high loaders etc). Moreover, the HSE says, ‘This accident rate is rising compared to numbers of passengers, numbers of flights and cargo carried. Increasing congestion on the ramp, and pressure for ever-shorter turnaround times is a cause for concern.’ FSA MAY–JUNE09 Flight Safety Foundation (FSF) figures confirm the high cost of ground accidents – human and hull – to the industry. The FSF has calculated the annual worldwide financial cost at $10 billion, that total comprising a $4.2 billion cost for ground accidents and incidents; and a $5.8 billion cost for injuries. A comparison between the injury rates in aviation and other industries is revealing. ‘Scheduled commercial air’, with 10.5 total recordable injuries per 100 employees, is at the top of the list. Other industry sectors - oil and gas; pulp and paper manufacturing; the chemical Juanita Frantzi: Aero Illustrations industry; construction - sectors which would be perceived as being higher risk environments stereotypically, rate 2.5; 3.2; 3.5 and 6.4 injuries per 100 employees respectively. Despite this cost, a focus on ground accident prevention has been slow to emerge. For too long, Dr Geoff Dell argues, ‘flight safety and ground safety have been regarded differently.’ He is Dean, College of Fellows, of the Safety Institute of Australia, and a career safety systems and accident investigation specialist with 30 years’ airline experience in both flight safety and airport operations safety. Geoff was awarded the Flight Safety Foundation’s inaugural Ramp Safety Award in 1996 for his research into the causes and prevention of aircraft pushback accidents. ‘The principles of Reason, Hudson and Rasmussen transcend all industries’ he explains, ‘but aviation has always regarded itself as being special.’ He is passionate about the need to treat ground safety with the same level of concern as flight safety, and instances the technological developments which have been readily adopted in the air. ‘Aviation has embraced new technology – glass cockpits, ground proximity warning systems/ TCAS – quantum leaps in safety technology ground ompany, c g n i handl , can service One therefore , each operating n w o ir e with th n edures. I c o r p d n policies a orm ramp if n u f o e nc the abse s, rocedure p d n a s policie icies l o p le ip t l u these m e can caus s e r u d e c and pro and ines l r i a l a r e sev in the air,’ but he argues, ‘there’s a resistance to technology on the ground.’ The introduction of the A380 he says is a ‘classic example of high technology aircraft design’ and was the perfect opportunity, with a blank sheet of paper, to carry that technology over to ground operations. But ‘have a look at how they handle it on the ground – it’s circled by how many vehicles on the tarmac?’ The complexity of the ground operations environment is also an important factor in why ground safety has been slow in gaining recognition as an aviation safety issue. While safety in the air and on the runway is the direct jurisdiction of various regulators, safety oversight of operations in ramp areas of airports is handled primarily by airlines and airports, and only indirectly by regulators through the airline and airport operators’ AOCs. The US Government Accountability Office (GAO) in its November 2007 report to Congress found ‘no federal or industry-wide standards for ramp operations … In the United States, airlines typically control the ramp areas, and each operates its ramps with its own specific sets of polices and procedures.’ The situation is similar in Australia. Add to that complexity the fact that increasingly, ground handling services are being contracted out. One ground handling company, therefore, can service several airlines, each with their own operating policies and procedures. In the absence of uniform ramp policies and procedures, these multiple policies and procedures can cause confusion and increase the likelihood of accidents. n o i s u f n o c of likelihood . s t n e d i acc the increase GROUND SAFETY 11 Lack of data has also hampered improvements in ground safety. The GAO report noted that ‘Efforts to improve airport ramp safety are hindered by a lack of complete accident data and standards for ground handling. We found no complete source of data on ramp accidents … (nor) no complete non-fatal injury data’. While individual operators have comprehensive incident databases, this data is not available to determine industry trends. However, this shortage of data is gradually being addressed, by agencies such as the FSF, through their ground accident prevention program (GAP) and its data collection and analysis service; and the International Air Transport Association’s (IATA) global safety information centre due for launch in late 2009. This centre’s aim will be to integrate safety data from various industry sources to identify issues and develop prevention strategies. As the GAP and IATA programs demonstrate, increasingly, work on ground safety is gaining momentum, but Chris Barber says, ‘It’s an enormous task’. When Flight Safety spoke to Chris, he had just returned from a meeting of the IATA Airside Safety Group, which he chairs. In his ‘day job’ as Manager, Ground Safety and Environment with Qantas Airways Airport Services segment, Chris works on the premise that ‘critical risk management starts from the ground’, and the Airports segment is embarking on an ‘end-to-end risk identification process’ as part of their safety strategy, identifying all the risks from an airport’s perspective ‘from the moment a passenger steps out of their car at the airport, and goes to the terminal, until they reach the airport at the other end’. H According to Chris, Qantas’ list of key risks parallels the UK Health and Safety Executive’s: ‘manual handling and trips, slips and falls are the big ones for us; falls from heights; impact by moving equipment, airside traffic management, and we’re looking at innovation and best practice around the world.’ Part of the solution, he says, will be increased mechanisation, quoting the Scandinavians as world leaders in this area. The ‘big bag box’ which has streamlined manual handling originated there, as did the ‘RampSnake’ (pictured below). 12 FSA MAY–JUNE09 Chris Barber is also chairman of the Australasian Aviation Ground Safety Council (AAGSC), founded over 25 years ago. The AAGSC was one of the driving forces behind the introduction, years ago, of the 32kg bag weight, adopted by IATA some five years later. The IATA Airside Safety Group recently recommended in their Airport Handling Manual, that this be further reduced to a 23kg individual checked maximum bag weight. This limit already applies in the United Kingdom, driven by the Health and Safety Executive. European industry estimates the workload per man per shift for a baggage loader to be an average five and a half tons, rising to nine tons in the peak summer season. There is little public understanding of the difficulties of working in a confined space, especially in the narrow bodies, as shown in a Brisbane Times ‘Your say’ blog which ran from April to December 2008. The responses to the question: ‘Is it fair for baggage handlers to expect travellers to keep their luggage in bags weighing less than 20kg?’ displayed ignorance at best, and vitriol at worst. ‘Col’s’ post was typical: ‘In all seriousness, there is lifting equipment, all these turkeys have to do is lift something, what is it 32kg, from a trolley to a conveyor?’ The hold of an aeroplane has been described by Norman Hogwood, (the grandfather of ground safety, according to Chris Barber) as ‘like a mine pit – dark, sweaty, hot and confined’. Conditions are more difficult in the loose-loaded, narrow bodies, such as the 737, where space is confined, and lifting while kneeling and crouching can lead to musculoskeletal injury. lit tle publicrstanding undeif ficulties of There is of the d onfined c a n i g he workin ially in t c e p s e , . space bodies.. narrow Consequently, an affiliated group in Scandanavia (Copenhagen Airport Company, airlines, group handling companies and unions) is embarking on an awareness campaign to educate travellers about taking extra luggage on board, in an effort to reduce bag weights. Obviously, manual handling is the key driver, but other cost-saving, both in fuel and handling is a secondary driver. If successful, the campaign will have an impact on E Manual handling assessment chart (MAC) MAC lifting score for one operator outside the aircraft MAC lifting score for one operator inside the aircraft Bag weight Bag weight One lift every 5 secs 9 secs 14 secs Less than 10kg 10kg 15kg 20kg 25kg 32kg (IATA max) Colour code: Low level risk One lift every 5 secs 9 secs 30 secs 14 secs 30 secs Less than 10kg 10kg 15kg 20kg 25kg 32kg (IATA max) Medium level of risk, task should be examined closely. High level of risk, prompt action needed Very high level of risk HSE 2005 ‘Bagagge handling report page 11’ 5. Baggage handling 6. Aircraft handling & loading 7. Aircraft ground movement 8. Cargo & mail handling. Modification to aircraft design is another area where advances can be made in improving safety for manual handlers Chris Barber explains. ‘For example, in our 737 aircraft we have ‘sliding carpets’ (a poly-coated Kevlar conveyor belt which moves baggage within the compartment) fitted in the hold, like a roller system, which in conjunction with our RTTs, (a mechanised belt-loader extension), assist us greatly in reducing manual handling when loading our aeroplanes.’ Qantas may be demonstrating best practice in adopting such technology, but according to a 2005 study on manual handling at Dublin Airport, while such ‘systems are available, they are not yet the industry norm.’ And although made four years ago, it seems that statement still applies. Geoff Dell would agree, arguing there are still many changes necessary to bring aviation manual handling standards in line with other industries. ‘If you compare baggage handling standards with every other industry,’ he says, ‘the difference is very apparent. They’re now all automated, even cement handlers. If you’re making decisions based on risk,’ he claims, ‘you wouldn’t be lifting bags.’ ‘It’s a massive task,’ Chris Barber acknowledges, ‘getting airlines to see the benefits, such as reducing the number of third-party audits; and changing the culture’, but he remains hopeful of the success of the program. Qantas undertakes its own Compliance Audit Program and have also initiated their own Human Factor type Threat and Error Safety Audit process called Ground Operations Safety Audit (GOSA) and in the US, Continental Airlines is working with the University of Texas on a ramp operations safety audit, or ROSA. Last year IATA launched an initiative which promises to assist in bringing some standardisation to ground operations. Based on the successful flight ‘lATA operational safety audit’ – IOSA principle, the IATA Safety Audit for Ground Operations, or ISAGO, aims to audit all industry ground service providers, establishing a ‘worldwide ground operational safety benchmark and standard.’ The program was launched in February 2008, and during the year, trained 200 auditors from 60 different airlines, and conducted 45 audits. The 2009 target is 80 audits, examining eight ground safety areas: 1. Organisation & management system 2. Station management 3. Load control 4. Passenger handling Arguably, to improve the safety of ground operations effectively requires several concurrent strategies. Perhaps the most challenging of these is changing the culture; through the implementation of robust and integrated safety management systems to establish a ‘just culture’, so that increased reporting of incidents, for example, would create data to drive improvement. As the FSF’s Bob Vandel said in a presentation given on the Gold Coast in 2004, ‘It is a time-proven adage that the workers do well what the boss checks. If the CEO puts safety high on his corporate agenda, and checks the results, then his managers who set safety policy will conform to the CEO’s lead.’ Geoff Dell is passionate about the need to apply the same safety management standards to ground safety as those which apply to flight 13 GROUND SAFETY manual handling injuries. However, any adoption of further reductions in bag weight has to be standardised, because stringency in applying such restrictions can place compliant airlines at a commercial disadvantage, as can be seen in the comments on the Brisbane Times blog. safety. He instances the case of the fuelling of a hypothetical B-747 flying from Sydney to Los Angeles, arguing that the integrity of the fuel for the flight is checked between six to eight times between the distillation towers at the refinery, to when passengers buckle themselves into their seats for takeoff. ‘There are six to eight levels of administrative redundancy in that process, but we don’t do that anywhere else.’ 14 FSA MAY–JUNE09 Then, he argues, improved training is needed. ‘At the minimum end, there’s basic training, in lifting techniques for example, but that’s about it. At the enlightened end, there are behavioural observation/intervention programs’, such as the one introduced at Frankfurt Airport in the mid-nineties by Dr Walter Gaber. He treated baggage handling as a human performance issue, asking the question Geoff Dell says, ‘How do we get administrative reliability into baggage handling?’ His solution was to treat baggage handlers like athletes, if necessary intervening early at the first sign of discomfort, before damage such as muscle tears occurred. In Geoff’s recollection, the ground handling company involved had a workforce of about 4,500 baggage handlers, and was spending $60 million a year in workers’ compensation. Outlaying $2.5 million, Gaber engaged human performance specialists, who coached the handlers individually in fitness and technique on a weekly basis. This program reduced compensation claims over three years by 90 per cent. Automation of some features of ground operations has already been discussed, but Geoff Dell says more is needed. ‘We need to move from a vehiclebased industry to a technology-based one.’ The vehicle-free ramp is not a futuristic concept, but was instituted at two airports in the 1990s: Terminal 2 at Stockholm’s Arlanda International Airport (with eight gates), and the purpose-built Zhuhai Airport in southern China (with four). Again, the concept resulted from Scandinavian technology, the product of Swedish company, Fabriksmontering i Trelleborg (FMT). Rather than being serviced by a fleet of vehicles and accident-prone human drivers, a ‘set of modules pop-up from the tarmac and supply fuel, water, air, ground power, toilet waste disposal, and cabin heating or air conditioning to the parked aircraft. Combined with an ‘automatic push-back pilot, eliminating the need for manned tractors’, FMT claims the technology can dispense with 80 per cent of current ramp vehicles. However, take-up of the technology has been slow: it is expensive, with the cost of retrofitting the units in existing infrastructure deterring many European airports; and Zhuhai Airport has faced economic difficulties since its opening. The technology therefore does not seem to have been promoted widely. Then there is the considerable pressure to maintain the status quo: with significant money and resources committed to existing infrastructure by airports and airlines; and in some countries, pressure from unskilled and semi-skilled airport ground workers, who are highly-unionised, politically-strong and resistant to change. So where to from here? Geoff Dell contends that ground safety would be advanced by the widespread application of real safety management systems, with appropriate validation, rather than systems which just ‘tick the boxes’. Future ground safety efforts, he says, need to address the two high risk areas: the congestion around ramp operation, and baggage handling. The Dublin manual handling practices study concluded that ‘solutions to reducing manual handling-related injuries among airport workers are, in the short term, to be found in the introduction of mechanical aids, but in the long term, through the implementation of higher levels of automation.’ As the Scandinavian experience shows, higher levels of automation, reflecting standards in other high-risk industries, are likely to gain wider acceptance. R For more information ‘Aircraft Turnaround Inspection’ – Sector Information Minute ‘Ground Crew Injuries in US Commercial Aviation’ y Audit for Ground Operations p - ISAGO IATA Safety ‘Aviation Runway & Ramp Safety – sustained efforts to address leadership, technology and other challenges need to reduce accidents & incidents’ ‘Equipment damage and human injury on the apron. Is it a cost of doingg business?’ ‘Safety management systems for regular public transport operators’ p Duignan, CA & Fallon, EF – National University of Ireland for the Health & Safety y Authority y 2005 British Health & Safety Executive (accessed at www.hse.gov.uk April p 2009, due for cancellation May y 2009) Grabowski, T; Baker, S & Guohua, Li in Aviation, Space & Environmental Medicine, November 2005 www.iata.org/isago US Government Accountability Office (GAO) Congressional Report November 2007 Flight Safety Foundation presentation – Bob Vandel. International Society y of Air Safety y Investigators g 2004 conference. Civil Aviation Advisory Publication (CAAP-SMS-1(0), downloadable from www.casa.gov.au Flight Safety Foundation: e-tools to eliminate accidents & incidents Ground accident prevention (GAP) which occur on airport ramps & adjacent taxiways, www.flightsafety.org/gap Earl Weener, PhD. May 2007. Presentation given to 52nd Annual ‘Ground accident prevention: the Foundation’s answer’ Corporate p Aviation Safety y Seminar. ‘European p Ramp p Checks Find Increase’ Aviation Safety y World August g 2006 ‘Ramp accidents & incidents constitute a significant safety Robert Matthews Federal Aviation Administration in the ICAO issue’ JJournal , No. 3 2004 ‘Communicating from the pushback-tractor seat helps Flight Safety Foundation ‘Airport Operations’, May-June 2004 prevent serious injuries’ p j ‘Airline baggage handler back injuries: a survey of baggage Geoff Dell in Safety Science Monitor Issue 2 1998 handler opinion p on causes & prevention’ p ‘Baggage handling in narrow-bodied aircraft: identification Sarah Tapley & David Riley, January 2005. Health and Safety & assessment of musculoskeletal injury j y risk factors’ Executive ‘Safe access to aircraft for catering operations’ Sector Health and Safety Executive, May 2008 Information Minute 05/2008/02 Flying towards SMS The introduction of safety management systems (SMS) is considered by many to be the most significant development in the history of aviation safety. Consequently, CASA has developed two new tools to assist operators in meeting the new SMS and human factors (HF) requirements. There’s also a regular electronic newsletter so that industry will know what assistance is available, and to keep operators up-to-date with SMS and HF information. To subscribe to the e-newsletter please contact SMS@casa.gov.au. The first is a ‘manual builder’ to assist in developing CASA-required manuals. The Manual Authoring and Assessment Tool (MAAT) proposes text which meets CASA requirements, but importantly, can also be modified to suit your individual organisation. The tool also provides guidance material, so organisations know what needs to be addressed within each element. This means that not only will you know what is required, but you can ensure that your manual reflects your operations. MAAT is free and will be available on the CASA website. MAAT will assist in, and provide guidance on, building an SMS manual. The tool will be expanded to meet other requirements in the future. The first phase requires regular public transport (RPT) operators to submit an implementation plan (low capacity RPT); and draft manual and SMS infrastructure (high capacity RPT) to CASA by 1 July 2009. The SMS infrastructure requires establishment of a safety management organisation, policies, procedures and accountabilities. These are part of the planned three-phase SMS implementation process, following legislation coming into effect from 31 January 2009. The second phase includes establishment of a pro-active risk management system, and SMS training for safety-critical personnel. The final phase is full implementation of all elements of the SMS, and the continuous improvement of the system. Under the new CASR 119 regulations (currently under development) these requirements will extend to all passenger-carrying operations. CASA recognises that some of these requirements may prove challenging, particularly for low capacity airlines. CASA has held a series of workshops for RPT-operator safety managers throughout April to assist them in meeting the new requirements, with more planned in the future. For more information on SMS, HF or MAAT, please contact SMS@casa.gov.au. 15 GROUND SAFETY ‘Best manual handling practices at Dublin Airport’ ATC.MRCQ Casting out a SAFETY NET to pilots 16 Y FSA MAY–JUNE09 our flight is progressing smoothly, only a light breeze, no cloud and all your requested clearances approved by ATC. Approach and landing go without a hitch. As you’’re vacating the runway, one of your passengers compliments you on an excellent flight. Momentarily distracted, you have only just regathered your thoughts when the controller’s voice echoes in yo our headphones advising that you have just crossed an active runway without a clearance - then comes the sound of an aircraft engine at full throttle some 100 feet over head. For the next few minutes you focus solely on making your way to the apron. With the passengers disembarked and your final checks complete, you secure the aircraft and stroll towards the terminal — the only thought on your mind being “that was close!” Runway safety is B major concern for the aviation industry and runway incursions in particular represent a serious threat to safe surface operations. Unauthorised entry into controlled airspace is another safety concern as such events have the potential to bring aircraft into unsafe proximity with each other. In response, Airservices has developed Safety Net — a series of safety related fact-sheets to help you enhance Tafety. Safety Net is a single page summary of tips to assist pilots in managing operational risk. The Safety Nets developed so far relate to: t 3VOXBZ 4BGFUZ t 4BGF 0QFSBUJPOT BSPVOE $POUSPMMFE "JSTQBDF These fact-sheets are available online at airservicesaustralia.com ition on t secon i a In addition, th thee second d edi edition diti off R Runway SSafety f t — A Pil Pilot’s Guide to Safe Surface Operations at Controlled Aerodromes booklet has been published. The guide includes information on stop bars (introduced at Melbourne airport); gives instruction on planning your aerodrome operation; taxi procedures; appropriate use of aircraft lights; communications; phraseology and aerodrome markings, signs and lights. The guide is also available at our website at http://www.airservicesaustralia.com/flying/runwaysafety/docs/ pilot’s_runway_safety_booklet_09.pdf To find out more about Safety Net or the Runway Safety pilot’s guide pleasee con contact Chris Thomson, Safety Promotions Manager, on n (02) 02) 6268 5035 or firstname.lastname@example.org chris.s. Runway Visual Range (RVR) assessment, traditionally measured in Australia solely by the human observer technique, is now also being calculated at some locations electronically using instrumented RVR reporting. The change to electronic measuring is reflected in recent changes to the AIP (Sup H11/09 and H13/09), redefining Runway Visual Range (RVR) and introducing the term Runway Visibility (RV). Changes to ATC procedures now clearly distinguish between human and electronic measurement to account for the differences perceived in the level of quality and usability between the two measurements. The term RUNWAY VISIBILITY will be used when quoting visibility values estimated by an observer seeing a visibility marker or counting runway lights. The term RUNWAY VISUAL RANGE or RVR will apply to reports based on values determined by electronic measurement. RVR is also now associated with the electronic measurement required for Category I ILS approaches below 800 M visibility, Category II and III approaches and take-offs in less than 350 M visibility. Sydney and Melbourne airports are commissioning electronic Runway Visual Range sensors (transmissometers) – a method delivering more accurate and valid measurements than the human observer technique. Minima specified on an instrument approach chart followed by the term RVR, must only be used when ATC provides appropriate RUNWAY VISUAL RANGE or RVR information. RVR minima must not be used when visibility along the runway is reported as a RUNWAY VISIBILITY. AIP Sups H11/09 and H13/09 are available to view on our website at http://www.airservicesaustralia.com/publications/aip.asp?pg=50 the Circuit D id you know that when arriving at an ATC Class C or D controlled aerodrome, an instruction to track to a position in the circuit does not constitute a clearance for a visual approach? Surprisingly several incidents in recent years suggest that there are some pilot’s who don’t. The common thread linking these incidents is non-compliance occurring when the pilot is given tracking instructions to a position in the circuit and manoeuvring instructions. In at least one instance, ATC restricted descent and gave traffic information to an arriving aircraft on a conflicting aircraft below in conjunction with a clearance to a position in the circuit. However, the crew initiated a visual approach and descended below the cleared level. This is why Airservices is introducing a new procedure to counter situations where there is conflicting traffic or other restrictions affecting an aircraft approaching a controlled aerodrome circuit. Under the new procedure the previously assigned level will be restated by ATC concurrently with the clearance to track to a circuit position. AIP is clear in specifying the flight crew responsibilities: AIP ENR 1.1 – 1 para 3.2 The pilot is responsible for obtaining a clearance and, once obtained, must not amend a planned route, deviate from the cleared track, or change level without obtaining ATC approval. 0UIFS SFMFWBOU "*1 SFRVJSFNFOUT BSF AIP ENR 1.1 – 20 para 11.1.8 Approach Control will provide instructions for progressive descent and specify any change in route, clearance limits and holding instructions. AIP ENR 1.1 – 21 para 11.4.1 Aircraft cleared for a visual approach or instrument approach procedure will not be assigned a level restriction. 17 ATC NOTES Electronic Runway Visual Range (RVR) and ATC procedures Jumping International Accidents/Incidents 19 January - 2 April 2009 Date Aircraft Location Fatalities Damage Description 19 Jan Fokker 100 0 Substantial As the Fokker landed on the runway, the right-hand main landing gear broke. 20 Jan Bombardier BD-700 Global 5000 ATR-42-320 Tehran-Mehrabad Airport, Iran Wichita-MidContinent Airport, Kansas Lubbock Preston Smith Int’l Airport, Texas NovosibirskTolmachevo Airport, Russia 0 Substantial The Bombardier Global 5000 was conducting static engine ground runs when the aircraft ran into a blast fence. The nose burst through the fence. 0 Destroyed The ATR came down 330 metres short of the runway and the right wing caught fire. 0 Substantial 0 Substantial The crew of the Cessna were not able to obtain a ‘main landing gear down and locked’ indication. They diverted to Novosibirsk-Tolmachevo Airport and did three fly-bys where airport personnel confirmed that the main landing gear was not down. The crew carried out a forced landing. The Douglas C-17A landed with its landing gear retracted.There was significant damage to the underside and a small fire broke out as a result of the mishap. 27 Jan 27 Jan Cessna 560 Citation V 30 Jan Douglas C-17A Globemaster lll Airbus A320 -232 Bagram Air Base, Afghanistan Delhi-Indira Gandhi 0 International Airport, India None 04 Feb AMI 65 TP Turbo DC-3 0 Substantial 04 Feb DHC-6 Twin Otter 100 Cessna 650 Citation lll Embraer EMB-110P1 Bandeirante Cessna 208 Caravan DHC-8-402 Q400 Dassault Falcon 100 Mojave-Kern County Airport, California La Ronge Airport, Saskatchewan Trigoria, Italy 0 Substantial The DHC was on skis about to become airborne; the aircraft took a hard right turn hitting the fence and trees adjacent to the runway. 2 Written off The Cessna 650 Citation struck the ground at high speed. Coari Airport, Brazil 24 Written off The Embraer stated intentions of returning to Caori due to heavy rainfall. The aircraft crashed into Manacapuru River. Radio contact was lost and one of the survivors reported an engine failure. Boma Airstrip, Sudan 10 km NE Buffalo Niagara Int’l Airport St. MoritzSamedan Airport, Switzerland Kotzebue Airport, Alaska Shahin Shahr-Hesa Air Base, Iran PalanqueroGerman Olano, Columbia Medellín-Enrique Olaya Herrera Airport, Columbia Luxor Airport, Egypt 0 Written off The Cessna’s main landing gear strut broke on landing. A fire erupted, destroying the aircraft. 50 Written off The de Havilland crashed in a residential area of Buffalo, New York while on approach to runway 23. It struck a house starting a huge fire. 2 Written off Dassault touched down left of centreline with the right wing and right main gear. The nose hit a snow wall at the runway edge, turned to the left and broke into two parts. 0 Substantial The CASA 212 crashed short of the runway. 5 Written off The HESA crashed during a training flight. 5 Written off The Basler Turbo was on a training flight out of Palanquero-German Olano and crashed in the vicinity of the air base. 0 Written off An explosion occurred as the occupants were boarding the Basler Turbo. The fuselage ruptured and the airplane broke in two. Media suggests it was caused by the inadvertent detonation of one or more gas grenades used by ESMAD. 5 Written off AmsterdamSchiphol International Airport, Netherlands Winnipeg-James Armstrong Richardson International Airport, Canada Maridi Airport, Sudan 9 Written off The Antonov 12 crashed about 600-700 metres away from the runway after takeoff and caught fire. ITAR-TASS reports, according to Russian diplomats, the Antonov had fuel leakage and pilots had been advised not to take off The Boeing 737 was on final approach when it came down in a farm field 1.5 km short of the runway. The aircraft broke in three, but there was no fire. 0 Minor The Swearingen had landing-gear trouble and carried out a forced gear-up landing. 0 Substantial Bidadi, India 3 Written off The Cessna 208 suffered engine failure; the pilot performed a forced landing shortly after take off. The aircraft landed, came to a stop off the end of the landing strip, hitting a tree and removing the wing. The aircraft crashed 31km from Bangalore-Hindustan Airport. 01 Feb 07 Feb 18 07 Feb 11 Feb FSA MAY–JUNE09 12 Feb 12 Feb 14 Feb 15 Feb 18 Feb CASA 212 Aviocar HESAIran-140-100 Basler Turbo-67 18 Feb Basler Turbo-67 20 Feb Antonov 12 25 Feb Boeing 7378F2 03 Mar Swearingen SA226TC Metro ll 04 Mar Cessna 208 Caravan l 06 Mar National Aerospace Laboratories Saras A male passenger on the Airbus A320 was prevented from changing seat, and claimed he had a gun & an infectious needle, as well as claiming to have been involved in the 1999 Flight 814 hijacking. Another passenger was behaving agressively and the pilot gave a distress call for emergency landing. The AMI 65 attempted to take off, but lifted, dropped back to the ground and veered off the runway. The fuel tank was damaged on impact and leaked 600 gallons of fuel. 06 Mar 09 Mar 09 Mar 23 Mar 31 Mar 02 April GAF N22B Nomad Ilyushin 76T McDonnell Douglas MD90-30 McDonnell Douglas MD-11F PZL M28TD Bryza Britten Norman BN2A Islander Lop Buri Air Base, Thailand Lake Victoria, Uganda Jakarta-SoekarnoHatta International Airport, Indonesia Tokyo-Narita Airport, Japan 1 Substantial The GAF N22B suffered engine problems and crashed shortly after takeoff, shearing off the left hand wing. 11 Written off The Ilyushin crashed into Lake Victoria shortly after takeoff. 0 Substantial Th MD-90-30 landed in heavy rain, then skidded off the runway in a 180-degree spin, stopping in an open field. Tthe landing gear was damaged, and there were some cracks on the left wing. 2 Written off Gdynia Babie Doly, Poland between Tuguegarao and Maconacon. 4 Written off The McDonnell Douglas bounced on first touchdown to the runway then dropped from 50-100ft onto the nosewheel. It banked to the left where the port wing impacted the ground and a fire erupted. It then slid off the runway. The Bryza crashed on landing and caught fire. ? Missing The BN-2A Islander took off in the Philippines, from Tuguegarao Airport on a thirtyminute flight to Maconacon. It failed to arrive - authorities are still searching for it. 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 6 February - 24 March 2009 Aircraft Location Damage Description 6 Feb PIPER PA-31350 Chieftain Darwin Aerodrome, Nil W M 6Km, NT Serious 22 Feb PIPER PA-32260 Cherokee Six BOEING B75N1 Stearman PIPER PA-28180 Archer Mount Beauty (ALA), VIC Nil Serious Benalla Aerodrome, VIC Normanton Aerodrome, SW M 120Km, QLD Newcastle Waters (ALA), NW M 87Km, NT near Shepparton Aerodrome, VIC Nil Serious Fatal Serious During the initial climb, the right engine lost power. The pilot shut the engine down and feathered the propeller. The aircraft did not maintain altitude and subsequently the pilot landed the aircraft on the water. The pilot and passengers walked to shore in knee- deep water. Just after rotation, the aircraft’s engine failed and the pilot immediately landed on the remaining runway. After vacating the aircraft, smoke was observed emanating from under the cowling and the aircraft fuselage was subsequently destroyed by fire. During the landing, the pilot lost control of the aircraft and entered a ground loop. The aircraft was seriously damaged when the wing scraped along the ground. It was reported that the aircraft crashed. The pilot who was the sole occupant was fatally injured. The investigation is continuing. Minor Serious Fatal Serious Bendigo Aerodrome, VIC Nil Serious 22 Feb 24 Feb 25 Feb CESSNA 182Q Skylane 25 Feb AMATEUR BUILT PITTS SAMSON PIPER PA-44180 Seminole 26 Feb 5 Mar 6 Mar 7 Mar 9 Mar 11 Mar 11 Mar 16 Mar 24 Mar Injuries AMERICAN CHAMPION 8GCBC Scout AMATEUR BUILT RJF2 Albany Aerodrome, Minor WA Serious Cessnock (ALA), NSW Nil Serious CESSNA 182K Skylane AMATEUR BUILT VANS RV-7A GIPPSLAND AERONAUTICS GA-200 Fatman SCHWEIZER 269C-1 Maryvale (ALA), QLD Penfield (ALA), VIC Nil Serious Nil Serious Cobden (ALA), SSE M 11Km, VIC Minor Serious Abingdon Downs (ALA), NNE M 44Km, QLD Murwillumbah (ALA), NSW Riddell (ALA), VIC Nil Serious Nil Serious Nil Serious CESSNA 172R Skyhawk CESSNA 172M\ Skyhawk At 500 ft, the aircraft’s engine failed. A significant quantity of oil covered the windshield and strong vibrations were felt throughout the aircraft. The pilot conducted a forced landing. The aircraft was substantially damaged and the two occupants sustained minor injuries. It was reported that the aircraft crashed. The pilot who was the sole person on board suffered fatal injuries. During the initial climb, while retracting the landing gear, the crew received an unsafe landing gear indication. During the cruise, the landing gear was extended and retracted several times, but the crew did not receive a ‘left main landing gear extended and locked’ indication. On arrival at Moorabbin, the aircraft overflew several times and ground observers advised the crew that the left main landing gear appeared to be extended. During the landing roll, the left main landing gear collapsed and the aircraft veered off the runway to the left. An engineering inspection revealed a worn bolt and bush in the left main landing gear drag brace attach-point swivel joint assembly. During the landing roll on runway 14, the pilot over-braked, causing the aircraft to nose over. The pilot suffered minor injuries, but the aircraft was seriously damaged. During taxi trials, the aircraft unintentionally became airborne. The pilot returned the aircraft to the ground but landed heavily. The main landing gear collapsed and the nonstructural fuselage enclosure sustained serious damage. During cruise, the engine failed. During the subsequent forced landing, the aircraft was seriously damaged when it struck trees. After touchdown on runway 36, the aircraft pitched up and down on an undulating runway, causing the front wheel to bury into a slight mound. Subsequently, the propeller struck the ground causing the aircraft to flip onto its back. During aerial baiting operations, the aircraft lost power, struck trees, impacted the ground and was destroyed by fire. During a private flight, the helicopter’s engine failed. The pilot conducted a forced landing on rough ground and subsequently the helicopter rolled over. The pilot was uninjured but the helicopter was seriously damaged. During the missed approach, the pilot decided to land. The aircraft ran through the runway and collided with the bank of a sugar canefield canal. The aircraft landed long but the pilot decided not to go around due to high trees at the upwind end of the runway. The aircraft overran the runway and struck a shipping container. Both occupants evacuated the aircraft without injury. Text courtesy of the Australian Transport Safety Bureau (ATSB). Disclaimer – information on accidents is the result of a co-operative effort between the ATSB and the Australian aviation industry. Data quality and consistency depend on the efforts of industry where no follow-up action is undertaken by the ATSB. The ATSB accepts no liability for any loss or damage suffered by any person or corporation resulting from the use of these data. Please note that descriptions are based on preliminary reports, and should not be interpreted as findings by the ATSB. The data do not include sports aviation accidents. 19 ACCIDENT REPORT Date In the March-April issue of Flight Safety editor, verview Margo Marchbank, gave an overview of unmanned aerial systems (UAS) in Australia. The story continues when she speaks with er; UAS researcher, Dr Rod Walker; and three of Australia’s certified UAS operators. 20 FSA MAY–JUNE09 – thenues … S A U stor y conti ‘W ithin 24 hours of the 9/11 attacks on the World Trade Center, Robin Murphy was on the scene with a team of robots to help sor t through the debris. “Search cams typically penetrate only 18f t, and the heat was melting the heads off some of them,” says Murphy, 46, a professor of computer science and engineering at the Universit y of South Florida. “Our robots are able to go 60f t through rubble that’s still on fire.”’ Time Online, posted 8 June 200 4. It is this type of o sce ce enario, Professor Rod Walker says, wh hich will turn the tide for public acceptance of UAS and broad den public awarenesss of the vital role UAS S can play. Rod Walker W is an academic an nd researcher at thee Queensland Univers rsit rs ity it y of o Technology’s School of Engineering Systems. ‘It’s only a mattter of time until we hear this person was saved from attack, attack or this sailor rescued because of UAS surveillance.’ In the UK, for example, he says, police are conducting aerial surveillance of parkland using electric UAVs. Rod Walker is also part of the collaborative Smart Skies research project, which is conducting tests at Kingaroy during April this year, as Flight Safety goes to print. The three-year project brings together Boeing Research & Technology and the Australian Research Centre for Aerospace Automation (ARCAA), a joint venture of Queensland University of Technology and CSIRO. ‘As far as the aaircraft were concerned this was a real collision scenario using real data links,’ Rod Walkeer said. ‘It detected a potential collision and automatically isssued new flight trajectories to the aircraft. The aircraft a then safely continued on with their fligh ht. Passengers onboard would never have even known that a collision had been avoided, it w was so smooth.’ Continuing testts during April aim to ‘automatically seeparate a specially modified Cessna 172R aircraft, developed at ARCAA, from the unman nned helicopter,’ Rod Walker said. He said they t were also developing unmanned aircraft that could see and perceive airspace in much the same way as human pilots do, working towards the ‘holy grail’ of UAS – ‘sense and avoid’. This was one of the four challenges for UAS identified in the last issue of Flight Safety, in addition to available bandwidth; ‘equivalent safety’ and public and industry acceptance of UAS. Rod Walker undertook his PhD research on GPS in 1993, and argues that it took 12 years for uptake of that technology. And it’s likely to be similar for UAS. ‘Most people now,’ he says, ‘don’t derive a benefit from current UAS’. But it’s the ‘dull, dirty and dangerous’ categories which he says will see their early application. Three Queensland-based UAS operators would agree. In early March 2009, there were eight certified unmanned aerial vehicle (UAV) operators in Australia. Three of these are based in Queensland: HELImetrex, the oldest; VTOL Aerospace; and the most recent, UAV Systems. HELImetrex was the fi rst Australian operator to be certified under CASA’s Part 101, in July 2002. According to director, Ray Gillinder, ‘It’s been a rocky road since 2002, with a number of issues restricting development, including “see-and-avoid”, and finding the appropriate systems stacking up to reliability. But over the last couple of years, there are better systems,’ he explains, ‘and the biggest hurdle now is market confidence in UAVs. The market is now at an acceptance stage,’ Ray says, ‘but it’s been the slowest and hardest thing to do: educating the market what our UAVs are capable of doing.’ These three operations exemplify the tasks for which UAS are ideally suited. HELImetrex focus on survey and monitoring activities, in particular small areas, such as mining stockpile calculations, vegetation mapping and GIS applications, and forestry work. Similarly, VTOL argue that they capitalise on the three core strengths UAS have to offer - low-cost, high-resolution and rapid delivery of data – to carry out asset and environmental management; and cropping and animal monitoring, operating four UAV types on their aircraft operator’s certificate (AOC). Certified in 2007, UAV Systems focuses mainly on aerial photography. Joe Urli, the managing director of UAV Systems, operates a rotary UAV; the entire helicopter (pictured left) weighing 12kg. He monitors weed infestation for the Environment Protection Authority, for example, and monitors banana crops at 400ft, taking high-resolution photographs which allow the grower to examine the health of the crop in great detail (pictured below). Banana crop monitoring: showing the UAV operator (centre), landing target and obstacles–wires, water. Photo: Joe Urli 21 UAS In the first test, conducted earlier this month, computers in Seattle averted a virtual midair collision between an unmanned helicopter and simulated aircraft over Kingaroy. The flight test involved a small s unmanned helicopter, develope ed and operated by ARCAA, which was placed in a conflict scenario with a virtual aircraft. Joe has a background in the military, US civil aviation administration and quality management, so he treats his UAV as a manned aircraft, undertaking detailed preflight planning, for example. ‘Every situation is different,’ he says, ‘so you need to do a risk assessment. You’re still operating an aircraft, so the level of safety must be maintained. You have to ensure the area you will be operating in is secure.’ This extends to issues of flight and duty times. ‘UAV activities are very intense,’ the operators explain. ‘After half an hour, at the end of a flight, you need a break. It’s exactly the same ‘UAV activities are ver y intense. 22 as a pilot flying instruments – under the hood and the black screen – for four hours.’ The three operators are happy with the existing regulation, Part 101, arguing that it’s very workable, and only requires minor tweaking. They feel they can work well within the existing framework, but have concerns about those who are not certified, and who are not aware of requirements regarding UAS. This applies particularly to the distinction between the ‘hobbyist’ and the ‘UAV operator’, Peter Hill from VTOLAerospace argues. CASA’s UAS office, based in Brisbane, is currently investigating the FSA MAY–JUNE09 t, you need a break . It’s Af ter half an hour, at the end of a fligh truments – under the hood and exactly the same as a pilot flying ins the black screen – for four hours.’ According to The West Australian, 21 April 2009, WA Police are investigating video footage taken by a camera attached to a remote-controlled model aircraft deliberately flown at a Virgin Blue jet as it came in to land at Perth airport. The model plane came within seconds of colliding with the 160seat 737 aircraft and crashed to the ground after being hit by the jet wash last Friday. The man believed responsible took the video off YouTube on Saturday after a report in The West Australian, but not before it was recorded and saved by fellow model aircraft enthusiasts furious at the reckless stunt. Enthusiasts from Australia and New Zealand have tracked down the man they believe responsible for the stunt and have given his details and the video to WA Police. These three operators recently underwent what they describe as a ‘productive’ CASA review, conducted by CASA inspectors from the Brisbane office. The comprehensive review included interviews with the UAV operator’s key personnel, looked at the administrative systems and the safety and risk management systems employed by each company, and reviewed a range of operational issues, including airworthiness & maintenance; flight crew skills and experience; and public liability insurance. Joe Urli felt this review gave CASA a greater understanding, and the opportunity to accurately assess the standards and the scope of commercial UAV activity in Australia. So, while researchers such as Rod Walker continue their work on, as he describes it, ‘putting the brains in the plane’, commercial operators such as the three Queenslanders: HELImetrex, VTOL-Aerospace and UAV Systems are building their businesses on the growing, but vulnerable, public acceptance of the usefulness of UAS in performing the ‘dull, dirty and dangerous’. 23 UAS Part 101 definitions of both accordingly. The operators, who are proud of their safety standards, are concerned that the hard-won acceptance of UAS could be compromised by some rogue individual. ‘A maverick can simply take a remote-controlled aircraft, and belt on a camera,’ Joe Urli says. This issue was highlighted by an incident which occurred in Western Australia on 17 April. A rotary unmanned aerial system (UAS) comprises - the helicopter UAV, or flight vehicle; the ground station; and the communication or data links. BOB TAIT’S AVIATION THEORY SCHOOL Has New Premises at Redcliffe Aerodrome - Queensland Full-time BAK and PPL courses now available! Check out our web page at www.bobtait.com.au BAK & PPL All CPL subjects plus IREX Courses available full-time or by home study PO Box 2018 Redcliffe North QLD 4020 P:07 3204 0965 F:07 3204 1902 W:www.bobtait.com.au E:email@example.com 24 FSA MAY–JUNE09 Squadron Leader John-John Rozells, from the Directorate of Defence Aviation and Air Force Safety, looks at restricted airspace, and why it’s important to avoid such areas. Portions of airspace designated as ‘danger’ or ‘prohibited areas’ clearly indicate to aviators that a potential hazard exists within the area, or that aircraft are required to keep out, in the case of the latter. For example, areas specifically for GA training may be listed as a ‘danger’ area to make pilots aware of the need to maintain vigilance for other air traffic, but pilots do not require a clearance to enter. Prohibited areas such as P229 at Pine Gap are designated as such to ensure all aircraft remain out. This is is fairly straightforward; however, some confusion or misconceptions may ay exist e about the use of restricted airspace or areas. Restricted areas may be permanent or activated via NOTA NOTAM, or deactivated for civil use as necessary. There are numerous purposes urposes for which airspace can be designated as restricted (R). A portion of these are assigned for military use by the Australian Defence Force (ADF). These areas are activated for exclusive use by the controlling or administering authority for its activities; however, it also ensures a safety buffer for other aviation participants, provided they do not enter the airspace without the appropriate clearance. What does the ADF use this airspace for? The ADF have R areas for training, research, testing or major exercise activities that may present hazards to aircraft. These hazards could be high-energy aircraft moving at high speed and randomly manoeuvring, live firing from surface or airborne assets, laser hazards or demolition of ordnances, to name a few. Aircraft straying into these areas place themselves in potentially dangerous situations. The Air Force may use R areas to control airspace around its airfields. This provides operators out of its airfield, or transiting its airspace, with a level of air traffic services the same as Class C airspace. Permission to enter this airspace is similar to controlled airspace around civil airfields. Aircraft may flight plan and request clearances to transit the airspace subject to the ADF’s operations. The Army may use restricted areas for small-arms firing, artillery practice, demolition, or other forms of live firing. Aircraft inadvertently entering these areas are under increased risk as a result of these activities. In recent times, a number of incidents have occurred where civil traffic operating or transiting through the Singleton area in NSW have inadvertently strayed into R532A/B. This area is designated from SFC to A045 in R532A as 24/7 for live firing, with higher levels in R532B activated via NOTAM. An aircraft straying into such an activity could face dire consequences. It is particularly important for pilots to ensure they avoid these areas, as limited surveillance by ATC may also exist. Other restricted areas posing a danger to unauthorised penetration of its airspace are those used by the Royal Australian Navy. These areas can have operating levels from surface to FL950, which highlights the potential for naval gunnery to reach extremely high altitudes. These areas are used for a combination of aerial activity and live ggunnery y situated on or off the coast - mainly near Nowra, NSW, and Western Australia. During large-scale military m exercises a combin nation of established restricted areas and temporary As) restricted areas (TRA are activated to safeely segregate military and civil operations. Thesee operations, which can take months to Singleton organise and cost millions of dollars, ensure that a particular task is completed so that the ADF can fulfil its combat capability role. These exercise areas are detailed in an AIP Supp in advance ce of the event and NOTAMs are promulgated to provide other airspace users the time m to flight plan around these areas. Hopefully this article has provided readers a better understanding of military restricted airspace. But what resources are available to pilots when planning their next flight to avoid entering one of these areas unwittingly? One of the best resources available to civil pilots is the Airservices Australia website, www.airservicesaustralia.com particularly its ‘Flying Around’ webpage. This provides excellent information and helpful hints for pilots to avoid violating controlled or restricted airspace. It’s imperative to carry the most up-to-date charts. These help identify the various restricted-area boundaries and vertical limits. In conjunction with these, detailed information on restricted-area activation or deactivation times, as the case may be, are published via NOTAMs and need to be checked if a flight is operating in the vicinity of R areas. Enroute Supplement Australia (ERSA) and the Designated Airspace Handbook (DAH), also available through the Airservices Australia website, provide further information on restricted areas. What then when a pilot is airborne? When tracking in the vicinity of R areas, gross error checks of navigation will help avoid a violation of airspace, whether it is controlled or restricted. With the growing popularity of GPS as an aid to navigation it’s important to note that some R areas have boundaries that are arcs based on specific points. Users should check to determine if they have used the correct reference point. Some of these arcs can be based on a navigation aid, while others are based on an aerodrome reference point, or latitude and longitude. This subtle difference could mean the difference between entering the airspace without a clearance, or clipping the boundary when navigation tolerances are factored in. In those restricted areas where an ATS is provided, a timely call on the appropriate cleara ance delivery frequency can assist contrrollers and pilots in issuing a clea arance. However, deelays in the issue of a clearance may be eexperienced, and pilots w will need to ensure that they hold in a p position that will not infringe the airspace un ntil in receipt of an airways clearance. If you are unsure at a any stage about the status of airspace, sp peak up and ask. 25 RESTRICTED AREAS In addition, the airspace may also be utilised for the purposes of military flying training. This allows protection from other aircraft when this flying training involves large numbers of fast, randomly manoeuvring aircraft operating in random significant concentrations. These high-energy sig aircraft may be operating at low levels one minute, then abruptly climb to higher levels in a matter of seconds or minutes. Violations of these areas by a civil aircraft could easily put them in close proximity, with little warning for military traffic. In recent times, a number of incidents have occurred where civil traffic operating or transiting through the area in NSW have inadvertently strayed into R532A/B. 26 BABY, ITU’STSIDE O D L O C FSA MAY–JUNE09 With winter almost upon us, Flight Safety cautions pilots to beware of aircraft upper-wing surface ice accumulation, before takeoff. ‘frost, ice or snow with the thickness and surface roughness of medium or coarse sandpaper reduces lift by as much as 30 per cent, and increases drag by 40 per cent. Even a small area can significantly affect the airflow’ May until October: that’s when ssouthern inland Australia experiences a dramatic drop in temperature, perature with the mountainous regions of NSW and Victoria, and Tasmania mania m most severely affected. Most pilots are more than aware of the dangers ar an posed by in-flight icing, whether carburettor; air-frame or intake, ak and the steps to take if these aaree encountered. enc Howeve there is not the same level of awareness of the potential for However, iicing on the upper wing surface when on the ground, and as these south-eastern outh-eastern states s head into winter, it is advisable to remember the dangers angers associated assoc with the colder conditions. Sadly failure Sadly, fai fa to recognise and deal with icing on the ground can have fatal conse fa consequences, as the following cases demonstrate. While both thesee accidents acc occurred in aircraft with a specific wing type, tests have shown that frost, ice or snow with the thickness and surface roughn oughness of medium or coarse sandpaper reduces lift by as much as 30 pe per cent, and increases drag by 40 per cent. Even a small area can significantly affect the airflow. Photo above: Australian conditions do not demand the de-icing procedure seen here at Denver International Airport Colorado, but there is no room for complacency about ice. (Photo: MWP 1969 Dreamstime.com) The investigation showed that the aircraft’s takeoff roll was normal up to the time of lift off. Immediately after lift off, however, the aircraft rolled to the left despite full-right-aileron and right-rudder application by the flight crew. Within three and a half seconds after lift off, the bank angle aural warning and the stickshaker activated, and the aircraft struck the ground about five and a half seconds after lift off at a bank angle of 111º left-wing down and a pitch angle of 13º aircraft nose-down. The AAIB investigation concluded the following: ‘The roll had resulted from the left wing stalling at an abnormally low angle of attack due to flow disturbance resulting from frost contamination of the wing. A relatively small degree of wing surface roughness had a major adverse effect on the wing stall characteristics and the stall protection system was ineffective i this in thi situation.’ it ti ’ a Challenger operating an on-demand charter flight suffered a similar fate. On 28 November 2004, a Canadair Ltd CL600-2A12, N873G, collided with the ground during takeoff at Montrose Regional Airport (MTJ), Montrose, Colorado. The on-demand charter flight was operating on an instrument flight rules (IFR) flight plan. According to the National Transpertation Safety Board (NTSB) report, instrument meteorological conditions prevailed, and snow was falling. Of the six occupants on board, the captain, the flight attendant, and one passenger were killed, and the first officer and two passengers were seriously injured. The aircraft was destroyed by impact forces and post-crash fire. The flight was en route to South Bend Regional Airport (SBN), South Bend, Indiana. Before the accident flight, the airplane had arrived at MTJ from Van Nuys Airport, California, about 0910. Witnesses observed that the airplane had landed on runway 17, taxied to the ramp for fuel, and remained parked on the ramp at the fi xed-base operator (FBO) for about 40 to 45 minutes with its auxiliary power unit (APU) running. According to a passenger, one of the pilots remained on board the airplane the entire time. A pilot-certificated witness stated that there appeared to be snow on the accident airplane’s wings, but he could not tell how much. He made a comment about the contamination to his own co-pilot, and his co-pilot remarked to him that both the snow and the airplane’s paint scheme were white. The pilot-certificated witness further stated he did not observe either the captain or the first officer conduct a tactile examination of the wing surfaces. A lineman fuelled the accident airplane at its single-point fuel filler port, which is located at the right-wing root, with 400 gallons of Jet A fuel. The fuel was pumped from a fuel truck that was kept outside and unheated. The lineman stated that he noticed ice on the airplane’s nose landing gear area and slush-type ice on the wheels, but did not look at the airplane’s wings. Personnel in the FBO office and a lineman who was on the ramp de-icing other airplanes stated that the accident flight crewmembers did not request de-icing services for the airplane According to the cockpit voice recorder transcript, while the airplane was parked on the ramp, at 0942:15, the captain asked the first officer, ‘How do you see the wings?’ The first officer stated, ‘Good,’ and the captain replied, ‘Looks clear to me.’ At 0949:02, during engine start procedures, the first officer asked the captain if he wanted engine bleeds open (on) or closed (off), and the captain replied that he wanted them open. The first officer stated, ‘Yup. Okay so we need to a [sic] eight thousand foot of runway.’ The captain stated, ‘So it means [runway] three five.’ The first officer announced over the airport’s common traffic advisory frequency (CTAF) the crew’s intention to taxi the airplane to runway 35. The airport operations manager, who was monitoring ing adverse ef fect on the w or aj m a d ha s es hn ug ee of wing surface ro n.’ ‘A relatively small degr ef fective in this situatio in as w em st sy n tio ec d the stall prot stall characteris tics an 27 BABY IT’S COLD The Air Accidents Investigation Branch (AAIB) of the United Kingdom investigated the crash of a flight data recorder (FDR)- and cockpit voice recorder (CVR)-equipped Bombardier Challenger-600-2B16 at Birmingham Airport on 4 January 2002. The crash resulted in five fatalities: the two crew and three passengers. Evidence from the CVR indicated that the operating pilots discussed the presence of frost on the leading edge prior to engine start. However, neither requested deicing. At 1150 hrs the Birmingham METAR was: surface wind 150°/6 kts; visibility 8,000 metres; win cloud d scattered sc at 700 feet AGL and broken at 800 feet AGL; temperature minus 2°C with dew point minus 3°C; QNH 1027 mb.’ the frequency while operating a radioequipped snow plough on that runway, advised the flight crew over the CTAF that snow removal was in progress on runway 35. The first officer asked how long it would take for the snow removal equipment to exit the runway, and the CVR recorded no reply. He repeated the question, and, again, no reply was recorded. At 0953:31, the first officer stated, ‘Oh well, we gotta get out there anyway,’ and the captain replied, ‘Well runway three one is here.’ According to the airport configuration diagram, the airplane was parked on the ramp adjacent to runway 31; the taxi distance from the airplane’s parked location to runway 35 was approximately one mile. 28 FSA MAY–JUNE09 At 0953:35, the first officer stated to the captain that runway 31 was 7,500 feet long, and the captain asked what length of runway would be needed for takeoff, ‘…let’s say with the bleeds off.’ The first officer replied, ‘…that’s seventy eight hundred [feet], I think…tenth [stage] closed.” The captain asked, ‘Six thousand [feet]?’ The first officer replied, ‘Seventy five ninety…seventy eight [hundred feet].’ The captain stated, ‘Well we are between we are forty one thousand [pounds] so’ The first officer replied, ‘Sixty eight seventy five so right at seven thousand [feet], I guess. seventy two hundred [feet]?’ The captain stated, ‘Okay, we can do that…okay. okay we’ll go for [runway] three one, then. you agree?’ The first officer then stated, ‘These number [sic] are always conservative anyway.’ At 0954:54, the first officer contacted the Denver Air Route Traffic Control Center controller and received the flight’s IFR clearance to SBN. The controller instructed the first officer to report back on his frequency after departure, the first officer acknowledged, and the controller received no further radio communication from the flight. According to the passenger seated on the right side of the cabin, while the airplane taxied for takeoff, slushy clumps of snow and water slid down from the top of the fuselage and across his window. Another passenger stated he noticed water ran off the airplane’s skin, ‘like it had taken a shower.’ At 0957:32, the captain stated to the first officer, ‘You know what lets [sic] have the (engine) cowls and ah do a performance takeoff.’ At 0958:09, the captain stated, ‘Set power.’ Ten seconds later, the first officer reported, ‘Eighty knots.’ At 0958:32, the first officer stated, ‘There’s vee one,’ followed by, ‘Rotate.’ At 0958:39, the first officer asked, ‘Want the gear up?’ Immediately thereafter, the CVR recorded the sound of the stick-pusher horn, and the mechanical voice ‘bank angle’ warning, followed by mechanical voice ‘five hundred’ warning. The recording ended at 0958:46 with the sound of a loud rumble. The passenger seated on the right side of the cabin stated that the airplane lifted off and climbed to about 20 to 50 feet; then the left wing dropped abruptly and banked to an angle he described as greater than the 7 o’clock position. He indicated that the right wing then dropped to about the 5:30 position, then the left wing dropped again. He stated that he heard a loud thump, his upper body was knocked into the aisle, and he was hanging by the seatbelt. He stated the airplane then fell straight onto its nose. Witnesses in a building near the departure end of the runway reported that they heard a loud ‘boom’ and ‘whooshing’ noise, and that they y looked out the window and saw the airplane on the ground in flames. SUPERCRITICAL WING The accident aircraft’s wing design uses what is known as a supercritical airfoil, which is designed to reduce drag at the airplane’s cruise airspeed. This airfoil design, when contrasted with more conventional airfoils, is characterised by a larger leading-edge radius, reduced upper-surface camber, and a concavity in the lower aft surface. These features provide a reduced drag at high airspeeds, yet the airfoil behaves much like a conventional airfoil at lower airspeeds. At lower airspeeds, the pressure distribution on the upper surface of the wing is peaked near the leading edge, and this peak increases with increasing angle of attack. As this increases beyond the natural stall angle of attack, the pressure gradient in the leading-edge region reaches a critical value, and flow separation initiates. Depending on the span-wise location of the separation onset, the region of separated flow can grow rapidly to adjacent span-wise locations, eventually stalling the entire wing and resulting in a large drop in lift and an increase in drag. Temperatures in Australia may not reach the extreme lows seen in n the UK and the US, but similar occurrences are possible, leaving little ittle room for complacency. The NTSB, concerned about a spate of such accidents, especially y involving Cessna 208s, issued a safety warning, ning, an adapted version ion of which is reproduced below. Fine particles of frost or ice, the size of a grain of table salt and distributed as sparsely as one per square centimetre over the upper surface of an aircraft’s wing, can destroy enough lift to prevent a plane from taking off. Almost virtually imperceptible amounts of ice on an aircraft wing’s upper surface during takeoff can result in significant performance degradation. Small, almost visually imperceptible amounts of ice distributed on an aircraft’s wing upper surface cause the same aerodynamic penalties as much larger (and more visible) ice accumulations. Small patches of ice or frost can result in localised, asymmetrical stalls on the wing, which can result in roll control problems during lift off. It is nearly impossible to determine by observation whether a wing is wet or has a thin film of ice. A very thin film of ice or frost will degrade the aerodynamic performance of any aircraft. Ice accumulation on the wing upper surface may be very difficult to detect from the cockpit, cabin, or front and back of the wing because it is clear/white. Accident history shows that non-slatted, turbojet, transport-category airplanes have been involved in a disproportionate number of takeoff accidents where undetected upper wing ice contamination has been cited as the probable cause or sole contributing factor. Most pilots understand that visible ice contamination on a wing can cause severe aerodynamic and control penalties, but it is apparent that many pilots do not recognise that minute amounts of ice adhering to a wing can result in similar penalties. Despite evidence to the contrary, these beliefs may still exist because many pilots have seen their aircraft operate with large amounts of ice adhering to the leadin leading edges (including the dramatic double horn accretion) and consider a thin layer of ice or frost on the wing upper surface to be more benign. WHAT SHOULD PILOTS KNOW AND DO ABOUT AIRCRAFT ICING BEFORE TAKEOFF? Pilots should be aware that no amount of snow, ice or frost accumulation on the wing upper surface should be considered safe for takeoff. It is critically important to ensure, by any means necessary, that the upper wing surface is clear of contamination before takeoff. The NTSB believes strongly that the only way to ensure that the wing is free from critical contamination is to touch it. With a careful and thorough pre-flight inspection, including tactile inspections and proper and liberal use of de-icing processes and techniques, aircraft can be operated safely in spite of the adversities encountered during winter months. Pilot should be aware that even with the wing inspection light, the observation of a wing from a ten metre distance, through a window that may be wet from precipitation, does not constitute a careful examination. Depending on the aircraft’s design (size, high-wing, low-wing, etc.) and the environmental and lighting conditions (wet wings, dark night, dim lights, etc.) it may be difficult for a pilot to see frost, snow and rime ice on the upper wing surface from the ground or through the cockpit or other windows. Frost, snow, and rime ice may be very difficult to detect on a white upper wing surface and clear ice can be difficult to detect on an upper wing surface of any colour. Many pilots may believe that if they have sufficient engine power available, they can simply ‘power through’ any performance degradation that might result from almost imperceptible amounts of upper wing surface ice accumulation. However, engine power will not prevent a stall and loss of control at lift off, where the highest angles of attack are normally achieved. FOR MORE INFORMATION ‘Winter flying’ SafetySense leaflet no.3 UK Civil Aviation Authority March 2009 ‘Aircraft ground icing’ NTSB Safety Alert ‘Into the cold’ Flight Safety Australia May-June y-June 2007 p25-27 29 BABY IT’S COLD THERE IS NO SUCH THING AS A ‘LITTLE ICE’ rtant oting impo m ro p in rt pp o it. f the tool k for their su donation o to Snap-on ir e u o th y h k it n a w th n, A nd a big as corrosio issues such ss e in h rt o air w APER OF THE SN N IN W E H T D AN … ON TOOL KIT IS am 30 h tagg from Nort -S w to s ri B n Ia rrosion Air Services ve 50 per cent co RUNNER-UP L IA C E P S A H WIT POD GOING TO IN A F O E IZ PR nd n of Queensla o id le K s e m a J ed by the na 18 2K , describ FSA MAY–JUNE09 to ha raft was found e right-hand An S3 5 Beechc et located on th ss gu d ar rw an fo d an -h raft was having of the right through. The airc yrr al ca ov ar m sp re e d th ssitate fuselage at ange which nece ch x as bo w ar n ge io ge os undercarria . Ex tensive corr be associated trim ion is believed to of the floor and ubler. The corros do e at s. pl al sh se fi e or found on th ith degraded do ly-rigged door w caused by a poor These two SDR submissions stood out to the judges as best fulfilling the competition criteria. Both showed substantial corrosion which would not have been picked up under normal scheduled maintenance. It was only by chance that circumstances meant a more detailed examination of the aircraft, which led to the detection of the corrosion. Thank you to all those who took the time to submit SDRs. Ian Bristow-Stagg says that this was the first SDR he has completed online, and many still submitted paper-based SDRs. We understand that workshops are busy places, and that the last thing at the end of a long shift you may want to do is sit in front of a computer screen and fill ss curred on a Ce R’ they are The second oc of the type of SD e pl am ex ct fe er skinning of both judges as a ‘p brought in for re as w ft ra rc ai e W hen the skins looking for. Th ing hail damage. w llo fo s or at ev d to be severely left and right el tubes were foun ue rq to th bo , iceable items. were removed placed with serv re e er w s be tu been detected corroded. The would not have n io os rr co is e skins, as no Importantly, th ce removal of th an ch e th r fo acturer. This had it not been from the manuf ts is ex n tio ec ’s airwor thiness published insp viewed by CASA re g in be tly en mat ter is curr ssna. engineers and Ce out SDR forms forms. The competition has highlighted the fact that many LAMEs find it difficult, and don’t see value in submitting SDRs So, we would like to highlight two things: 1. The support of LAMES in submitting SDRs is critical in helping to build a database of such occurrences, so that trends can be identified, and remedial action taken where necessary. 2. Submitting an SDR is easy if you follow the step-bystep instructions. These are posted on the website, and because of space limitations in this issue of Flight Safety, we’ll also include them in the July-August issue. g High G n i r v u e ano PULL-OUT SECTION M AIRWORTHINESS 31 Darren Morris is a CASA structures specialist with an interest in aircraft corrosion and fatigue issues. He looks at aerobatics and the need for additional record-keeping because of airframe fatigue. A recent audit of an operator by a CASA airworthiness inspector revealed poor record keeping by previous owners of an aerobatic aircraft. Many aerobatic types have a defined useful life of airframe structure. This can be established at certification, but more often than not occurs later in the type’s life when feedback from in-service experience can refine the initial limits. This aircraft had a determined safe life for the airframe, but unfortunately the current operator was unable to substantiate the aerobatic usage of the airframe throughout its life. The only responsible course of action for CASA to take because of this was to determine a conservative percentage of the total airframe hours that would have likely been used up in aerobatic manoeuvres. Following this calculation, the aircraft was grounded. So the moral of the story is: if you are purchasing an aerobatic aircraft, make sure you do your homework on the type. Check the type certificate data sheet and CASA airworthiness directives for a mandated life. Make sure that you are given the complete history of the aircraft so that you can substantiate the useful remaining life on the airframe. This will prevent your newly-acquired ‘toy’ from becoming a garden ornament. What does the ‘life limitation’ mean? The ‘life limitation’ is an engineering estimate of the useful life of a structure. The life limit takes into account the variability of manufacture, materials and usage, and is PULL-OUT SECTION an estimate of the safe life of the aircraft or component. Below the life limit, the likelihood of structural failure is very remote. Beyond that limit a failure becomes increasingly likely. Victa Airtourer, pic courtes y: Mark Pracy 32 Where can I ﬁnd the life limitation? FSA MAY–JUNE09 The life limitation may be stated by the manufacturer in the airworthiness limitations section of the aircraft maintenance manual. These limitations are also mentioned in the aircraft type certificate data sheet (TCDS). Additional limitations can be mandated through an airworthiness directive(AD). design and involves disassembly of the wings from the fuselage and inspecting the structure in known fatigue-susceptible sites. Every flight can damage the structure a small amount as the forces of flight and landing loads are reacted by the structure. This structural damage is cumulative, and naturally, aerobatics accelerates the rate of accumulation of damage. Whilst some older airframes are fitted with fatigue meters to measure the actual g loads experienced in-flight (accelerometers), other airframes will rely on detailed record keeping to track parameters used in the calculation of fatigue. These parameters may include aerobatic hours, positioning time, aircraft weight etc. The parameters required will be specified in the life limitation. It would be a good idea to maintain a flight log for aerobatic airframes such as that shown in the table below, so that you can demonstrate to CASA that the airframe fatigue is being managed: Aircraft Type / Model: Aircraft Serial Number: Regi Re gist sttrra rati ati tion on:: on Dat atee Detail Det ailss Tacho/ Tac ho/ Tacho/ ho// VDO VD VDO Start Finish Hrs Aero Hrs Tot ot al ot a Time Ti Many aircraft types have life limitations due to structural fatigue. Some examples are: Victa Airtourers have a requirement to replace wing and tailplane structure after 17,200 hours time in service. This life limitation is based on measured stress and loads data. Avions Mudry Cap10 aircraft have had a limitation placed on the flight envelope (g restrictions) following wing in-flight structural failures. It was determined that the existing inspection service bulletin was ineffective in detecting damage to the wing’s structure. Avions Pierre Robins (R2000 series) once had an AD which placed a retirement life on the wing spar structure of 3300 hrs. This was later replaced by an inspection routine allowing the continued operation of the aircraft. This damage tolerance approach was based on further fatigue analysis of the Please note: this is an example only. Make sure you refer to the specific life limitation for your aircraft type for which parameters you should record. Can anything be done about a life-expired airframe? After reaching the safe-life, the structure can only remain usable by replacing critical parts, or adopting a sophisticated maintenance program. This maintenance program ensures the detection and repair of corrosion, fatigue cracking and other damage before such damage degrades structural strength below an acceptable limit. Who can develop the sophisticated maintenance program required for a life extension? You should ask the aircraft manufacturer, or an aeronautical engineer skilled and experienced in damage tolerance. This is specialised work which involves knowledge of crack propagation, growth rates and methods of inspecting aircraft structures. SELECTED SERVICE DIFFICULTY REPORTS Airbus A320232 Landing gear door actuator hose ruptured. Ref 510007767 LH main landing gear door actuator hose ruptured. Loss of ‘green’ system hydraulic fluid. P/No: AE2463921G0097. TSN: 15,283 hours/9,146 cycles. Airbus A330203 ADIRU failed. Ref 510007888 No1 Air Data Inertial Reference Unit (ADIRU) failed. P/No: 46502003030316. (1 similar occurrence) Airbus A330303 Cabin kerosene fumes. Ref 510008009 Kerosene type smell reported around rows 58/60. Investigation could find no source for the smell which eventually dissipated. Defect not confirmed. Boeing 7373YO Fuselage door frame cracked. Ref 510007823 R1 door cut-out cracked at forward upper corner in fastener holes No1 and No8. A scribe line was also found under the lower edge of the rain gutter above the door cut-out. Found during inspection iaw AD/B737/24 Amdt1. (1 similar occurrence) Boeing 7373YO Spoiler actuator eye end broken. Ref 510007779 LH inboard ground spoiler actuator fixed eye end broken. P/No: 65448517. TSN: 15,355 hours/8,595 cycles. TSO: 15,355 hours/8,595 cycles. (13 similar occurrences) Airbus A380842 Aircraft fuel systems pipe leaking. Ref 510007954 Fuel feed pipe from No4 feed tank to APU isolation valve failed and leaking. Investigation continuing. Boeing 7373YO Spoiler actuator idler crank bolt sheared. Ref 510007857 No5 spoiler outboard actuator idler crank bolt seized and sheared. P/No: BACB30TR8. Airbus A380842 Aircraft fuel tank contaminated. Ref 510008078 No2 and No3 feed tanks contained minor contamination which affected fuel quantity readings. (4 similar occurrences) Boeing 737476 Aircraft centre tank boost pump faulty. Ref 510007913 No1 centre tank boost pump faulty causing fuel imbalance. P/No: 568126713005. TSN: 52,806 hours. TSO: 18,602 hours. (9 similar occurrences) Airbus A380842 Electrical power systems relay faulty. Ref 510008134 Electrical system relay 15XR1 faulty. Investigation continuing. P/No: 15XR1. Boeing 737476 Air conditioning system outflow valve stuck. Ref 510007911 Pressurisation system forward outflow valve stuck open. Investigation found corrosion, internal contamination and excessive leaking due to worn /leaking seal. P/No: 322384007. TSN: 36,671 hours. TSO: 36,671 hours. (1 similar occurrence) Airbus A380842 Landing gear systems RVDT water contaminated. Ref 510007958 Nose wheel steering system faulty. Investigation found the rotary variable displacement transducers (RVDT) contaminated with water. Investigation continuing. (2 similar occurrences) BAC 146300 Aircraft vibrates. Ref 510007758 Vibration and stall ident problems caused return to base. Suspect roll spoiler out of adjustment causing vibration. Investigation found wire P/ No WL1005S connection not locked in terminal block DGD. (1 similar occurrence) Boeing 717200 Aircraft lightning strike. Ref 510007850 Aircraft suffered a lightning strike in the area of the nose. Minor damage to static wicks and elevator trailing edge. (1 similar occurrence) Boeing 717200 Engine vibration – accelerometer suspect faulty. Ref 510008064 LH engine vibration high. Suspect faulty vibration system accelerometer. P/No: 8AC1AAB1. Boeing 737229 Wing flap carriage worn. Ref 510008135 RH outboard trailing edge flap carriage and LH outboard flap outboard carriage worn. P/No: 66232141. Boeing 737376 Aileron control systems seal incorrectly fi tted. Ref 510007791 Aileron controls heavy/notchy. Investigation found balance panel edge seals incorrectly fitted. Aileron centering cam bearing faulty. Investigation continuing. (1 similar occurrence) Boeing 737376 Fuselage systems shear tie cracked. Ref 510007998 Shear tie located at BS 294.5 Stringer 11L cracked. Boeing 737476 Aircraft door handle moved from latched to unlatched. Ref 510008028 Door L1 inner door handle moved from latched to unlatched position. Suspect rigging out of adjustment. Investigation continuing. Boeing 737476 CSD faulty. Ref 510008065 No2 engine constant speed drive (CSD) suspect faulty. (11 similar occurrences) Boeing 737476 DADC suspect faulty. Ref 510007907 Auto throttle tripped followed by stick shaker. Suspect caused by faulty digital air data computer (DADC). Investigation continuing. (2 similar occurrences) Boeing 737476 GCU faulty. Ref 510007832 No2 engine Generator Control Unit (GCU) unserviceable. (8 similar occurrences) Boeing 737476 Hydraulic pump overheated. Ref 510007845 System ‘A’ electric hydraulic pump overheated. P/No: GENM29501013. TSN: 41,903 hours. TSO: 480 hours. (3 similar occurrences) Boeing 7374L7 Spoiler actuator mount fi tting broken. Ref 510008150 RH ground spoiler inboard and outboard actuator mount fittings part number 65-67186-7 and part number 65-671868 fractured across the top of the main bearing support structure. Pivot bearings also worn. P/No: 654645262A. TSN: 52,283 hours. TSO: 7,155 hours. Boeing 7377BX Rudder fi tment incorrect data. Ref 510007849 During rudder fitment as per the maintenance manual, the fitment of the spacer below the hinge arm led to the rudder upper hinge frame contacting the hinge bearing retainer bolts. The IPC reference showed the spacer fitted above the hinge arm. If the IPC drawing is followed, then clearance is obtained between the hinge fitting and the bolts. Suspect information in maintenance manual is incorrect. Boeing 737838 Aircraft fuel system check valve faulty. Ref 510007824 Fuel system imbalance. Investigation found the No2 fuelling valve check valve missing both flappers. Centre tank missing one flapper. No2 fuel tank refuel valve unserviceable. Investigation continuing. (1 similar occurrence) Boeing 737838 Elevator balance panel attachment bolt fouled. Ref 510008083 RH elevator balance panel attachment bolts fouling on panel support structure on horizontal stabiliser. Investigation found the panel deviated from the drawing. Investigation continuing. Boeing 737838 Elevator control system restricted. Ref 510008035 Elevator control system restricted. Investigation found the RH balance panel unbolted and damaged. Investigation continuing. P/No: 183A91038. Boeing 7378FE Wing flap skin missing. Ref 510007800 LH outboard aft flap inboard upper skin partially missing. Area of missing skin approximately 203.2mm by 88.9mm (8in by 3.5in). Boeing 747438 Aileron control load limiter rough. Ref 510008132 First officer’s aileron control load limiter notchy in operation. Boeing 747438 Engine compressor fairing separated. Ref 510008010 No4 engine LH lower compressor fairing partially separated. Missing segment was trapped beneath No7 thrust reverser blocker door. Impact damage to blocker door. P/No: UL37463Q. (28 similar occurrences) Boeing 747438 Passenger oxygen bottle closed. Ref 510007927 Two aft passenger oxygen bottles located at Stn 700 in the forward cargo ceiling were found closed and not lock wired. (2 similar occurrences) Boeing 747438 Passenger oxygen cylinder damaged. Ref 510008090 No7 sidewall passenger oxygen cylinder damaged. Investigation found that damage to paint was caused by the upper cylinder retaining strap which was missing the rubber cushion. Investigation of other oxygen cylinders found similar problems. P/No: 80130700. Boeing 747438 Water drain mast heating inoperative. Ref 510008017 Forward water drain mast heating inoperative. Water contamination in passenger area. P/No: E0158751. Boeing 7474H6 Electrical power system cable short circuit. Ref 510007771 Ground service bus aft feeder damaged and short circuited at Stn 2120. The AME had contacted feeder during unconnected maintenance. Suspect due to some undetected existing damage of the feeder and ‘P’ clip that this resulted in a short circuit of the feeder to the metal part of the ‘P’ clip and airframe via a metal standoff and bracket. This resulted in the disintegration of the standoff and bracket and severe damage to the electrical feeders. The heat generated also resulted in some burns to the AME. Investigation continuing. (2 similar occurrences) Boeing 7474H6 Pylon spring beam lug damaged. Ref 510007820 No4 pylon spring beam aft inboard lug damaged. Investigation found that the lug had a ‘V’-shaped PULL-OUT SECTION AIRCRAFT ABOVE 5700KG Boeing 737376 Rudder nuts failed torque check. Ref 510007924 Rudder nuts (3off) failed torque checks. Found during inspection iaw EI 737-055-0021. 33 AIRWORTHINESS 1 February 2009 – 31 March 2009 groove machined into it. Groove measures 2.54mm (0.100in) thick and 1.524mm (0.060in) deep. P/No: 311U005038. (1 similar occurrence) PULL-OUT SECTION Boeing 767336 Fuselage lightning strike. Ref 510007894 Several lightning strikes noted on forward LH fuselage and possible damage to upper rudder static wick. Investigation found evidence of approximately thirty strikes. Lightning strike inspection carried out. 34 Boeing 767338ER APU sensor dislodged. Ref 510008114 Smoke in cabin and flight deck. Investigation found APU oil quantity low and internal plenum contaminated with oil. N1 sensor was found to be dislodged from plenum allowing oil leakage. Sensor was lock wired but not screwed into plenum. Investigation continuing. Boeing 767338ER Autopilot system clutch pack faulty. Ref 510007819 Autopilot system clutch pack faulty causing throttle levers to stick. Investigation continuing. Boeing 767338ER Engine fuel spar valve unapproved part. Ref 510007899 LH engine fuel spar valve unapproved part. Spar valve was a loan item. Spar valve P/No MA20A2027 incorrectly fitted instead of correct P/No AV31-1 valve. Investigation continuing. P/No: MA20A2027. FSA MAY–JUNE09 Boeing 767338ER Engine throttle system stiff. Ref 510007940 RH engine throttle system stiff and ‘graunchy’ in operation. Throttle cables P/No 580-299-104 and P/ No 580-299-107 replaced. Cables had been replaced in December 2008, and were found to be in good condition. P/No: 580299104. (1 similar occurrence) Boeing 767338ER Flight control systems servo faulty. Ref 510008001 Autopilot disconnected and aircraft pitched nose up. Suspect faulty elevator servo. Investigation continuing. Boeing 767338ER Instrument warning system suspect faulty. Ref 510008136 Spoiler warning during takeoff. Investigation could find no cause for the defect. Bombardier DHC8102 Nose landing gear door actuating bell crank lug failed. Ref 510008148 (photo below) Nose landing gear door actuating bell crank lug failed at over-centre link connection. Forward nose landing gear doors jammed in half open position. P/No: 83232013103. Bombardier DHC8102 Pilot’s side window screw missing. Ref 510008149 Pilot’s side window screw/bolt missing 4th from bottom at windscreen to side window join. Impact damage caused to No1 engine propeller blade. Investigation found all other screws were correct length and part number and correctly torqued. Investigation continuing. Bombardier DHC8202 Aileron servo faulty. Ref 510008055 Autopilot system faulty. Investigation found a faulty LH aileron servo. P/No: 7002260723. Bombardier DHC8202 GCU failed. Ref 510007783 No2 generator control unit (GCU) internal failure. Investigation found failure was due to open circuit of resistor R242 resulting in no field output to generator. P/No: 51608002. Bombardier DHC8202 Main landing gear anti-skid transducers incorrectly wired. Ref 510007912 RH main landing gear tyre locked up and ruptured during landing. Investigation found the RH main landing gear antiskid transducers were incorrectly wired, with the wires to the inboard and outboard positions transposed. Aircraft had a main landing gear strut replacement in December 2007. TSN: 25,321 hours/27,103 cycles. Bombardier DHC8402 Baggage door handle incorrectly stowed. Ref 510007977 Baggage door handle protruding from correct stowed position. Door latching system correctly locked. (9 similar occurrences) CVAC 340 Propeller de-ice slip ring failed. Ref 510007847 LH propeller de-ice slip ring failed. Slip ring peeled back from supporting material causing extensive damage to brush blocks. Signs of arcing and burning on the insulating support material suggesting that the failure occurred while electrical power was applied. P/No: 6506538. TSN: 9,584 hours. TSO: 2,243 hours. Dornier DO328100 Wing fuel feeder tank lower skin corroded. Ref 510007886 RH wing fuel feeder tank lower skin cracked. Internal inspection found several areas of pitting corrosion resulting in pin holes through the skin. A crack was also noted running longitudinally through the RH fuel feeder tank fuel transfer pump inboard mounting boss. Suspect corrosion caused by microbiological contamination. TSN: 24,683 hours/21,923 cycles/21,923 landings/168 months. Embraer EMB120 Cabin pressure controller faulty. Ref 510007745 Cabin pressure controller failed in automatic mode: manual mode operation OK. Suspect caused by moisture ingress due to operations in North Queensland. P/No: 22201T011400. (1 similar occurrence) Embraer EMB120 Cargo door track support fi tting cracked. Ref 510007957 (photo below) Cargo door track lower aft support fitting cracked along rear stiffener web. Crack originates from an area of corrosion at the base of the web. As an aside from the defect, the IPC was also found to be incorrect. P/No: 12034400001. (1 similar occurrence) Embraer EMB120 Engine check valve contaminated. Ref 510007755 LH engine check valve located between the nacelle collector tank and fuel tank contained debris under the valve seat causing the valve to be stuck open. Embraer EMB120 Fuselage flooring structure profile corroded. Ref 510007965 Centre fuselage flooring structure profile corroded beyond repair. P/No: 12006660001. (4 similar occurrences) Embraer EMB120 Main landing gear leg proximity sensor unserviceable. Ref 510007948 RH main landing gear leg proximity sensor unserviceable. P/No: 122FS2A6N2735A. (3 similar occurrences) Embraer EMB120 Rudder actuator faulty. Ref 510007902 Rudder actuator failed differential pressure check. Suspect caused by internal leakage. P/No: 3081401003. TSN: 7,227 hours/6,100 cycles. TSO: 5,040 hours/3,789 cycles. (1 similar occurrence) Embraer EMB120 Wing flap track bearing unserviceable. Ref 510007778 Flap disagreement faults. Numerous parts replaced but fault persists. Fault could not be duplicated on the ground. Investigation found the RH inboard/forward flap track bearing unserviceable. P/No: KRP189510VTZ. Embraer ERJ190100 Flight control columns sensors rubbing. Ref 510007838 Captain’s outboard and first officer’s inboard control column command position sensors rubbing causing friction on full aft elevator deflection. P/No: 4259001001. Fokker F28MK0100 Engine fuel lever stiff. Ref 510007760 Engine fuel lever stuck in ‘open’ position. Investigation found the control linkages stiff. Lear 45 Elevator bearing seized. Ref 510007995 (photo below) RH elevator outboard bearing seized and corroded due to insufficient lubrication. Further investigation found the LH elevator outboard bearing balls disintegrated due to lack of lubrication. TSN: 3,400 hours/5,776 cycles. Saab SF340B Engine tailpipe heat detector water contaminated. Ref 510007854 LH engine tailpipe heat detector sealant contaminated with water. Moisture ingress was also found in the harness terminal. P/No: 1734362450. Saab SF340B Main landing gear wheel speed transducers transposed. Ref 510008111 LH main landing gear wheel speed transducers incorrectly fitted. Transducers transposed with outboard transducer fitted to the inboard position and vice versa. Investigation found maintenance (oleo seal replacement) was carried out on the LH axle assembly 196 cycles prior to the incident. The transducers and wiring would have been disturbed during this maintenance. No1 main wheel was found to be flat spotted. P/No: 140041. Saab SF340B Main wheel tyre tread separation. Ref 510007967 No2 main wheel tyre tread separation. Tyre impact damage on LH engine nacelle aft of the LH inboard landing gear door and propeller blade causing delamination. P/No: 247714. TSN: 39 hours/43 cycles. Cessna 404 Vacuum system inlet filter blocked. Ref 510007917 Vacuum system inlet filter blocked and restricting flow. Suspect caused by moisture contamination due to high humidity. P/No: AM103535IA. TSN: 572 hours/8 months. Cessna 441 Elevator trim tab control rods faulty. Ref 510007777 Elevator trim tab control rods failed X-ray inspection. P/No: 571515823. (4 similar occurrences) P/No: 50092371. TSO: 251 hours/293 cycles/293 landings. (1 similar occurrence) AIRCRAFT BELOW 5700KG Beech 58 Aircraft components time expired. Ref 510007863 Numerous components time expired. The following components were affected: 1. LH fuel selector valve 2. RH fuel selector valve 3. Landing gear selector switch 4. Nose gear retraction rods and rod ends 5. All engine magnetos Beech 58 Landing gear steering yoke seized. Ref 510007860 Nose landing gear steering yoke seized. Grease nipple broken off. P/No: 358250072. Cirrus SR20 NLG strut cracked. Ref 510007968 Nose landing gear strut cracked. P/No: 14082004. TSN: 351 hours/33 months. (12 similar occurrences) Gippsland GA8 Cabin blower fan electrical connector overheated. Ref 510008154 Cabin blower fan electrical connector - J104 overheating. Suspect caused by faulty terminal crimp. Connector is located in cabin roof area aft of the overhead panel. P/No: J104. (1 similar occurrence) Gippsland GA8 Fuel strainer bowl corroded. Ref 510008119 Fuel strainer bowls corroded between bowls and bottom skin of aircraft. P/No: GA828201611. TSN: 1,119 hours. Pilatus PC12 Nose landing gear strut guide ring damaged. Ref 510007818 Nose landing gear strut not fully extended. Investigation found guide ring P/No 532-20-12-200 jammed between barrel nut - P/No 532-20-12-165 and inner cylinder, causing the strut to jam. P/No: 5322012200. TSN: 4,453 hours. (1 similar occurrence) Piper PA31 RH main landing gear faulty. Ref 510007869 RH main landing gear did not indicate down and locked when selected. Investigation confirmed gear was down and locked before aircraft landed. Investigation continuing. Piper PA44180 Wheel well ribs cracked. Ref 510008053 LH and RH wheel well ribs P/No 78475-06 and P/No 78475-07 located behind main landing gear drag braces cracked. Crack lengths approximately 25.4 mm (1in). Found during inspection iaw Piper SB 1161. P/No: 7847506. TSN: 4,039 hours. Swearingen SA227AC Flap hydraulic hoses chafed/ruptured. Ref 510008007 Flap system teflon hydraulic hoses chafed and ruptured. Loss of hydraulic fluid. (2 similar occurrences) Victa 115 Aileron pivot pin/bearing seized. Ref 510007762 LH aileron outboard pivot pin seized in pivot bearing. Bearing was excessively loose in outer housing allowing the bearing to move in the housing. P/No: 170491. TSN: 4,359 hours. Cessna 152 Flap actuator mount bracket corroded. Ref 510008008 RH flap actuator lower mount bracket corroded. P/No: 04200152. TSN: 10,208 hours. Gippsland GA8 Fuel sump tank leaking. Ref 510008117 Sump tank assembly leaking from pin hole. Suspect defective weld. P/No: GA828101111. TSN: 558 hours. (1 similar occurrence) Victa 115 Differential units between ailerons and flaperons worn. Ref 510007764 (photo below) LH and RH differential units located between ailerons and flaperons worn excessively. Excess movement between pivot bolt, bearing, idling lever pivot and idling lever. Cessna 152 Nose landing gear fork attachment bolt missing. Ref 510008122 Nose landing gear leg fork attachment bolt missing. Fork moved up oleo, contacting the lower torque link attachment fitting. P/No: AN533A. Gippsland GA8 Horizontal stabiliser hinge bolt failed. Ref 510007844 LH horizontal stabiliser hinge rear attachment bolt failed. Further investigation found rib and rear channel cracked (AD/GA8/5-1). TSN: 5,691 hours. P/No: 932601EI1. TSN: 4,359 hours. Cessna 172M Wing inboard rear spar cracked. Ref 510007848 LH wing inboard rear spar cracked in area of flap track attachment. Flap track lower rivets sheared. Suspect caused by flap over-speed. P/No: 052340014. (1 similar occurrence) Gippsland GA8 Tailplane rib cracked. Ref 510008029 No1 tailplane rib cracked at the forward channel mount bolt hole and splice plate radius. Found during inspection iaw SB-GA8-2002-02. (4 similar occurrences) Cessna 207 Engine throttle inner cable sheared. Ref 510007761 Engine throttle inner cable failed at swaged fitting. Outer cable pulled loose from end piece. P/No: S122225. Grob G115 Fuel system hose suspect faulty. Ref 510007807 Aeroquip 303-4 and Aeroquip 303-5 hose suspect reacting with fuel. Hoses were received from hose repair shop. When fitted to aircraft fuel system, the fuel changed to a yellow/orange colour. Investigation continuing. P/No: AEROQUIP303. Cessna 310R Wing attachment fi tting corroded. Ref 510008145 Forward and aft wing attachment fittings (10 of16) contained exfoliation corrosion. P/No: 08112761. TSN: 5,684 hours. Cessna 401B Emergency rear latch pin incorrect part. Ref 510007984 Emergency window/exit rear latch pin replaced by incorrect rivet. Pin is meant to break when latch operated – with the rivet fitted, this would not have occurred. Cessna 402C Hydraulic hose failed. Ref 510008130 RH engine driven hydraulic pump to firewall hose failed. Jabiru J160C Landing gear nut stripped. Ref 510008104 Landing gear nut stripped. Found during inspection iaw SB JSB025-1. TSN: 28 hours. Pilatus PC12 Aileron tab hinges seized. Ref 510008079 LH aileron tab hinges P/No 527-15-12-097, P/No 55760-12-269 and P/No 557-60-12-271 seized. Tab was still moving, but was distorting the attaching metal, rather than the hinge moving. P/No: 5271512097. TSN: 7,606 hours/10,336 cycles/87 months. TSO: 7,606 hours/10,336 cycles/87 months. Victa 115 Firewall repair cracked. Ref 510007769 (photo below) Firewall repair cracked. Victa 115 Tailplane mounting spigots loose. Ref 510007766 Both tailplane mounting spigots badly stepped. Wear/ play between mounting spigots on rear bulkhead and mounting spigot packers on tailplane forward spar. P/No: 300122. TSN: 4,359 hours. ROTORCRAFT Agusta Westland AW139 Modular Avionics Unit contaminated with water. Ref 510008032 Modular avionics unit (MAU) contaminated with water entering baggage compartment where the MAUs are located. PULL-OUT SECTION Cessna 404 Engine air filter faulty manufacture. Ref 510007938 New P/No P12-8157 engine air filter smaller in diameter than previous P/No AM103035EA filter allowing it to move around in the filter housing and cause damage to the filter. P/No: P128157. 35 AIRWORTHINESS Saab SF340B Wheel inner flange cracked. Ref 510007813 (photo below) LH main landing gear inboard wheel inner flange cracked and separated. Damage to brake assembly and axle. Investigation continuing. P/No: 3G4600A00133. TSN: 291 hours. TSO: 291 hours. (3 similar occurrences) PULL-OUT SECTION Agusta Westland AW139 tail boom disbonded. Ref 510007855 Tail boom disbonded beyond limits. P/No: 3G5350A00133. TSN: 797 hours/1,862 landings. TSO: 797 hours/1,862 landings. 36 Bell UH1H Main rotor blades faulty. Ref 510007859 Main rotor blade could not be tracked or balanced. Suspect manufacturing fault. P/No: 204011250113. MDHC 369E Cyclic control trim switch sticking. Ref 510007987 Cyclic control trim switch sticking. P/No: A21810064603. Lycoming O360 Engine muffler unserviceable. Ref 510007825 RH engine exhaust muffler cracked and unserviceable. P/No: 86299008. TSN: 2,548 hours/3,735 cycles/3,735 landings. (4 similar occurrences) Lycoming TIO540AH1A Engine fuel pump drive shaft failed. Ref 510008141 (photo below) Engine driven fuel pump drive shaft failed. Pump is hard to turn by hand. Investigation continuing. FSA MAY–JUNE09 Robinson R44 Muffler collapsed. Ref 510008061 Exhaust muffler/collector assembly holed. Paint on side panel scorched. P/No: C1695. TSN: 394 hours. (8 similar occurrences) Robinson R44 Tail rotor blade cracked. Ref 510007858 Tail rotor blade cracked on leading edge. Crack located approximately 177.8mm (7in) from pitch horn. P/No: CO292. TSN: 990 hours/48 months. (1 similar occurrence) PISTON ENGINES Continental GTSIO520M Engine failure. Ref 510007939 RH engine lost power and was shut down. Initial investigation found the propeller spinning freely but the engine was unable to be turned. Significant metal contamination of the oil system. Investigation continuing. (1 similar occurrence) Continental IO520B Engine throttle butterfly valve screw missing. Ref 510008014 During flight, the throttle plate dislodged and the engine was unable to be controlled. Investigation found the engine throttle butterfly valve attachment screw missing. TSN: 34 hours. Lycoming IO540K1A5 Engine cylinder fuel injector line broken. Ref 510008077 No5 cylinder fuel injection supply line separated at nipple on manifold end. P/No: LW120980210. TSN: 6 hours. (5 similar occurrences) Lycoming LTIO540J2BD Exhaust turbocharger seized. Ref 510007814 RH engine turbocharger seized. Investigation found rotating impact damage to the compressor impeller tips, and excessive radial play on the turbine. Aircraft crash landed in the water causing extensive damage. Investigation continuing. P/No: 4019709001. (3 similar occurrences) Rolls Royce TRENT97284 Engine bearing failed. Ref 510007900 Metal contamination of No1 engine chip detectors. Found during chip detector inspection. Investigation found a bearing had failed. Engine changed. Limited information provided. Investigation continuing. TSN: 979 hours. Rolls Royce TRENT97284 Fuel flow transmitter faulty. Ref 510008027 No2 engine fuel flow transmitter faulty. Rolls Royce TRENT97284 Engine oil system pump suspect faulty. Ref 510007956 No1 engine oil pressure message. Suspect faulty oil pump. Investigation continuing. Robinson R22Beta Engine mount frame worn. Ref 510008022 Lower RH engine mount frame worn by air inlet duct internal support wire. Investigation found the duct securing clamps distorted allowing the duct to rub on the frame. P/No: A0462. TSN: 720 hours. Robinson R22Beta Tail rotor gearbox unserviceable. Ref 510008127 Tail rotor gearbox excessive backlash through drive train. Output shaft moving, without movement of input shaft. Investigation found keyway, key and cog worn excessively. P/No: A0211. TSO: 988 hours. Rolls Royce RB211524G Engine compressor fan assembly vibrates. Ref 510008026 No3 engine fan section vibrating. Suspect lack of lubrication. Investigation continuing. TURBINE ENGINES Allison 250C20B Engine compressor bearing housing stud broken. Ref 510008082 Front compressor bearing housing stud fractured, allowing the nut and fractured portion to be partially ingested into the compressor. Inlet guide vanes and first stage compressor blades damaged. The broken stud was found in the bottom of the particle separator. Stud appears to have been cracked for some time. P/No: 6893617. TSN: 8,139 hours/8,730 cycles. TSO: 1,154 hours/1,409 cycles/33 months. Garrett TFE73131G Engine failed. Ref 510008126 RH engine failed. Suspect blade failure. Investigation continuing. P/No: TFE73131G. (1 similar occurrence) Turbomeca ARRIEL1S Turbine engine failed. Ref 510007889 No2 engine shut down without notice. An emergency landing was carried out. Initial investigation found the following damage: 1. Gas producer would not rotate 2. Power turbine had mechanical damage to turbine blades 3. Exhaust pipe peppered 4. One main rotor blade had slight impact damage 5. Producer oil vent line (strut) broken internally. Investigation continuing. PROPELLERS Amateur APP005 Propeller and propulsor systems propeller cracked. Ref 510008112 (photo below) Propeller cracked between leading edge strip and base timber on both blades. Following removal of spinner, a crack was found on the forward face of the propeller adjacent to the hub, with another crack found on the rear face, following removal of the propeller. Owner (sole pilot) confirmed that no propeller strikes had occurred, and propeller had not been used for pulling aircraft around. Aircraft is amateur built. P/No: APP00520EXP. GE CFM567B Engine compressor fan module vibrates. Ref 510007750 RH engine vibration. Investigation found the vibration was caused by blade imbalance. Blade remapping carried out with nil further defects. (1 similar occurrence) PWA JT8D17 Engine sensing pipe fractured. Ref 510008120 No3 engine PT7 sensing pipe fractured. P/No: 511863. PWA PT6A67D Engine turbine vane ring damaged. Ref 510007806 Engine turbine vane ring assembly damaged for over 20 per cent of circumference. P/No: 3040972. TSO: 1,050 hours/911 cycles/26 months. (2 similar occurrences) PWA PT6C67C Compressor bleed valve faulty. Ref 510007775 No2 engine bleed valve faulty. Compressor stall heard. P/No: 305644205. TSN: 369 hours/12 months. TSO: 369 hours/12 months. (1 similar occurrence) PWA PW118B Compressor bleed control valve deteriorated. Ref 510008095 RH engine P2.5/P3 switching valve actuating cylinder worn/deteriorated. P/No: 3045593. Hartzell HCM2YR2 Propeller and propulsor systems screw loose. Ref 510008093 Propeller pitch change shaft latch stop screw loose. Screw wound out of the shaft causing coarse pitch adjustment to change. P/No: A3205. TSN: 978 hours. COMPONENTS Cylinder failed. Ref 510007797 During pressure testing of off-wing escape slide, high pressure cylinder adaptor fusible plug (P/No 300367-100) failed, causing an explosive depressurisation. Cylinder was damaged beyond repair, and damage to the testing equipment was also caused. Investigation continuing. P/No: 130104237. Kelly Aerospace Turbocharger faulty. Ref 510007865 Turbocharger faulty. Investigation prior to fitment found oil dirty and steel shot in exhaust turbine housing. P/No: 4066109020. (1 similar occurrence) Note: occurrence figures based on data received over the past five years. If the aircraft model was on the Australian Civil Aircraft Register before 1 October 2009, the registered operator must comply with state-ofdesign ADs issued on or after 1 October 2009. If the aircraft model was not on the Australian Civil Aircraft Register before 1 October 2009, the registered operator must comply with all state-ofdesign ADs issued for the aircraft prior to and after the 1 October 2009. These can be obtained from the CASA website, or the National Airworthiness Authority (NAA) website. The aircraft model and equipment list on the CASA website will contain any existing Australian ADs and state-of-design ADs. If you prefer to obtain state-of-design ADs directly from the NAA, you must establish the applicable NAA. The links to the state-of-design NAA will soon be located on the CASA website. Only emergency ADs will be sent by CASA via email or fax to registered operators; however, CASA will still provide a subscriber email service. An alternative means of compliance (AMOC) against a state-of-design AD approved by the NAA will now be accepted by CASA. If you enter a foreign manufactured aircraft on the Australian aircraft register, it is considered the Australian AD is complied with if the stateof-design AD has the equivalent requirements as the Australian AD. More information Advisory circular AC 39-01(3) (Airworthiness Directives) is available on the CASA website: P. 131 757 W. www.casa.gov.au E. firstname.lastname@example.org APPROVED AIRWORTHINESS DIRECTIVES 9 April 2009 Part 39-105 - Lighter than Air There are no amendments to Part 39-105 - Lighter than Air this issue Part 39-105 - Rotorcraft Agusta A109 Series Helicopters AD/A109/62 - Engine - Power Turbine Speed Operational Limitation Bell Helicopter Textron 205 Series Helicopters AD/BELL 205/6 - Cyclic Control Supports - Inspection - CANCELLED AD/BELL 205/22 - Transmission Oil System - Inspection - CANCELLED AD/BELL 205/35 Amdt 1 - Swashplate Support Assembly - Retirement Life - CANCELLED AD/BELL 205/53 - Main Rotor Pillow Block CANCELLED AD/BELL 205/55 - Pitch Change Link Universal CANCELLED Bell Helicopter Textron Canada (BHTC) 206 and Agusta Bell 206 Series Helicopters AD/BELL 206/175 - Engine - Power Turbine Speed Limitations 37 Bell Helicopter Textron 212 Series Helicopters AD/BELL 212/7 - Internal Rescue Hoist Assembly Modification - CANCELLED AD/BELL 212/16 - Cyclic SCAS Stops Installation Modification - CANCELLED AD/BELL 212/19 Amdt 1 - External Cargo Suspension Kit - Load Restriction and Modification - CANCELLED AD/BELL 212/20 - Emergency Float Bag Deflector Installation P/N 212-030-629-101 L/H and -102 R/H - CANCELLED AD/BELL 212/22 - Tail Rotor Drive Shaft - Replacement - CANCELLED AD/BELL 212/26 Amdt 1 - Hydraulic Servo Cylinder Assembly - Spanner Link Assembly Inspection and Rework - CANCELLED AD/BELL 212/29 - Emergency Flotation Installation Manual Actuation System - Modification and Rerigging - CANCELLED AD/BELL 212/30 - Engine Mount Fireshield - Installation - CANCELLED Attachment - Modification - CANCELLED AD/BELL 212/33 - Main Rotor Grip/Blade Bolt Inspection and Rework - CANCELLED AD/BELL 212/36 Amdt 1 - Emergency Flotation System and Squib Valve - CANCELLED AD/BELL 212/37 Amdt 1 - Main Rotor Pillow Block CANCELLED AD/BELL 212/38 - Engine Fuel Valve Electrical Connectors P/NO MS3456W14S-5S - CANCELLED AD/BELL 212/39 - Engine Fuel Switch - CANCELLED AD/BELL 212/41 - Pitch Change Link Universal CANCELLED AD/BELL 212/42 - Main Rotor Tension Torsion Straps - CANCELLED AD/BELL 212/43 - Bogus Pressure Gauge Emergency Floats P/N 212-073-905- 1 - CANCELLED AD/BELL 212/44 - Swashplate Outer Ring CANCELLED AD/BELL 212/48 - Tension Torsion Straps Retention Pins - CANCELLED Part 39-105 - Rotorcraft Bell Helicopter Textron 412 Series Helicopters AD/BELL 412/14 Amdt 1 - Emergency Flotation System and Squib Valve - CANCELLED AD/BELL 212/31 - Float Bags - Inspection - CANCELLED AD/BELL 212/32 - Elevator to Horn Assembly AIRWORTHINESS From 1st October 2009, changes to CASR Part 39 will mean CASA will no longer issue Australian ADs mirroring state-of-design ADs. All registered operators must ensure their aircraft complies with state-of-design ADs applicable to their aircraft and equipment. For example, if you own a Cessna which is designed in the United States, you must comply with all applicable ADs issued by their Federal Aviation Authority. This also applies to ADs for engines and propellers designed in the USA. PULL-OUT SECTION Mandatory compliance with state-of-design ADs PULL-OUT SECTION 38 Eurocopter AS 332 (Super Puma) Series Helicopters AD/S-PUMA/78 Amdt 2 - Main Rotor Blade De-Icing System Clamps Pilatus PC-12 Series Aeroplanes AD/PC-12/55 - ADAHRS - Incorrect Data AD/PC-12/56 - Stick-Pusher Servo-Cables Attachment Clamps Eurocopter AS 350 (Ecureuil) Series Helicopters AD/ECUREUIL/71 Amdt 4 - Tail Rotor Blade Trailing Edge AD/ECUREUIL/107 Amdt 2 - Stabilisers - Upper and Lower Vertical Fin Spars - CANCELLED AD/ECUREUIL/118 Amdt 1 - Upper and Lower Fins of Stabilisers - CANCELLED AD/ECUREUIL/131 Amdt 1 - Stabiliser Upper and Lower Fin Attachment Fitting - Modification AD/ECUREUIL/135 - Time Limits/Maintenance Checks Piper PA-42 (Cheyenne III) Series Aeroplanes AD/PA-42/1 - Powerplant Firewall - Inspection CANCELLED AD/PA-42/2 - Nacelle Fuel Tank Check Valve Installation - CANCELLED AD/PA-42/3 - Tail Fin/Fuselage, Rivet Installation Replacement - CANCELLED AD/PA-42/4 Amdt 1 - Main Landing Gear Pivot Shaft Assembly Bolts - CANCELLED AD/PA-42/6 - Aileron Trim Tab Control Tube and Rudder Trim Cable Retainer Hardware - Inspection and Replacement - CANCELLED AD/PA-42/7 - Fuel Quantity Placards - Replacement CANCELLED AD/PA-42/8 - Engine Inlet Fuel Filter - Modification CANCELLED AD/PA-42/9 - Landing Gear Upper Bearing Retaining Pins and Strut Assemblies - CANCELLED AD/PA-42/10 - Stall/Flow Strip - CANCELLED AD/PA-42/12 - Engine Electrical Harness and Starter Generator Cables - CANCELLED AD/PA-42/13 Amdt 1 - Main Landing Gear Forward Side Brace - CANCELLED AD/PA-42/14 - Tailcone Drain Holes - CANCELLED AD/PA-42/15 - Engine Mount Tubes and Barrel Nuts CANCELLED AD/PA-42/16 - Control Column Control Chain Retainer Clips - CANCELLED AD/PA-42/17 - Main Landing Gear Actuator Attachment Bolt - CANCELLED AD/PA-42/18 - Elevator Upper Skin Cracking CANCELLED AD/PA-42/19 - Main Landing Gear Upper Strut and Oleo Tube Plug - CANCELLED AD/PA-42/20 - Main Landing Gear Forward Side Brace - CANCELLED AD/PA-42/21 - Main Landing Gear Upper Strut Housing - CANCELLED AD/PA-42/22 - Upper Main Landing Gear Housing Lower Side Brace Link Lug - CANCELLED Eurocopter AS 355 (Twin Ecureuil) Series Helicopters AD/AS 355/60 Amdt 4 - Tail Rotor Blade Trailing Edge AD/AS 355/84 Amdt 2 - Stabilisers - Upper and Lower Vertical Fin Spars - CANCELLED AD/AS 355/91 Amdt 2 - Upper and Lower Fins of Stabilisers - CANCELLED AD/AS 355/98 Amdt 1 - Stabiliser Upper and Lower Fin Attachment Fitting - Modification Eurocopter EC 225 Series Helicopters AD/EC 225/4 Amdt 1 - Main Rotor Hub Dome Fairing Attachment Screws AD/EC 225/6 Amdt 1 - Main Rotor Hub Coning Stop Supports Part 39-105 - Below 5700 kgs FSA MAY–JUNE09 Avions Mudry Cap Series Aeroplanes AD/CAP 10/13 Amdt 1 - Flight Controls Tie Rod Bolts C.A.C. CA-28 (Ceres) Series Aeroplanes AD/CERES/1 Amdt 1 - Aileron Outboard Mass Balance Weight Attachments - Modification - CANCELLED AD/CERES/2 Amdt 1 - Propeller Counterweights Modification - CANCELLED AD/CERES/3 Amdt 1 - Fuel Tank Vent - Modification CANCELLED AD/CERES/4 Amdt 1 - Mixture Control Lever Quadrant Modification - CANCELLED AD/CERES/5 Amdt 1 - Pilots Safety Harness Inertia Reel - Installation - CANCELLED AD/CERES/7 Amdt 1 - Turnover Truss - Modification CANCELLED Cessna 180, 182 and Wren 460 Series Aeroplanes AD/CESSNA 180/95 - Intercooler and Associated Hoses Cessna 400 Series Aeroplanes AD/CESSNA 400/118 - Auxiliary Wing Spars De Havilland DHC-1 (Chipmunk) Series Aeroplanes AD/DHC-1/39 - Flap Operating System Latch Plate Diamond DA40 Series Aeroplanes AD/DA40/6 Amdt 1 - Nose Landing Gear Leg Fairchild (Swearingen) SA226 and SA227 Series Aeroplanes AD/SWSA226/86 Amdt 3 - Wing Spar Centre Web Cutout Mooney M20 Series Aeroplanes AD/M20/10 - Main Landing Gear Retraction Truss Inspection - CANCELLED AD/M20/11 - Main Landing Gear Retraction Truss Modification - CANCELLED Piel Emeraude Series Aeroplanes AD/EMERAUDE/1 - Anti Spin Strakes - Installation CANCELLED Piper PA-44 (Seminole) Series Aeroplanes AD/PA-44/16 - Ailerons - CANCELLED Piper PA-46 (Malibu) Series Aeroplanes AD/PA-46/3 - Fuel Supply Line Replacement and Wing Rib Modification - CANCELLED AD/PA-46/6 Amdt 1 - Flap Drive Mechanism CANCELLED AD/PA-46/7 - Oxygen System Electrical Wiring Rerouting - CANCELLED AD/PA-46/8 - Turbocharger Oil Scavenge Reservoir Inspection/Modification, and Lower Cowl Modification - CANCELLED AD/PA-46/9 - Nose Landing Gear Steering Rotator CANCELLED AD/PA-46/10 - Aft Wing Attach Fitting Fastener Collars - CANCELLED AD/PA-46/11 - De-Ice Pressure Control Valve CANCELLED AD/PA-46/12 Amdt 1 - Alternate Air Control Linkage AD/PA-46/13 - Flap Actuator Tube - CANCELLED AD/PA-46/14 Amdt 2 - Aileron Cable Routing CANCELLED AD/PA-46/17 - Aileron Balance Weight Attachment Screws - CANCELLED AD/PA-46/25 - Fuselage Rivet Installation CANCELLED Part 39-105 - Above 5700 kgs Airbus Industrie A319, A320 and A321 Series Aeroplanes AD/A320/230 - High Pressure Compressor Deterioration AD/A320/231 - Flap Track No.1 Pendulum Assembly Airbus Industrie A330 Series Aeroplanes AD/A330/86 Amdt 3 - MLG Bogie Beam Boeing 737 Series Aeroplanes AD/B737/352 - Air Conditioning Outlet Extrusion Support Brackets Bombardier (Boeing Canada/De Havilland) DHC8 Series Aeroplanes AD/DHC-8/133 Amdt 2 - Main Landing Gear System AD/DHC-8/145 - Wing Fuel Tank Skin between Yw171 and Yw 261 British Aerospace BAe 146 Series Aeroplanes AD/BAe 146/133 Amdt 1 - Airworthiness Limitations AD/BAe 146/136 - Fixed Wing Leading Edge and Front Spar Structure Embraer ERJ-170 Series Aeroplanes AD/ERJ-170/21 - Outboard Slat Skew Sensor Fokker F50 (F27 Mk 50) Series Aeroplanes AD/F50/98 Amdt 1 - MLG Sliding Member End-stop Fokker F100 (F28 Mk 100) Series Aeroplanes AD/F100/94 - Passenger Door Actuator Attachment Part 39-106 - Piston Engines There are no amendments to Part 39-106 - Piston Engines this issue Part 39-106 - Turbine Engines CFM International Turbine Engines - CFM56 Series AD/CFM56/29 - 25 Degree Mid-span Shroud Fan Blades General Electric Turbine Engines - CF6 Series AD/CF6/46 - Inspection of Life Limited Parts CANCELLED AD/CF6/71 - Life Limited Parts General Electric Turbine Engines - CT7 Series AD/CT7/13 - No.3 Bearing Turbomeca Turbine Engines - Arrius Series AD/ARRIUS/16 Amdt 1 - Engine Fuel and Control - P3 Air Pipe Turbomeca Turbine Engines - Makila Series AD/MAKILA/10 - Time Limits - Maintenance Checks CANCELLED AD/MAKILA/11 - Airworthiness Limitation Items Part 39-107 - Equipment Airconditioning Equipment AD/AIRCON/14 Amdt 3 - Zonal Drying System Regeneration Air Duct Overheat Instruments and Automatic Pilots AD/INST/34 - Honeywell SP-300 DFCS Mode Control Panel - CANCELLED Oxygen Systems AD/OXY/1 - Mask Rebreather Bag Security - Inspection and Modification - CANCELLED AD/OXY/2 - Scott Oxygen Mask Filter Retention Modification - CANCELLED Pneumatic Equipment AD/PNEU/2 - Oil and Water Traps - Retirement CANCELLED The issue of future capability revolves around the capability of the aircraft’s radio equipment to receive and transmit on channels with 25 kHz separation. The addition of a new frequency within an area became increasingly difficult due to interference issues. Aircraft owners and operators will need to carefully check the radio installations in their aircraft to see if the equipment is ready to handle the unavoidable changes which will be completed by November 2009. The aeronautical Very High Frequency (VHF) band extends from 118 - 137 MHz and, until 1991, divided into discrete channels at 100 kHz intervals. With the growth of traffic and the need to ensure interference-free communications between aircraft, air traffic control and other aircraft, the available channels were quickly allocated. The addition of a new frequency within an area became increasingly difficult due to interference issues. The channel separation was halved to 50 kHz, effectively doubling the available channels and easing the interference problems. As air travel in Australia continued to grow, the shortage of communications channels came to a head in 2004, with the same problems being experienced. Airservices, in consultation with industry groups, implemented a phased introduction of 25 kHz channel separation commencing in November 2005. This increased the number of discrete channels to 720 which provides for the projected growth in Australia for the next 20-30 years. Airservices began assigning 25 kHz channel spacing frequencies for Class A airspace frequencies in November 2005, beginning in areas of high traffic density as needed. In November 2006, Airservices continued PULL-OUT SECTION 39 AIRWORTHINESS Significant changes are about to be made to the way aircraft radio communications are to be conducted in Australia. This is due to the ever– increasing number of aircraft operating in Australian airspace. Severe operational limitations may result if the aircraft’s radio equipment is incapable of handling the coming changes. the assignment of 25 kHz channel spacing frequencies by expanding in other areas of high traffic density, mainly Class C, D and E airspace. Again this was on an as-needed basis. PULL-OUT SECTION These changes have not involved mandated change to equipment fit for aircraft and in reality aircraft operating in some of these classes of airspace have continued to use 50 kHz radios. 40 The final phase of the changeover is due to be completed in November 2009 and, according to Airservices, 25 kHz will only be introduced in Class G (including CTAF, MBZ) after other frequency planning options are exhausted. The table below gives examples of radio displays with two decimal places showing the differences between 50 kHz and 25 kHz spacing. The 50 kHz display increases by 0.05, whilst the 25 kHz display increases by 0.02 per channel. Displayed Frequency A sample of the coming available frequencies Note: the tighter 25 kHz separation gives more channels. In light of this, it is timely for owners/operators of older aircraft to identify, if this hasn’t already been done, what channel separation their radios operate on so as to confirm their ongoing compatibility with any new frequency allocations. HOW DO I FIND OUT WHAT MY RADIO’S CHANNEL SPACING IS? FSA MAY–JUNE09 You can find out the channel spacing by looking it up in the equipment handbook, by checking the number of decimal places on the display and the selectable channel steps, or asking your approved maintenance organisation. By looking at the frequency displayed on the majority of radio control panels you will be able to identify whether two or three decimal places are used when displaying the selected frequency. Most older radios in Australia will display two decimal places–examples are reproduced below and can have either 50 kHz or 25 kHz spacing. Aircraft equipped with a radio able to receive and transmit with only 50kHz separation. When you turn the display on, you will not be able to dial up (for example) the 118.02 channel. It will jump from 118.00 to 118.05 - note the restrictions. Aircraft equipped with a radio able to receive and transmit with 25 kHz separation. Such a radio can dial up all the coming frequencies. No restrictions. 118.000 118.00 118.00 118.025 Not Displayed 118.02 118.050 118.05 118.05 118.075 Not Displayed 118.07 118.100 118.10 118.10 118.125 Not Displayed 118.12 118.150 118.15 118.15 118.175 Not Displayed 118.17 118.200 118.20 118.20 Example of a panel mounted radio with 3 decimal place display If the radio displays three decimal places it supports 50 kHz, 25 kHz and possibly 8.33 kHz. The photo above shows a panel-mounted combined navigation/communication unit with three decimal places displayed in the left hand (communications) display. Examples of panel mounted radios with two-decimal place displays The final responsibility rests with the aircraft owner/operator. They must ensure that the communication equipment fitted to the aircraft is capable of operating at the frequencies published by Airservices for the area they intend operating in, or transiting through. Aircraft owners/operators will need to monitor the frequency assignments in their areas of operation and/or transit to confirm their ongoing capability. Electrical sis Load Analy analysis aly lysis sis is (EL (ELA) LLA) keep cropping up. Generally, you need eed ee d aan ELA when any changes are planned to an aircraft’s electrical system, The design rules do not make any distinction between VFR or IFR aircraft. As an owner/operator you must ensure that the electrical system in your aircraft is capable of performing its design function. simply to ensure that the aircraft’s electrical systems have the capacity to handle those changes. It provides some assurance that there is sufficient electrical capacity in the event of an emergency. WHEN DO I NEED TO DO AN ELA? You don’t need to do an ELA until you’re contemplating a modification to the electrical system in your aircraft. In most aircraft, the design rules for certification require the electrical system capacity to be verified either by analysis or measurement. [AWB 24-007(2) details a number of those rules.] Under civil aviation regulation – CAR 35, your maintenance organisation must maintain compliance to these design rules when approving any modification to an aircraft registered in Australia. WHO IS RESPONSIBLE FOR PERFORMING THE ELA? The ELA can be performed by an appropriately licensed LAME. The results are accepted by the CAR 35 authorised person when the engineering order authorising the electrical system modification is approved. HOW IS AN ELA PERFORMED? PULL-OUT SECTION A number umber of um of questions qu u about electrical load l I HAVE A VFR AIRCRAFT. DO I NEED TO DO AN ELA? A 41 There are several ways of performing an ELA: By analysis, where each item of equipment connected to the electrical system is listed together with the stated current draw (both peak and steady state) and duration of use. For guidance on this, see airworthiness advisory circular 21-38(0). Direct measurement of the actual current draw in the aircraft’s electrical system with all loads applied. When older equipment is being removed and newer, more efficient items are being installed, the ELA need only be a summary; for example: ‘X’ item was removed having a current draw of five amp and a new item added with a total current draw of three amp, resulting in a net power reduction of two amp. This should be entered in the aircraft log book. l as t s CASA avionics specialists, Charles Lenarcic and Graeme Ward, take a new look at old transponders. As detailed in the November-December 2008 issue of Flight Safety, y Airservices Australia is installing new terminal area radars, replacing radars introduced originally in the early 1990s. So, it is timely to look at the differences between the two radar types and how this affects flying in controlled airspace. The Australian mode-S terminal area radar (AMSTAR) project replaces ageing terminal area radars with solid-state primary surveillance radar and Mode A/C and S capable secondary surveillance radar (SSR) systems at eight locations: Coolangatta, Melbourne, Adelaide, Perth, Sydney, Cairns, Canberra and Brisbane. The new radars can provide substantial system safety improvements operating with both traditional Mode A/C only AIRWORTHINESS WHY IS IT IMPORTANT? W TANT? PULL-OUT SECTION transponders, as well as with newer Mode-S transponders. These benefits do not rely on introducing any new standards for transponders. 42 WHAT ARE THE DIFFERENCES BETWEEN THE OLD RADARS AND THE NEW AMSTAR? The new radars have been built to a common European surveillance system standard, with a number of improvements over previous generations of radar. FSA MAY–JUNE09 A weakness of the traditional secondary radar system is that signals from aircraft close to one another interfere, causing problems such as position errors, two aircraft plots merging into one, corruption of Mode-A identity codes (which can cause incorrect call sign labelling), or corruption of Mode-C data (which can cause aircraft to be shown on controllers’ screens at incorrect altitudes). The new radars can selectively interrogate aircraft equipped with Mode-S transponders, thus eliminating mutual interference for Mode-S equipped aircraft. The new radars offer improved interference-rejection processing for overlapping signals from traditional Mode A/C transponders by exploiting a characteristic from existing transponder standards which older radars could not measure. (This characteristic is detailed in International Civil Aviation Organization [ICAO] standards as well as a number of other international standards). It requires the amplitude of any information data pulse in a transponder reply to be within 1 dB of the rest of the data pulse amplitudes. The new radars measure the amplitudes of each received pulse and, on the basis of differences in amplitude, can often separate out replies from different aircraft, even though the pulse trains are overlapping in time. This improves the ability of the radar to detect two aircraft close to one another correctly, rather than merging the replies from the two aircraft into one ATC report. In other words, it provides better resolution and less corruption of information. However, because the older radars could not measure pulse amplitudes, they accepted replies from transponders which were no longer meeting specifications for consistency of pulse amplitudes (a specification that is not new, but has been in place for at least 35 years). Therefore, while the new radars offer improved performance for overlapping replies from transponders meeting specifications, a by-product of this improvement is rejection of replies from ‘out-of-specification’ transponders. Older transponders utilising electron valve technology are more likely to demonstrate unstable outputs due to ageing of some components. This corrupts the information pulse train – both the ‘rise time’ – the time taken for an information pulse to reach maximum amplitude, and the actual amplitude. Pulse rise times and pulse amplitudes that are non- Some of the older transponder test sets, particularly the ramp check units, are not identifying unserviceable equipment. This has resulted in transponders being checked ‘serviceable’ on the aircraft, only to be found to be out of specification when removed and tested with more modern equipment. compliant to the published standards can cause the radar to reject individual pulses, resulting in detection failures, or incorrect codes being reported. Unstable transponder outputs can also cause multiple variations to the transmitted code in a short time frame. This has significant safety implications in controlled airspace. ATC needs to have positive identification of each aircraft to allow referencing to the submitted flight plan. Airworthiness directive AD/RAD/47 mandates certain functional testing to be performed at specific intervals; however, it does not identify all the tests necessary to confirm that the transponder is serviceable in accordance with the manufacturer’s maintenance manual. Recent incidents have confirmed that transponders, while having been checked in accordance with AD/RAD/47, are transmitting incorrect responses to interrogation by the new radar. As an owner/operator, you should remember that, while older designs utilising electron tube technology meet the original specification, they are more likely to exhibit inconsistencies in amplitude and pulse rise time brought about by a number of factors, the least of which being age. You should consider replacing them. Put simply, nothing lasts forever. Precision Aerial Delivery System AD/PADS/1 - Precision Aerial Delivery System (PADS) Static Line - CANCELLED Propeller Governors AD/GOV/3 - Speed Adjusting Lever Retention Modification - CANCELLED AD/GOV/4 - Flyweight Pin Retainer - Modification CANCELLED AD/GOV/5 - Governor Pump Idler Gear Stud Replacement - CANCELLED AD/GOV/9 - Governor Control Arm Attachment Cap Screw A-1635-105 - Replacement - CANCELLED AD/GOV/10 Amdt 1 - Governor Flyweight Assembly CANCELLED Propellers - Fixed Pitch AD/PFP/6 - McCauley Propellers - Modification CANCELLED AD/PFP/16 - Ken Brock Propeller Hub Extension CANCELLED Propellers - Variable Pitch - De Havilland AD/PDH/1 - Model 3/1000/2 - Hub Modification CANCELLED AD/PDH/2 - Model 3/1000/2 - Propeller Retaining Nut Inspection - CANCELLED AD/PDH/3 - Model 3/1000/2 - Hub Inspection CANCELLED AD/PDH/4 - Model 4/4000/6 Blade - Modification CANCELLED AD/PDH/5 Amdt 3 - Bracket Type Propellers Inspection - CANCELLED AD/PDH/7 - Barrel Support Blocks - Modification CANCELLED AD/PDH/8 - Oil Transfer Tube Locking - Modification CANCELLED Propellers - Variable Pitch - Hamilton Standard AD/PHS/3 - Model 23260 and 43E-60 Low Pitch Stop Assembly - Inspection - CANCELLED AD/PHS/6 - Model 23e-50, Barrel Bolt Boss Modification - CANCELLED AD/PHS/12 - Pacific 6533A Propeller Blade CANCELLED AD/PHS/13 - Hub Rework - CANCELLED AD/PHS/16 - Blade Retaining Rings - CANCELLED Propellers - Variable Pitch - Hartzell AD/PHZL/39 Amdt 1 - Propeller Damper - Replacement - CANCELLED AD/PHZL/50 - A-4025 Spring Retainer - Inspection CANCELLED AD/PHZL/58 - Piston Nut B474 - CANCELLED AD/PHZL/62 Amdt 4 - Propeller Blade Pilot Tube Bore - CANCELLED Propellers - Variable Pitch - McCauley AD/PMC/12 Amdt 3 - Propeller Hub - Replacement CANCELLED AD/PMC/18 Amdt 1 - Propeller Hub - Modification or Replacement - CANCELLED AD/PMC/27 Amdt 1 - Attachment Studs - CANCELLED AD/PMC/29 - Propeller Hub - Replacement CANCELLED AD/PMC/33 - Propeller Hubs - Modification to Oil Filled Standard - CANCELLED AD/PMC/39 - Propeller Blade Replacement CANCELLED Radio Communication and Navigation Equipment AD/RAD/4 - Bendix D.F. Receiver Mechanical Filter Circuit - Modification - CANCELLED AD/RAD/5 - Collins Glide Slope Receivers, Flag Alarm and Deviation Circuits - Modification - CANCELLED AD/RAD/6 - Bendix VHF Nav. Receivers, Flag Alarm and Deviation Circuit Modification - CANCELLED AD/RAD/7 - Marconi Automatic Loops - Capacitor Insulation - Modification - CANCELLED AD/RAD/8 - Channel Tuning Mechanism AWA VHF Nav/Com Receiver AD704 - Modification - CANCELLED AD/RAD/9 Amdt 1 - Rexair Amspeaker - Fuse Installation - CANCELLED AD/RAD/11 Amdt 2 - VHF Transceiver - Modification CANCELLED AD/RAD/13 Amdt 1 - VHF Transceiver Circuit Protection - Modification - CANCELLED AD/RAD/15 - Localiser Flag Circuit - Modification CANCELLED AD/RAD/16 - Localiser and Glide Slope Flag Circuit Modification - CANCELLED AD/RAD/17 - AWA VC-10 VHF Transceiver Modification - CANCELLED AD/RAD/19 - ‘Aircom’ VHF Transceiver - Modification - CANCELLED AD/RAD/20 - King VHF - KTR-900 Transceiver Modification - CANCELLED AD/RAD/21 - Instrument Landing Systems (ILS) Instrumentation - CANCELLED AD/RAD/22 - Press-to-Talk Assembly - Modification CANCELLED AD/RAD/25 - Bayside VHF Transceiver Modification or Retirement - CANCELLED AD/RAD/28 - Garrett Rescue 88A Crash Locator Beacon - CANCELLED AD/RAD/29 - Sunair HF Transceiver - Modification CANCELLED AD/RAD/30 - Sunair HF Transceiver - Modification CANCELLED AD/RAD/31 - Sunair HF Transceiver - Modification CANCELLED AD/RAD/32 - Garrett Emergency Locator Transmitter - CANCELLED AD/RAD/34 - Sunair HF Transceiver - Modification CANCELLED AD/RAD/36 Amdt 1 - Collins ADF Type ADF-650 Operation From 27.5 Volt Supply - CANCELLED AD/RAD/37 - Narco VHF NAV OBS Gear Assembly Modification - CANCELLED AD/RAD/38 - Collins ATC Transponder TDR-950 Modification - CANCELLED AD/RAD/46 - Bendix/King VN 411B VHF Nav Receiver - CANCELLED AD/RAD/53 - Australian Domestic Distance Measuring Equipment - CANCELLED Restraint Equipment AD/RES/3 - Safety Belts - Davis FDC-2700 - Inspection - CANCELLED AD/RES/6 - Safety Belts - Mills ME 2402 and ME 2402T - Inspection and Rectification - CANCELLED AD/RES/11 Amdt 1 - Eon Corporation E8000 Buckle Assemblies - CANCELLED AD/RES/15 - Pacific Scientific Dual Tension Reel Assembly P/Nos 0109101-01, -03, -05, -07 Modification - CANCELLED AD/RES/17 Amdt 1 - American Safety Equipment Lap Belt/Shoulder Harness and/or Crotch Strap Buckle/ Adaptor - Inspection and Modification - CANCELLED AD/RES/18 - Securaiglon (Ex L’Aiglon) Safety Belts Modification - CANCELLED AD/RES/22 Amdt 1 - Pacific Scientific Buckle Agricultural Aircraft - CANCELLED AD/RES/24 - Aeronautique Seat Belts and Harnesses - CANCELLED AD/RES/27 Amdt 2 - HEMCO Seat Belts and Harnesses - CANCELLED AD/RES/30 - Aeronautique Equipment Seat Belts, Harnesses and Cargo Restraint Equipment CANCELLED Supplementary Equipment AD/SUPP/2 Amdt 1 - Breeze Hoists - Deactivation CANCELLED AD/SUPP/5 Amdt 1 - Air Equipment Hoists - ‘Up Limit’ Micro Switches - Inspection and Modification CANCELLED AD/SUPP/6 - Air Equipment Hoists - CANCELLED AD/SUPP/7 Amdt 1 - Conversion of Breeze Hoist P/N BL-16600 to P/N BL-16600-110 or -120 - CANCELLED Wheels and Tyres AD/WHE/3 Amdt 1 - Aircraft Tyres - Retreading CANCELLED The leading edge in aviation insurance. 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For us, it’s the only way we do business. email@example.com | www.aviationinsurance.com.au Archerﬁeld Ofﬁce Ian Tait , Chris Stainer Dylan ylan Jones (07) 3274 4732 S uthern Regional Ofﬁcce Southern Geoff eoff Butler Bu Butle (03) 03) 5778 76 7680 0407 170 70 789 89 43 AIRWORTHINESS Part 39-107 - Equipment (continued) PULL-OUT SECTION APPROVED AIRWORTHINESS DIRECTIVES CONT ... t i p k Coc pl acency c om PRESS N O M I S BY 44 FSA MAY–JUNE09 I had only b been een instructing at a large flight training ng school fo for seveent n een days as a grade grad de 3 instructor, inst in s ructor, when, unintentionally, I came ame as close clo ose as I have ever ver been to o another aircraft airborne. sstill illl continue c nttin co i ue the e flight ig without the weather being a problem, p ob pr oble lem so lli like k mot o hs to a flame, we headed ed for this th area. I started instructing at the new school, had done my area familiarisation ili l aris rides and was quite happy with the procedures required to transit to and from the D523B training area. They consisted of a western and a southern one-way route outbound, and a single south-western approach inbound to the aerodrome. It was this student’s secondever flight to practise straight-and-level techniques and work-cycles. We chose to fly the gate south route from Tamworth, at the standard altitude. This consisted of tracking south abeam a railway at 2500ft, and then at five nautical miles, climbing to 3000ft and continuing to track the standard route until clear of class D airspace. Having turned the aircraft craft onto a suitable heading, I handed over so my student stude could continue his straight-and-level practice. It was a fairly simple monitoring task, so I sat back and watched him check his attitude, look around for traffic, check c his attitude again, and confirm his perf performance, which was to maintain 3000ft. Taking his time to do each sequence led to a slight loss of altitude of about 150ft, which he was very conscious of, and began to remedy. After about four to five minutes during one of his lookout sequences, the student identified an aircraft. ‘Aircraft high 10.30, should I take avoiding action?’ I was not prepared for the second part of this sentence! I leaned forward to see past the student, and saw another aircraft only three or so wingspans away, roughly 75ft. At the same time I ghosted the controls, as I was not going to let a brand-new student try a collision avoidance manoeuvre. He had never seen one. By the time I had done this, the aircraft passed perpendicularly, directly overhead our path at approximately 130ft. There might have I was allowing my student to practise his work-cycle on the level segments, as it takes approximately 10 minutes to reach the airspace boundary. During this time, there ree were altitude variations of around 100ft as you u mi might expect from a new student. Once we reached h the training area, the area I had intended to use initially had overcast cloud at about 5000ft, showers and was only 20nm away. Needless to say, the horizon in this direction was obscured and was no good for training. I spotted an area to our north-west which had SCT-BKN cloud at about 6000ft, and there were some large areas of clear air. ‘Brilliant,’ I thought, I can ‘Aircraf t high 1I0ta.3ke0, should avoiding action?’ been only a single second, at the most, to react. The last thing I needed was for thee student to over-react with an uncommanded pitch up up, or turn to lose ose sight of the other aircraft. Having flown much formation form flight previously, I knew we would not collide provided we did d nothing; so in the calmest voice I could muster I said, ‘Maintain heading,’ to provide the greatest rate of separation. The other aircraft was heading for the inbound point for Tamworth, Duri Gap, at the standard altitude of 3000ft. Both of us were cruising at 110kts. I tuned into the tower frequency, hoping to catch their inbound report, but the radio was silent. They had obviously made it early, so I could not identify them, and it was not until ntil a few hours later we found out the crew of the conflicting traffic had not ot seen se us at all. Our track had us clear of any controlled airspace, but on reflection it was too close to a busy arrival point, and had us crossing many potential paths to this point. After calming ourselves, and ensuring no one else could possibly be tracking again for the same point, we continued our flight. On reflection, it was probably the fact that my student was not so good at maintaining his altitude that saved us that att day. Had he been as good as he is now, back at that stage, I think the he situation si could have been quite different. It is also interesting to notee that th the other aircraft was conducting exactly the same flight, and the other student actually saw us, but did not mention the close call until later! The fact that the outbound routes and tracking to the inbound point from Tamworth’s training area are flown at the same altitude, and although separated by approximately five to six nautical miles, the gate south area is often misidentified as the Duri Gap, contributed to this incident. Fortunately on this day it wasn’t, as our perpendicular path could have turned d into o a he head a -to-head sit ituation. An And d although h the he sstudent was cconducting ondu on duccting a loo lookout ok t for traffic, I should shoul uld d have been more pro-active in looking aro around roun u d the th student, rather r than just settling into nto looking lloo oki k ng g after a my side of the aircraft. It seemed med surreal, surr rreal, as as if we were two ships passing in the hee night night, ht cruising on by as if nothing had happened. But at least we saw the other ship this time, which proved to me as a new instructor that lookout is essential to see-and-avoid. I now also instil into all my new students that they should speak up if they see another aircraft, even if I am talking to them at the time. I would rather be interrupted to o update my situational awareness, than be e un unaware of a potential collision while I am briefi b i ng on climbing and descending. ‘proved to me as a new instructor that lookout is essential to see-and-avoid’ CLOSE CALL 45 E AL A VERY R SIMULATION 46 BY JACK CURTIS FSA MAY–JUNE09 In the days when aircraft were designed and built well before anyone y to this than capable. Responding instantl knew how to spell the word ‘simulator’, flying training could sometimes k pushed critical situation, the pilot under chec be a quite challenging exercise. Nothing has changed today. ng the day. the left-hand feather button, savi would probability whose This event happened recently, and is one is minima l The DC-3 aircraft performance have to be measured as a million-to-one chance. It happened during 04 of 1943). under the old code of CAR (Pt. an airline training and base check exercise. Fortunately, both pilots the severe This was deteriorated further by had considerable experience on this type of aircraft – the DC-3. by the rapid fish-tailing of the aircraft caused full The session commenced with a simulated left-hand engine failure, change in asymmetric configuration, from use beca er rudd t DC-3 righ company’s full the in which was correctly handled as prescribed left rudder to almost the check & training manual. This was followed by a standard single- of the rapid restoration of full power to engine circuit and landing. This exercise is achieved by the check pilot right-hand engine. slowly retarding the throttle lever of the selected engine for ‘failure’ amassed a Although both pilots had and, at the same time calling, ‘Simulated failure only’. rs on this combined tota l of over 10,000 hou nced this erie exp had engine, failed the The pilot under check is then required to nominate type of aircraft, neither of such ct effe cal the await confirmation from the pilot not flying, before commencing situation before. The criti many on d usse simulated engine failure drills. Having successfully completed the an emergency had been disc , this ence above circuit, the aircraft lined up for a second circuit. It does not take an occasion and, as a consequ k an intellectual giant to realise that the next failure would involve the procedure had been devised to train chec n. opposite engine! pilots to handle this very situatio uit, In the same manner, this next failure was simulated by retarding the This procedure constitutes a 1,500ft circ ort. airp the of right-hand throttle shortly after ‘lift off’. Confirmation was established flown within gliding distance down-wind and, the pilot under check called, ‘Gear up’. One engine is feathered early on the the exercise, leg and then, for the purpose of It was at this point, indicated airspeed of 81kts (V2) and when only g) engine it is assumed that the other (operatin 150ft AGL, with almost full left-hand rudder applied, that the operating, feathered has developed a problem. The left-hand engine loudly announced its loss of power by the noise which returned engine must then be restarted and accompanies a departing cylinder head. The check pilot immediately r engine othe the re to operating power befo re-applied power to the simulated, failed right-hand engine. However, gine le-en sing a by is feathered, followed the aircraft was now in an extremely delicate situation, 150ft AGL, of a t efi ben the approach and landing. Without five knots above minimum control speed (air), left-hand propeller res edu proc simu lator, this training exercise in windmilling and sixty-foot tall trees looming just ahead at the far end ng duri le and coordination proved inva luab of the runway. this ‘once-in-a-lifetime’ emergency. The pilot under check was also an experienced DC-3 check & training ay was a The successf ul landing on the runw pilot and continued to fly the aircraft, as I considered him to be more thought ng eeti far better outcome than the fl of a nearby paddock. BY BRIAN WARING It was a 15,000 hour plus, excommuter airline craft which had limped back to Australia after a holiday in New Guinea. A CASA auditor looked over the aircraft one day and pointed out that the alternate air doors for the turbo charger induction looked tired and were in need of attention. So we carried out the suggested maintenance, installing new closing springs, bushes, magnet alignment and new pull cables. From then on, the doors always required a considerable tap or pull on the cockpit cables in order to open them for turbo inspection. The Chieftain made it through the first 1800-hour TBO (time between overhauls) without too many problems, apart from all 12 cylinders being renewed under warranty after 350 hours; a buckled wastegate butterfly; and infrequent reports that the engines didn’t always stay in synchronisation during cruise. I had been taught to check the waste-gate for freedom and operation very early in my career at the Royal Flying Doctor Service while helping to maintain five Piper Navajos. This 310HP engine installation has a different alternate air door system and the aircraft were all brand new, 47 CLOSE CALL This story goes back nearly 12 years, when I first became the licensed engineer (LAME) responsible for our company’s Piper Chieftain. The 1976 aircraft had been refurbished in 1996, with both engines overhauled and an airframe tidy up. It was a 15,000 hour plus, excommuter airline craft which had limped back to Australia after a holiday in New Guinea. The information in the two aircraft log books was sparse; mostly aircraft maintained in accordance with approved data, job number XXX refers. In my early days with this company we had all service and parts manuals on microfilm, so it wasn’t easy to look things up, or to print pages to read. but some of the more experienced engineers had been plagued by turbocharged-twin problems before. I now know that governors and automatic waste gates on twin-engine aircraft can conspire to show symptoms seemingly unrelated to the true cause of the problem. In 2001, when both engines reached their 1800-hour TBO, there was considerable debate about the merit of factory-overhauled engines versus local overhauls: which one was better for reliability and warranty. When this involves a $150,000 decision, there is pressure to make the right choice. The timing for our double-engine overhaul meant the factory choice may have led us down the path of crankshaft recalls. In any case, during engine overhauls, the induction system, as with baffles, is often not given much consideration because of the amount of labour involved. If the alternate air door appears to be satisfactory, it is refitted to the overhauled engine, or repaired as required. 48 FSA MAY–JUNE09 After the double engine overhaul in 2001, on its maiden trip to Northern Queensland, the pilots reported that engine synchronisation was still a problem, and they thought the right engine was the culprit. This led to checking of waste gate, controllers, calibration of gauges and their plumbing; renewal of tacho drive cables; different governor, governor transfer leakage, and the engine control cables, ‘I always heeded the advice of John Schwaner who wrote the Sky Ranch Engineering Manual.’ which were all renewed. The engines would be difficult to trim at the top of climb, or when flying into clouds and the left engine would often peak at a higher turbine inlet temperature than the right engine. Some time later, the left engine started to receive attention. During magneto inspection, we discovered that the magneto contact base plate screw was poorly earthed to the case. Then we found incorrect material, not Teflon as required near the turbocharger, had been used to make the differential control sense line and it had cracked under the fire sleeving. We fitted a new ignition harness, thinking it might have been cross-firing intermittently at cruising altitudes. Then we looked at the ignition primary wiring in the airframe and tried different ignition and start control switches. There was a leak in one induction tube, so we tried a new set of injectors. We had a very helpful engine overhaul shop at the airfield, and were able to try enginedriven fuel pump replacement, flight control unit checking and waste-gate and controller swapping. There were many test flights where it was pronounced cured, and often it would conduct hundreds of hours of flying without complaint. On a charter between Coolangatta and Bathurst, two hours cruise, the left manifold pressure suddenly lost 3” boost after behaving perfectly for 90 minutes. At 8000 feet cruise altitude, the throttle could be opened fully with no increase in power for 30 seconds; then suddenly the manifold pressure rose again. This seemed like a sticking waste-gate. After anti-seize lubricant was applied to the butterfly, there were no problems on the return journey. The engine always made rated takeoff power on ground runs and density controller checks. It was often noted that the left compressor deck temperature was 9°C higher than the right engine. Occasionally, we would hear reports from ground observers that there would be excessive black smoke in the exhaust during takeoff. If you watched the left engine exhaust at dusk there was more The aircraft often gave trouble during the takeoff run with asymmetric boost; different pilots had varying opinions why that might be. We referred to the service manual troubleshooting chart frequently, tried tests flights with alternate air doors taped up; even checked valve lifters, valve springs and camshaft lifts, and never found a conclusive cause. I always heeded the advice of John Schwaner who wrote the Sky Ranch Engineering Manual. He advised making ‘a list of every conceivable cause and use the phone. An excellent way to stop the process mid-stream and have people bail out is to place blame during the troubleshooting process. Wait until a fault is found.’ Alas none of my trials, tribulations and enquiries revealed an answer. in information between manuals, textbooks, service bulletins and engine symptoms sooner. What would have really helped is an aircraft-specific training course pointing out that the alternate air door magnet strength needs to be tested using a calibrated push of eight pounds force as the service manual states in paragraph 8B-13A. I realise now that Lycoming and the Lycoming engine overhaul shops would have often been criticised for problems which could only be discovered if the operator opts for a quick engine change unit, where the induction air system is repaired and tested in accordance with the Piper service manual at overhaul. Even then the criterion is different for higher horsepower installations. The simple tool pictured below is my idea for checking the clamping force of the magnet. It provides a calibrated push force similar to a commercial drive belt tension tester. Thanks to all the colleagues and engineers who have helped, patiently giving advice; the internet, where other forums have given leads or made comments; and John Schwaner for his wonderful book: the Sky Ranch Engineering Manual. We finally discovered the cause by doing something I’d always been taught never to do: running the engine to full boost with the cowls off. I was lucky the left engine turned out to be the faulty one, because you can see the induction door from the pilot’s seat when the cowls are off. As the manifold pressure rose above 33” Hg, the alternate air door would unlatch from its magnet and allow very hot unfiltered air into the compressor. When flying, the governor and the waste-gate adjust to compensate for the much lower density air resulting in a subtle, uncommanded power change. It turns out that Piper already knew of these problems, because in 1974 they published a service bulletin (SB 497A) to modify the magnetic door latch from the top of the door, to the side, incorporating a stronger magnet. Several of the top-mounted magnets had detached in service and been ingested by the turbocharger. All our costly troubleshooting could have been averted if only I had stumbled across the links Ed: Not exactly a close call but one for the LAMEs? 49 CLOSE CALL orange glow exiting the tailpipe than the right engine, indicating a richer mixture, although a fuel flow of 42 gallons per hour seemed normal for full power. SEE GULL NAME WITHHELD BY REQUEST 50 Today, many of us take electronic aids such as GPS, weather radars and terrain awareness systems for granted, but they have not always been available. They weren’t for our flight that day: planned route Kalgoorlie, Esperance and Albany. We filed a flight plan with the flight service unit and before we departed, I asked for the NOTAMs for Esperance and Albany. ‘Look out for seagulls at Albany’, was all I was told. FSA MAY–JUNE09 The weather was perfect on the trip and we spent a most enjoyable day at Esperance. We left early in the afternoon, but about thirty miles out from Albany I had to travel out to sea to avoid a major storm on land. So although we reached Albany an hour before last light, the stormy weather meant it was quite dark when we arrived in the circuit area. I called Perth to announce our arrival, telling them I was in the circuit area and would be landing on the main runway. It was now quite dark due to the storm; this is when things started to go wrong. We reached short final to land and, at the last minute, I noticed that there was heavy machinery all along the main runway. Not only that, but there were steel posts set in to the runway every few metres. I performed a go-around and found that where the main tarmac runway intersected with the dirt strip, there was a gaping hole: three metres by three metres, and two metres deep. The passing storm had cut us off - there was no t was the airpor te in compless. I was ne VFR dark not nightqualified. option to divert to another airport, as it was IMC to our west, north, and east. Circling the Albany airport airport, I radioed Perth to ask if there was anybody who could put out some emergency lights on the only remaining useable dirt strip. They told me to keep circling the airport while somebody came out to provide emergency lighting. Fifteen minutes later, there was good news, a groundsman arrived in a ute, but he said it would take a further 30 minutes to set up the goose-neck emergency lighting. By that stage the airport was in complete darkness. I was not night-VFR qualified. I told the groundsman I did not have 30 more minutes of fuel left, and asked him to position his ute on the end of the useable part of the dirt airstrip, shining the ute headlights down the strip, and I would land over the top of him. I reasoned that it was better to land while I still had engine power, and not run the risk of running out of fuel. The very heavy rain because of the passing storm hadn’t helped the surface on the dirt strip. The surface was dark and it was hard to pull the aircraft to a stop using the brakes. We landed safely; however, with only half the runway to land on, came within a metre of hitting the perimeter fence. The next day we found out they were resurfacing the main runway - hence the bulldozers, graders and other heavy machinery already in position. In fact, in two days time, the whole airport was to be closed. ‘Seagulls at Albany’ the NOTAM had warned. After all that, they were the least of our problems! there was heav y machinery all along the main runway. ;l[h^WZW Mh_j[ je ki WXekj Wd Wl_Wj_ed _dY_Z[djehWYY_Z[djj^WjoekÊl[ X[[d_dlebl[Z_d$?\m[fkXb_i^ oekhijeho"oekÊbbh[Y[_l[ 9BEI; 97BB5 +&& Write about a real-life incident that you’ve been involved in, and send it to us via email: fsa@casa. gov.au. Clearly mark your submission in the subject ﬁeld as ‘CLOSE CALL’ 51 Cozart® provides peace of mind with saliva drug testing. Cozart® has a highly advanced reader which removes user error or bias through accurate analysis and recording of results. Processing five drug classes in only five minutes, Cozart® significantly reduces workforce downtime. All tests are fully supervised, decreasing any chances of tampering and adulteration. Australian police trust the accuracy and robustness of Cozart® and currently use this technnology across five states. Cozart® is also being utilised by CASA as part of their random testing program. For more information, email firstname.lastname@example.org or telephone 1300 368 378. Cozart® saliva drug testing Innovation for generations. ADVERTISING 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. The Australian Executive Director's Message From January to May of this year, I was seconded from the ATSB after Resources and Energy Minister Martin Ferguson appointed me to work on a joint Western Australian/Commonwealth Government inquiry into offshore petroleum industry regulatory arrangements. The inquiry follows the Varanus Island gas pipeline explosion on 3 June 2008. Two further signiﬁcant incidents occurred during Cyclone Billy (December 15-24, 2008) and involved maritime petroleum activities on the Karratha Spirit (which resulted in a fatality) and the Castorro Otto. The ATSB’s counterparts in Canada and the United States, the Transportation Safety Board of Canada and the US National Transportation Safety Board, are responsible for investigating and reporting on pipeline incidents. The systems safety knowledge and investigation techniques used in other transport investigations can be transferred very effectively to other high-risk industries such as the oil and gas pipeline industry. A previous investigation focussed on the technical causes of the Varanus Island incident rather than on broader issues. The current inquiry adopts a systemic approach with a particular emphasis on the regulatory regime and the role and performance of the various regulators. It has been my pleasure to collaborate with Mr David Agostini, a senior Western Australian offshore oil and gas industry executve. We were supported by an outstanding team that included staff drawn from the ATSB, the Department of Resources, Energy and Tourism, and the Western Australian Department of Mines and Petroleum, as well as several independent experts. . Kym Bills, Executive Director PO Box 967, Civic Square ACT 2608 Telephone: 1800 020 616 Email: email@example.com Website: www.atsb.gov.au Runway Excursions n the last decade, approach and landing accidents have shown little sign of improving, despite a continuing downward trend in commercial aircraft ft hull loss rates. Catastrophic landing accidents have occurred recently where aircraft ft overrun the end of the runway or veer off ff the side of the runway; collectively, these are called runway excursions. In 2007, notable runway excursions occurred in Th Thailand, Indonesia and Brazil claiming a total of 309 lives, while in 2008 there were five fi fatalities associated with an Airbus A320 overrun in Honduras, and four fatalities from a Learjet 60 overrun in South Carolina, United States. I The ATSB chose to study runway overrun accidents because of the serious consequences of this type of event. Part one of a two-part paper provides an overview of Australian and international excursion accidents, involving commercial jet aircraft ft over the 10-year period between 1998 and 2007, and safety factors that contribute to these accidents. Part two of this report will be released in May 2009, covering risk controls to prevent runway excursions. Worldwide, 141 runway excursion accidents were identifi fied, resulting in 550 fatalities to passengers, crew and persons on the ground. Most of those accidents (120) occurred during the landing phase. Contributing factors included fl flight crew techniques or decision, flight crew performance, weather, or systems-related factors. A detailed analysis of these factors showed flight fl crew technique and decision-related factors were associated with flying an unstabilised approach, landing too long or fast, incorrect or slow braking, or a decision to land despite unsafe conditions. Flight crew performance-related factors were associated with flight crew awareness of procedures and systems, spatial disorientation, visual illusions, fatigue and task saturation, and assessments of weather and runway condition and their eff ffect on landing length. Weather-related factors included wet or contaminated runways, excessive tailwinds or crosswinds, insuffi fficient reporting of runway conditions, and reduced braking action. Systems-related factors were most commonly associated with aquaplaning. In most runway excursions, any one or a combination of these factors can lead to an unsafe outcome. At the time of writing, Australia has been fortunate to not have a serious runway excursion accident such as those seen overseas. However, it is important to recognise that the risk of a runway excursion accident is ever present and that a range of safety measures should be utilised by aircraft operators and airport owners to ensure the risk is minimised. Q ATSB Research and Analysis Report AR-2008-018(1) Aviation Safety Investigator Fuel Mismanagement Issues D On 18 October 2007, the pilot of a Cessna Aircraft ft Company C404 Titan aircraft ft, registered VH-TMP, was conducting a charter flight from Beverley airstrip to Adelaide. The pilot had commenced descent when the right engine lost power. There were no apparent anomalies and Th the fuel quantity gauges were showing adequate fuel in each tank. After ft securing the right engine, the pilot continued to Adelaide Airport and landed without further incident. Aircraft ft maintenance engineers who inspected the aircraft ft reported that 3 L of fuel was drained from the right tank and 90 L was drained from the left ft tank. The sixth flight fl since the aircraft ft had been refuelled. When climbing through approximately 400 ft ft, the engine surged and lost power. The Th pilot ditched the aircraft ft between Brampton Island and Carlisle Island. 53 All of the occupants evacuated the aircraft ft and were later recovered by a rescue helicopter. fuel quantity gauge was indicating 150 lbs (95 L) in the right tank. An engineer found that one of the electrical circuits in the right fuel quantity indication system had a high resistance. After ft wiring in the circuit was repaired, the fuel quantity gauge correctly indicated zero fuel in the right tank. Calibration of the fuel quantity indication system was carried out and during that process, the left ft and right signal conditioners were found to be unreliable and were replaced or repaired. The operator amended its fuel documentation and fuel planning procedures to include a secondary means of verification fi of fuel on board to crosscheck the electric fuel indication system. On 3 April 2008, a Piper PA-32-300 Cherokee Six aircraft, ft registered VH-ZMP, lost engine power shortly after ft takeoff ff from Brampton Island, Qld under the visual flight fl rules (VFR) for a charter flight fl to Mackay, with a pilot and four passengers on board. This Th was the Technical inspection of the engine after ft the accident did not reveal any defect that could have led to the power loss, but the description was consistent with an interruption to the fuel supply to the engine. The Th aircraft ft operator’s procedures required that reserve fuel be kept in a separate fuel tank from fl ight fuel. Flight fuel was normally carried in the tip tanks, and reserve fuel was carried in the main tanks. There Th was suffi fficient fuel to complete the flight fl in the main tanks. However, reserve fuel would not have been immediately available because of the delays inherent in resuming fuel flow from another tank once the fuel lines had been purged of fuel. While the pilot did not follow the correct procedures for changing fuel tanks in the event of a reported fuel starvation, it was considered that, even if the correct procedures had been followed, power could not have been replaced in time to prevent the ditching. Following the event, the aircraft ft operator amended Cherokee Six fuel procedures to require a minimum of 30 L of fuel in the selected fuel tank for any take-off. ff Q ATSB Investigation Report 200706444 and 200802048 ATSB espite advances that have lead to significant fi improvements in air safety, there are some areas that continue to be of particular concern. One is the issue of fuel mismanagement. Fuel mismanagement can result in either fuel exhaustion (a lack of useable fuel on board the aircraft) ft or fuel starvation (an interruption of the fuel supply, although adequate fuel is on board). Australian accidents involving fuel exhaustion and fuel starvation have twice been the subject of specific fi aviation safety research reports: one in 1987 by BASI and the other in 2003 by the ATSB, indicating that that fuel mismanagement continues to be a significant fi safety issue. In recent weeks, the ATSB has released two investigation reports, detailing accidents that involved different ff problems with fuel. Investigation briefs 54 Controlled ﬂight into terrain Loss of control Breakdown of separation Occurrence 200402797 On 28 July 2004, a Piper PA-31T Cheyenne, VH-TNP, with one pilot and five passengers, on a private instrument fi flight rules flight from Bankstown to Benalla, collided with terrain 34 km south-east of Benalla. All occupants were fatally injured. Instrument meteorological conditions existed at the time and the pilot had reported commencing a Global Positioning System (GPS) Non-Precision Approach (NPA) to Benalla. Occurrence 200606530 On 31 October 2006, a Piper Aircraft Corporation PA-31-350 Chieftain aircraft, registered VH-ZGZ, was being operated on a private category instrument flight rules (IFR) flight from Emerald to Gladstone, Qld. On board were the pilot and two passengers. After departing at 1807 Eastern Standard Time, the flight proceeded normally until the aircraft disappeared from radar while passing about 4,500 ft on descent into Gladstone. It was subsequently determined that the aircraft had crashed 9 km SE of Raglan. The aircraft occupants received fatal injuries. Occurrence 200702893 On 8 May 2007, at about 1858 Eastern Standard Time, a Boeing Aircraft Company 767-338 (767), registered VH-OGI, was inbound to Sydney, NSW from Melbourne, Vic. on descent to 6,000 ft. At the same time, a SAAB Aircraft Company 340B (SAAB), registered VH-OLL, was departing Sydney for Moruya, NSW on climb to FL140. The distance between the aircraft reduced to 1.5 NM horizontal and 400 ft vertical separation. Separation standards as specified in the Manual of Air Traffic Services (MATS) required the provision of either 3 NM horizontal or 1,000 ft vertical separation between the aircraft. There was a breakdown of separation. FSA MAY–JUNE09 The experienced pilot was familiar with the aircraft ft and its navigation and autoflight fl systems. The aircraft ft diverged left ft of track, without the pilot being aware of the error. The air traffi ffic control Route Adherence Monitoring (RAM) system triggered alerts, but controllers believed the aircraft ft was tracking to a diff fferent waypoint and did not question the aircraft ft’s position. The destruction of the aircraft ft navigation and flight control systems did not permit verification fi of their operational status. Th The investigation found that instructions to controllers relating to RAM alerts could be ambiguous. The occurrence highlighted the need to pay careful attention to the use of automated flight and navigation systems and the need for effective ff communication between controllers and pilots to clarify any apparent tracking anomalies. During the coronial inquest, additional information about the possibility of dead reckoning navigation by the GPS receiver was provided. The ATSB investigation was reopened to examine that possibility and an amended report issued. That Th investigation found inconsistencies between dead reckoning principles and the recorded radar data. Nor could it reconcile how a pilot would continue navigation by GPS with the alerts and warnings provided by the GPS receiver and the instrument indications. As a result, the ATSB issued a safety advisory notice alerting users of GPS navigation receivers to ensure they were familiar with dead-reckoning operation and any associated receiver-generated warning messages. Q Conditions in the area of the accident were dark with some rain. Thunderstorms had been forecast but there was no thunderstorm or lightning activity in the area where radar contact was lost. Recorded radar and voice transmission information indicated that the aircraft was performing normally before it suddenly diverged left from a steady descending flight path and entered a spiral dive. The aircraft impacted the ground at high speed in a steep, left spiral descent. The aircraft structure was complete at impact. It was established that at impact, both engines were operating at between 2,200 and 2,400 RPM and both propellers were in the normal operating pitch range. There was evidence that the gyroscopic instruments were functioning. The destruction to the wreckage precluded examination of the electrical and fuel systems, the flight controls, and the autopilot. The pilot’s experience on the aircraft type was limited, as was his night and instrument flight experience. The dark and very likely cloudy conditions in the area where the aircraft suddenly diverged from its flight path meant that recovery to normal flight could only have been achieved by sole reference to the aircraft’s flight instruments. The difficulty associated with such a task when the aircraft was in a steep descent was likely to have been significant. Q The apparent distraction of the controller by his involvement in a non-operational control room discussion would probably have adversely affected his mental ‘air picture’ and traffic planning. That included unintentionally clearing the flight crew of the SAAB to climb through the assigned level of the inbound 767, rather than the routinely-assigned intermediate altitude of 5,000 ft. The traffic manager’s preoccupation with administrative duties meant that the monitoring and control of the distraction risk and operational activities in the control room was ineffective. Action by the controllers to issue traffic information to the flight crew of the 767 and a radar vector and altitude limit to the flight crew of the SAAB quickly re-established the required separation standards. Although no safety issue was identified as a result of this investigation, in its submission in response to the draft report, Airservices Australia advised of its development of an Air Traffic Control (ATC) Reform initiative. The aim of that initiative was to improve the structure and processes used by Airservices to verify ATC operational performance. Q Collision with terrain Collision with terrain Warning placards Occurrence 200805302 On 23 August 2008, at about 1030 Central Standard Time, a Robinson Helicopter Company R22 Beta, registered VH-HPY, with a pilot and passenger on board, arrived at the sports ground at Mataranka, NT. The passenger recalled that, on arrival at Mataranka, the pilot carried out a ‘bumpy’ landing. Occurrence 200801652 On 18 March 2008, at approximately 1115 Eastern Daylight-saving Time, a Pitts S-2A aircraft struck two trees before impacting the ground beside the Northern Road, 7 km north-east of Camden, NSW, fatally injuring the occupant of the rear cockpit. On 17 March 2009, Recreational Aviation Australia (RA-Aus) posted on their website Airworthiness Notice (AN) Identification fi Number – 231208-1 Issue 1, COMPULSORY FITMENT OF BALLISTIC PARACHUTE WARNING PLACARDS (see www.auf.asn.au/ airworthiness/AN231208-1.doc) Th occupant of the rear cockpit (the The candidate), an experienced aerobatic pilot, was undergoing a routine fl flight review with an instructor. In the instructor’s judgment, the candidate fl flew well during the flight review until a Practice Forced Landing (PFL) manoeuvre just before the accident. Th notice was related to the need for The warning placards to be attached to aircraft ft fitted with ballistic parachutes. The ATSB has warned of the danger that Th exists during an accident or incident if rescue personnel are unaware that an aircraft ft has a ballistic parachute fitted. The inadvertent activation of a ballistic Th parachute could result in serious injury or fatalities. Shortly before midday, the pilot and passenger boarded the helicopter to return to the pilot’s property. Witnesses nearby reported that soon after ft takeoff ff, the helicopter turned towards the approximate direction of the pilot’s property. Moments later, the helicopter circled back toward the sports ground at ‘tree-top height’. During the PFL, the candidate stopped responding to instructions and commands, so the instructor took control of the aircraft ft. A powerful nose-up force began acting on the control column. It required all of the instructor’s strength to counteract the force which was causing the control column to move backwards. Despite the instructor’s efforts ff to control the aircraft ft, it entered an incipient aerodynamic stall. The Th instructor recovered the aircraft ft from the stall but, as consequence of the nose-up force, this came too late to prevent a collision with trees. The helicopter struck powerlines at the entrance to the sports ground before impacting the ground. The Th passenger stated that the helicopter appeared to be operating normally until that time. Immediately after ft the accident, the instructor pulled himself free of the wreckage. Medical assistance arrived quickly at the scene and it was determined that the candidate was deceased. Bystanders were able to remove the seriously-injured passenger from the wreckage; however, the pilot received fatal injuries. The Th helicopter was seriously damaged. No evidence of any mechanical problem with the aircraft ft was found. Post mortem examination of the candidate found he had severe heart disease. Examination of the wreckage did not identify any mechanical defects that would have aff ffected the safe operation of the helicopter. The Th flight at ‘tree top height’ left ft little margin for error and toxicological testing of the pilot revealed an alcohol concentration of 0.254%. While the post mortem report indicated that this alcohol level was ‘...suffi fficient to have caused some degree of both mental and motor dysfunction’ the possibility for post-alcohol impairment to have negatively affected ff the pilot’s performance could not be quantified. fi Q Expert medical opinion considered it likely that the candidate suffered ff an incapacitating event as a result of his heart disease. The incapacitating event probably led to him exerting a force on the control column. The design of the aircraft Th ft made it diffi fficult for the instructor to override the control input made by the pilot under review (candidate), delaying the recovery from an incipient stall until it was too late to avoid a collision with trees. Q 55 ATSB The pilot and passenger interacted with people at the sports ground, a number of whom commented that the pilot appeared to them to be aff ffected by alcohol. AN 231208-1 requires all owners of RA-Aus registered aircraft ft fitted with ballistic parachutes to: • If not already fitted, fi place ballistic parachute warning placards in a position where any person approaching the aircraft ft from any direction is aware that a ballistic parachute is fi fitted. • Place the placard in a position near the parachute pack on the exterior of the aircraft ft and near the activation mechanism. Placards Must Not be placed on the disposable hatch or egress point of the Ballistic Rocket, instead in close proximity to the egress point and on the main fuselage/visible canister on the aircraft. ft RA-Aus have a supply of large (95mm x 95mm) and small (55mm x 55mm), placards available free to owners of the affected ff RA-Aus aircraft ft. Contact RA-Aus on 02 6280 4700 or by email firstname.lastname@example.org au Q REPCON briefs Australia’s voluntary conﬁdential aviation reporting scheme 56 FSA MAY–JUNE09 REPCON is established under the Air Navigation (Confi fidential Reporting) Regulations 2007 and allows any person who has an aviation safety concern to report it to the ATSB confidentially. fi Unless permission is provided by the person that personal information is about, the personal information will not be disclosed. Only de-identified fi information will be used for safety action. To avoid doubt, the following matters are not reportable safety concerns and are not guaranteed confidentiality: fi (a) matters showing a serious and imminent threat to a person’s health or life; (b) acts of unlawful interference with an aircraft ft; (c) industrial relations matters; (d) conduct that may constitute a serious crime. Note 1: REPCON is not an alternative to complying with reporting obligations under the Transport Safety Investigation Regulations 2003 (see www.atsb.gov.au). Note 2: Submission of a report known by the reporter to be false or misleading is an offence ff under section 137.1 of the Criminal Code. If you wish to obtain advice or further information, please call REPCON on 1800 020 505. Arrival procedures R200800056 Report narrative: The reporter expressed concerns that a Th Boeing 777 taxied directly to the gate at an international airport when the requirement was to shut down and to be towed to the gate. Due to terminal works in progress, the reporter expressed grave safety concerns for the works personnel, equipment and buildings due to jet blast. REPCON comment: REPCON provided the Civil Aviation Safety Authority (CASA) with the deidentifi fied report. CASA responded that it was aware of the incident and understood that the airport put in place appropriate safety measures and controls immediately aft fter the occurrence. Aerodromes in close proximity with the same frequency R200800075 Report narrative: The reporter expressed safety concerns that Busselton and Bunbury, WA share the same Common Traffi ffic Advisory Frequency (CTAF). The Th reporter believed that this results in radio chatter interference which increases the potential for a near miss or a midair collision, particularly when numerous training aircraft, ft including a number of highperformance turboprop aircraft, ft are operating at Busselton. Reporter comment: Either the Busselton or Bunbury CTAF frequency should be changed. REPCON comment: REPCON provided CASA with the deidentifi fied report. CASA responded that CASA’s General Aviation Operations Group and Offi ffice of Airspace Regulation will examine this matter. The issue has also been raised with Airservices Australia who have a briefing fi session at Bunbury/Busselton planned for May 2009. In the interim, CASA will be encouraging safety education to industry on the importance of abiding by radio procedures. Unsecured baggage on a commercial ﬂight R200800079 Report narrative: The reporter expressed safety concerns about the large amount of unsecured carry-on baggage allowed on board a wide-bodied aircraft ft, and that this may have impeded an emergency evacuation if it was required. It was reported that the large items of carry-on baggage that could not fit in the overhead lockers were stowed between the passenger’s legs and suit packs were carried on passenger laps. Reporter comment: Th This is not an isolated event and has been seen to occur regularly on this aircraft ft type and this sector. REPCON comment: REPCON supplied the operator with the de-identified fi report. The operator advised that it agreed with the general thrust of the report in respect of size and quantity of carry-on baggage on commercial airliners across the industry. The operator indicated that the issue is more pronounced on short-sector fl ights and, in particular, ‘business’ fl flights where passengers want to avoid the baggage belt on arrival. The operator stated that, hypothetically, the safest cabin would be one with no carry-on baggage at all. Anything more than that then becomes a combination of regulatory requirements and commercial considerations. One assertion in the report that the operator did not agree with was the issue with passengers having their suit packs on their laps. The operator reported that the cabin crew are not shy when it comes to writing safety reports on this subject; however, no such report has been submitted to the operator. Importantly, the pre-departure and pre-landing checks specifically fi focus on such issues. Th operator added that it carries a The significant fi number of people each year and an isolated situation can be imagined where an individual may pick something up from its stowed position under a seat and put it on their lap after ft the cabin checks have been conducted and the cabin crew have taken their seats. All precautions are taken to avoid this with cabin announcements and observation of the cabin. REPCON supplied CASA with the deidentified fi report and a version of the operator’s response. CASA advised that the operator’s response to the report was reasonable and practical. In accordance with Civil Aviation Order (CAO) 20.16.2 section 3.1, ‘Cargo stowed on or above the floor line of compartments occupied by persons and behind any person shall be restrained so as to prevent any article from moving under the maximum accelerations to be expected in flight and in an emergency alighting such as a ditching’. CASA also responded that this regulation is quite general in its terms. Therefore, it is standard for operators Th to have documented procedures to ensure compliance with the aircraft ft manufacturers’ design limitations. CASA has undertaken to monitor this issue as part of its ongoing operational surveillance of the operator. Trafﬁc Information Broadcast by Aircraft (TIBA) procedures R200800086 Report narrative: The reporter expressed safety concerns that Traffi ffic Information Broadcast by Aircraft ft (TIBA) procedures were not adequate to maintain aircraft ft separation at Moorabbin, Vic. and that full separation by Air Traffic ffi Control (ATC) would be a safer option. Reporter comment: Air traffi ffic separation services at Moorabbin may have prevented the latest midair collision at Moorabbin. REPCON comment: REPCON provided Airservices Australia with the de-identified fi report. Airservices advised that theyy were actively participating in the recently initiated CASA GAAP (General Aviation Aerodrome Procedures) Utility Review, which comprises all the procedures used at all GAAP aerodromes including Moorabbin. The review is expected to enable CASA’s Offi ffice of Airspace Regulation to determine the most appropriate procedures, and airspace design, to be used for GAAP aerodromes. It is understood that the review includes a safety assessment of the use of TIBA procedures at GAAP aerodromes. Airservices are currently fi finalising an internal review of all the GAAP Operational Risk Assessments to ensure that the CASA Review has captured all safety concerns. REPCON reports received Total 2007 117 Total 2008 121 Jan/Feb 2009 24 What happens to my report? For Your Information issued Total 2007 58 Total 2008 99 Jan/Feb 2009 32 Alert Bulletins issued Total 2007 1 Total 2008 12 Jan/Feb 2009 0 57 Who is reporting to REPCON? # Aircraft maintenance personnel 30% Air Trafﬁc controller 4% Cabin crew 2% Facilities maintenance personnel /ground crew 1% Flight crew 32% Passengers 5% Others* 26% # 29 Jan 2007 to 28 February 2009 * examples include residents, property owners, general public How can I report to REPCON? On line: ATSB website at <www.atsb.gov.au> Telephone: 1800 020 505 by email: email@example.com by facsimile: 02 6274 6461 by mail: Freepost 600, PO Box 600, Civic Square ACT 2608 For further information on REPCON, please visit our website <www.atsb.gov.au> or call REPCON on: 1800 020 505. ATSB Th operator emphasised that it operates The within the regulations and accepts the minimum amount of carry-on baggage that does not put it at a commercial disadvantage in the market place. The Th operator stated that there are several examples across the industry where an airline has restricted an aspect of their carry-on baggage policy, which has immediately resulted in passengers moving to a less restrictive competitor. Pho P Ph ho h oto to cco ourtesy o y of of Da Dav D aavve Cabral C al, l, Dr D rea eeam am amstime.com m ? What if 58 you had to ditch? FSA MAY–JUNE09 Recent events - such as the much-publicised Hudson River landing by Captain Chesley Sullenberger, and the February 2009 Piper Chieftain ditching in the choppy waters of Darwin Harbour - show that it is possible to make a successful deliberate emergency landing on water. However, as an official said of the senior pilot of the Chieftain, ‘Steve Bolle deserved commendation as ditchings are a particularly hard task for any pilot, no matter how expert.’ HOW GOOD’S YOUR KNOWLEDGE? Do you know the best glide speed, and how far your aircraft can glide per 1000 ft of altitude in still air? It’s in the pilot’s operating handbook or flight manual. The main cause of death after ditching is drowning, usually hastened by hypothermia and/or exhaustion. In many cases, those who died did not wear lifejackets, or have them available. It is vital TO WEAR a suitable lifejacket whilst flying in a single-engine aircraft over water beyond gliding range from land. Ditching is a deliberate emergency landing on water. It is NOT an uncontrolled impact . It’s important to select the correct lifejacket. A proper lifejacket provides 16 kg of buoyancy which can be enough to keep an unconscious person afloat with the head above water. It is essential to use a durable lifejacket designed for constant wear (not an airline one). Many automatically inflated lifejackets, used by sailors, are activated when a soluble tablet becomes wet. They are totally unsuitable for GA as they will inflate inside a waterfilled cabin. The lifejacket should include: • a light; a whistle for attracting attention; a crotch strap to stop the lifejacket from riding up over the face; and in cold climates, a spray hood or plastic face mask which can be pulled over the face and lobes of the jacket. It will reduce heat loss through the head as well as the amount of water flowing across the face; and should be a high-vis colour with reflective tape. Store the lifejacket properly in a dry environment and service it regularly. While this is not as great a probleem in Australia as it is, for example in the United Kingdom, where the ccoastal seas are below 10°C between October and April, winter temp peratures offshore in Australia range from an average low of 10°C in n the seas around Hobart to 13°C for Melbourne and 14°C for Adelaidee. Survival times for individuals in cold water will vary greatly dependiing on water temperature, individual build, metabolism, fitness and th he amount of clothing worn. The ideal solution is to get out of o the water by using a life-raft. As with lifejackets, an aviation life-raft (NOT a marine life-raft), with a recognised approval, is the safest option and this must also be regularly serviced and properly stored when not in use. Know how to use all your survival equipment. If, for any reason, a life-raft is not available, the survival time in cold water can be significantly increased by wearing suitable protective clothing, such as a survival suit. If a survival suit is not used, then generally, the more layers of clothes worn, the longer will be the survival time, depending on the type and amount of clothing being worn. If time permits, put on as much clothing as possible, including headwear, since a very large proportion of body heat escapes through the head. Wet wool retains 50 per cent of its insulating properties, whereas wet cotton retains only 10 per cent. An emergency locator transmitter (ELT) must be of an approved type and registered with AMSA. A personal locator beacon (PLB), a portable radio transmitter, will assist to locate you. It should be able to float. Those incorporating GPS automatically transmit position information, reducing the time taken in search and rescue. Pilots should attempt to transmit an initial distress call on a conventional communications radio BEFORE ditching. PREPARATION Before you set out on an overwater flight, you should allow for the possibility of having to ditch, and plan accordingly. Consider attending a survival course, where you will be taught the correct operation of lifejackets, getting into life-rafts, etc, if you fly over water often. On the day of the flight, obtain and correctly interpret the weather forecast. Ensure you have enough fuel onboard for the flight, plus any diversions. In many accidents and some ditchings, the reason for engine stoppage has proved to be fuel exhaustion. A four-person life-raft can weigh as much as 15 kg and is a significant extra load. Consider the total weight and centre of gravity position. Review any recommended procedures in the aircraft flight manual or pilot’s operating handbooks for both power-on and power-off ditching. As pilot-in-command of the aircraft, you MUST consider the survival equipment appropriate to the flight. You must also brief the passengers on the emergency escape features of the aircraft, operation of the seats, seatbelts, and for an overwater flight, should include lifejacket procedure. Before boarding the aircraft, brief the passengers carefully: 59 on the location of the life-raft; on the order in which people should vacate the aircraft in the event of a ditching, and who will be responsible for taking the life-raft with them; that lifejackets must not be inflated until clear of the aircraft and that the instructions normally state – ‘pull the toggle’ to inflate; tighten seat straps/harnesses prior to touchdown on the water. Rear seat passengers should assume a braced position; and indicate reference points on the aircraft’s internal structure that they should reach for when exiting the aircraft as well as any features which might impede exit. SECURE the life raft in an accessible position. If flying alone, place the life-raft on the front passenger seat and secure it with the harness. Check it will not interfere with the controls, lookout or exit. If you have a mobile phone, or hand-held GPS, put them in a sealed plastic bag to keep them dry. A waterproof torch, or better still a portable waterproof strobe could also be useful. DITCHING A prop properly fitted lifeja jacket may prevent people from drowning, but it does provide any prote doesn’t tection against hypothermia - the lowering of the ‘core’ co body temperature. In cold water, the skin and peripheral tissues cool very rapidly, but it can be 10 to 15 minutes before the temperature of the heart and brain begin to t decrease. Intense shivering occurs in a body’s attempt to increase its ts heat production and counteract the large heat loss. Decreasing conssciousness, mental confusion and the loss of the will to live occur when n core body temperature falls from the normal 37°C to about 32°C. Heaart failure is the usual cause of death when core body temperature falls below 30°C. Once airborne over the sea, fly as high as can be safely and legally flown. This will give better radio reception and more time between the onset of a problem and ditching. Before crossing the coast, carry out a particularly careful enroute flight check (FREDA – fuel; radio & navigation; engine & carb heat; direction & compass; and altitude). DITCHING The worst has happened: you can’t maintain height and a ditching appears likely. If you are flying a twin-engine aircraft and one engine stops, everyone should put on a lifejacket. Make a PAN call. Immediately adjust the airspeed for the best glide speed and taking into account the wind direction, either aim towards the nearest coast, or towards shipping. However, avoid landing immediately in front of a vessel; landing alongside and slightly ahead is better. 60 At this stage, transmit a MAYDAY call. Transmit the best and most accurate position fi x that you can. ABOVE ALL, THROUGHOUT, FLY THE AIRCRAFT. FSA MAY–JUNE09 The swell direction is more important than wind direction when planning a ditching. By the time you are down to 2000ft, the swell should be apparent and you should aim to touch down parallel to the line of the swell, if possible, landing along the crest. The table below describes sea states. Wind Speed Appearance of sea Effect on ditching 0-6 knots Glassy calm to small ripples. Height very difficult to judge above surface. Ditch parallel to swell. Small waves; few if any white caps. Ditch parallel to swell. Larger waves with many white caps. Use headwind component, but still ditch along general line of swell. (Beaufort 0-2) 7-10 knots (Beaufort 3) 11-21 knots (Beaufort 4-5) 22-33 knots (Beaufort 6-7) 34 knots & above (Beaufort 8+) with spray blowing like steam across waves and in these cases the waves could be three metres or more in height. Aim for the crest again or, failing that, into the down slope. The force of impact can be high, so ditch as slowly as possible whilst maintaining control. Retractable gear aircraft should be ditched with the gear retracted (beware of automatic lowering systems). Consider unlatching the door(s). Hold the aircraft off the water so as to land tail down at the lowest possible forward speed, but do not stall into the water from a height of several feet. There will often be one or two minor touches, ‘skips’, before the main impact with the water. This main impact will usually result in considerable deceleration with the nose bobbing downwards and water rushing over the cowling and windshield. With a high-wing aircraft, it may be necessary to wait until the cabin has filled with water before it is possible to open the doors. A determined push or kick on the windows may remove them. Consider leaving the master switch and the anti-collision beacon or strobes on. If the aircraft floats for a while or sinks in shallow water, the lights may continue operating and provide a further sign of your position. Exit the aircraft calmly and as swiftly as possible. If it is afloat after the passengers are clear, provided you don’t put yourself in danger, deploy loose items that could float on the surface and help rescuers spot you, e.g. blankets, overnight bags, seat cushions. The Life-raft Medium - large waves, some foam crests, numerous white caps. Ditch into wind on crest or down slope of swell. Large waves, streaks of foam, wave crests forming spindrift. Ditch into wind on crest or down slope of swell. Avoid at all costs ditching into the face of a rising swell. If you can see spray and spume on the surface, then the surface wind is strong. In this case it is probably better to plan to land into wind, rather than along the swell. Winds of 35 to 40 kts are generally associated Before inflating the life-raft, it should be tied to someone holding firmly onto the aircraft, so that it doesn’t blow away. (It will float even before it is inflated.) Climb into the life-raft. If anyone is in the water and injured, or cannot climb aboard, position their back towards the entrance. Two people should then hold the person under the armpits (not by the arms) while any others balance the life-raft by sitting at the far end. Push the person initially down into the water ater, REMEMBER Don’t panic – ditchings are SURVIVABLE. The key elements are a good ditching, then PROTECTION and LOCATION. Always wear a properly maintained constant-wear lifejacket when beyond gliding range from land in a single-engine aircraft. Carry a serviceable aviation life-raft, stowed so that it is accessible. Carry a personal locator beacon (and flares). Know how to use them. PROTECTION is the key to survival The second element of survival is LOCATION, so switch on your PLB. Rig it as high as possible with the aerial vertical. DO NOT leave it lying on the floor. A GPS position will assist rescuers. If close to shore, you could try texting on a mobile phone. No life-raft? In single-engine aircraft, route to minimise the time over water or fly high to increase your glide range. Know the range per 1000ft of altitude. Carefully pre-flight the aircraft and make sure there is enough fuel for all contingencies. Make Mayday calls. For the correct format – see AIP ERSA and set SSR to 7700. If you have to survive in the water with only a lifejacket, do NOT give up hope, the will to survive is the most powerful force to prolong life. Especially in southern waters, the sea is likely to be cold. Conserve essential body heat: Ditch along the crest of the swell, unless there is a very strong wind. The cold will cause you to lose the use of your hands very quickly, so perform any manual tasks straightaway while you can .Tie yourselves together if possible. Inflate lifejackets once clear of the aircraft cabin. Touch down as slowly as possible – but don’t stall. Do NOT swim in an attempt to keep warm. The heat generated due to more blood circulation in the arms, legs and skin will just be transferred to the cold water. Switch on the PLB (and hand-held radio or mobile phone). Don’t forget: 121.5MHzonly ELBs are no longer sensed by satellites so ensure you have changed all equipment to 406 MHz beacons (including any included in life raft survival equipment). Generally, don’t attempt to swim to the shore unless it’s less than one kilometre and you are a strong swimmer. Get everyone into the life-raft as quickly as possible and get the cover up. Conserve heat. The most critical areas of the body for heat loss are the head, sides of the chest and the groin region. If the lifejacket has one, cover your head with the spray hood. If in the water with no life-raft, conserve energy and heat by huddling together to reduce the risk of hypothermia. If there is a group of survivors, tie yourselves together and huddle with the sides of your chests and lower bodies pressed together. If there are children, sandwich them within the middle of the group for extra protection. Have the other signalling devices, e.g. pyrotechnics, heliograph (mirror) etc., ready. Ideally tie the PLB onto the lifejacket, keeping the aerial vertical. A lone survivor should adopt the ‘HELP’ position (this is the heat escaping lessening posture). Hold the inner sides of your arms in contact with the side of the chest. Hold your thighs together and raise e them slightly to protect the groin region. 61 Before take-off, brief passengers on ditching procedures and survival equipment. Let the rescuer take control of the actual rescue. Adapted from Ditching, UK CAA SafetySense leaflet 21c. See also CASA’s Ditching CAAP 253-(1)0, April 2003. DITCHING then give a good pull as the buoyancy from the lifejacket pushes the person back up again. Warn them first! Aviation safety ‘one-stop-info-shop’ - www.skybrary.aero EUROCONTROL’S ACCESSIBLE AND COMPREHENSIVE SAFETY KNOWLEDGE PROPONENTS - TZVETOMIR BLAJEV AND JOHN BARRASS - OUTLINE SKYBRARY’S PROGRESS. How often do we hear people say in the aftermath of an accident: ‘This is a known problem’? If a pilot, controller or safety manager in an airline, or air navigation service provider wants to find information about a specific problem or issue they are encountering, where can they go to find such knowledge, accident and incident reports, best-practice advice, training material and links to other credible sources of information? 62 Most organisations in the flight safety world publish their own journals and documents on their websites, but don’t link very well to other sources. There are also numerous amateur websites devoted to aspects of aviation safety, some of which are an excellent source of best practice, but how can visitors be sure the advice is correct? FSA MAY–JUNE09 How can we ensure that our collective knowledge and experience is shared and accessible to all in the aviation industry? Furthermore, how can we ensure that this knowledge helps to shape behaviour and promote best practice? SKYBRARY – CREATING A ‘ONE-STOPSHOP’ FOR AVIATION SAFETY Eurocontrol’s Safety Improvement Sub-Group (SISG) comprising safety representatives from Europe’s air navigation service providers, acts as a forum for learning about safety, particularly in relation to ATC-significant events and safety monitoring in general. The SISG wanted to create a Wiki-like knowledge base, harnessing the power of Wikipedia while ensuring quality information to serve the needs of aviation safety professionals worldwide. Particularly, they hoped to provide safety managers with solutions to their day-to-day work problems. Eurocontrol’s HindSight magazine, launched at this time, was intended to evolve to become an online knowledge base. Work began in 2005-2006 on developing the concept, design and content population of an aviation safety knowledge base, which became SKYbrary. The Flight Safety Foundation and the International Civil Aviation Organization (ICAO) gave crucial support to SKYbrary – support vital for its credibility and gaining access to existing content. Collecting, organising and keeping such aviation safety knowledge current is an enormous challenge. It quickly became obvious that any knowledge base needed to go beyond the needs of the air traffic control community, also addressing the needs of operators. Therefore the focus of the project is for now, on commercial air transport operators, since addressing the needs of that community has the potential to improve overall aviation safety for the benefit of all. WHAT IS SKYBRARY? The SKYbrary knowledge base is built on a media-Wiki platform and consist of a network of hyperlinked articles, similar to Wikipedia, but with more restrictive control over authorship rights. It is available free of charge to the aviation community via the internet. Substantial bespoke work has been in developing the ‘look-and-feel’ as well as content management logic, to meet the requirement of Eurocontrol and its partners. The ‘article’ is the prime content item in SKYbrary, and it can contain links to related articles, ‘bookshelf’ documents, or external documents and sources. Articles are along the lines of classic encyclopaedia entries – precise, concise and concept-related. Visitors can browse selected categories for information, look at recent safety alerts issued SKYbrary’s aim is not to reproduce the entire domain of aviation safety, but to provide an umbrella for easy search, reference and links to credible resources. wake/vortex turbulence and weather. As well as these operational issues, there are also two further portals: the ‘enhancing safety’ portal, which includes airworthiness, flight technical, safety management, safety nets and theory of flight; and the ‘safety regulations’ portal, which includes certification, licensing and regulation. WHO IS SKYBRARY’S TARGET AUDIENCE? Broadly, anyone interested in aviation safety. However, the production process is explicitly targeted to bring value to three main groups: Safety – safety managers, accident/incident investigators, flight safety officers, safety experts, safety regulators. ACCESSIBILITY Operations – ATC, chief pilots & pilots, operations experts. It is envisaged that the author population will eventually be built up from the SKYbrary user population. Each of the authors can draft articles in a special ‘work in progress’ area of SKYbrary. The editorial team discusses where the drafted articles belong, and in each category, an editor oversees the quality of material submitted, editing where necessary. Both the content of articles as well as the associated references come under scrutiny, as SKYbrary is not only a compendium of aviation safety articles, but a portal to the wider network of aviation safety knowledge. It is important therefore that external links represent credible, quality content. Training – instructors and experts. If registered users do not want to draft articles themselves, they can use the ‘request an article’ facility, suggesting ideas for articles they would like to see written. If the ensuing article meets SKYbrary editorial standards, then it may move into the main SKYbrary space. DEFINING THE SCOPE The SKYbrary partners (ICAO and the Flight Safety Foundation) provide their content to the SKYbrary platform as well, greatly enhancing the breadth and depth of subject matter. Initially, the project concentrated on operational issues of concern to the SISG, issues which were Eurocontrol safety improvement initiatives. This has since been extended to cover 14 principal categories: CFIT, runway incursions, loss of control, level bust, fire, ground operations, human factors, airspace infringement, bird strike, air-ground communications, loss of separation, PRIORITIES While the framework of the SKYbrary knowledgebase is maturing, in places the subject coverage is quite thin. The content development priorities are aviation’s major killers: loss of control, CFIT, runway incursions and excursions, and loss of separation. Within these priorities, the target is 100 per cent subject coverage by June 2009. And while achieving that target is a subjective assessment, the knowledgebase will, and must, continue to grow. By that time, it is hoped that coverage of other categories within SKYbrary will be at least 60 per cent. SKYBRARY NEEDS YOUR HELP In late 2008, SKYbrary had over 1200 articles and 500 documents stored, including nearly 100 official accident/serious incident reports linked to operational safety issues. In August 2008, monthly visitors passed the 10,000 mark, and while the majority were from Europe, worldwide visitation is increasing. To continue this growth, and to build the depth and breadth of knowledge aspired to, SKYbrary needs greater engagement from the aviation community. Log on to SKYbrary’s landing page: www.skybrary.aero, and join the SKYbrary community. Adapted from an article which appeared in Focus, the official publication of the United Kingdom Flight Safety Committee, Spring 2009. 63 SKYBRARY by Eurocontrol, or access a growing bookshelf of reference documents, including accident and serious incident reports. SKYbrary also gives the user a unique opportunity to search in ICAO documents. It also provides a coherent link from knowledge articles to direct behaviourinfluencing applications such as e-learning modules, videos, posters and presentations. There are 14 principal categories: CFIT, runway incursions, loss of control, level bust, fire, ground operations, human factors, airspace infringement, bird strike, air-ground communications, loss of separation, wake/vortex turbulence and weather. Error E rror m management anagement roadshow roadsho with th D Drr T Tony on Kern n ‘You should not be surprised when you succeed at something you are prepared for. Likewise, when you operate near the margins of your performance capabilities, you should not be surprised with less than perfect results.’ Tony Kern, 2004 Today, error management is a widely-used strategy to optimise aviation safety across all sectors of the industry. The contemporary view of system safety acknowledges that if an acceptable level of safety is to be achieved, variability in human performance and people’s unique capacities and limitations have to be managed. 64 FSA MAY–JUNE09 While people generally accept that ‘to err is human’, human performance cannot be left simply to chance. Our propensity as humans to make errors can be minimised through a range of personal safety management strategies. If we develop a deeper understanding of our natural capabilities and limitations, we then have the ability to optimise our individual performance by developing personal error management strategies. Adopting professionalism is one strategy which we can utilise as individuals to maximise our resilience to human error. One of Tony Kern’s central themes is that our individual professionalism, established through commitment to continuous self-improvement enhances our judgement (and situational awareness), in turn making us more resilient to human error. Many will be familiar with his work on airmanship. Kern expresses the guiding principles of airmanship through his Airmanship Model, which contends that airmanship requires physical, mental and emotional competence, acquired through an individual’s professional commitment to continuous self-improvement. The outputs of the Airmanship Model, situational awareness and judgement, are critical elements of successful error management. More recently, Kern has broadened the scope of his work on error management to look at maintenance, giving a series of presentations such as the one at the US Business Aviation conference in March last year, entitled: Waging a Global War on Error in Aviation Maintenance Operations. ‘This presentation on controlling human error was based on the US Marine Corps’ ‘Error Control Model’ (as covered in Aviation Week, 14 December 2006). Coupled with strategies he has collected from around the world, Kern teaches how to identify error and violation-producing conditions, and some of the mental bias traps which lead to maintenance and logistical errors. He also looks at how individuals and organisations can create ‘error reduction centres of gravity’, and develop and implement process checks and procedures to attack these hazardous error zones, which put aircraft and crew at risk, affecting safety and productivity.’ TONY KERN Tony Kern is the CEO of Convergent Knowledge. He recently served as the National Aviation Director of the U.S. Forest Service where he directed the largest non-military government aviation program in the world. He was formerly Director of Military History at the United States Air Force (USAF) Academy, and is an internationally recognised lecturer on human performance, training and safety. Tony is a retired USAF command pilot; was an instructor and flight examiner on the B1-B bomber; and also served as the chair of the USAF Human Factors Steering Group. Tony has written five books on pilot performance, including Redefining Airmanship, Flight Discipline and Darker Shades of Blue: the Rogue Pilot. He is the recipient of numerous awards, including the 2002 Aviation Week and Space Technology ‘Laurel Award’ for safety, and the 2003 Flight Safety Foundation ‘Distinguished Service Award’ for Aviation Program Leadership. He is a regular radio and television guest, and has appeared in segments on the Discovery Channel, NBC Nightly News and 48 Hours with Dan Rather. Tony holds masters degrees in public administration and military history as well as a doctorate in higher education, specialising in human factors training design. Tony Kern will be conducting a series of error management workshops for LAMES and pilots throughout Australia in June. The workshops are practically-focused and are aimed at providing a range of personal strategies for effective error management. Attendance at the workshops is limited, with registration on a first-come first-served basis. Demand for attendance at the workshops has been strong and available places are filling fast, so if you would like to reserve a place a one of Tony Kern’s workshops you should register via email at firstname.lastname@example.org, or by contacting the CASA human factors section on 131 757. Further information regarding the workshops will be posted on the CASA website at www.casa.gov.au/emroadshow. & Human factors TEM training Logically, before you can assess the skills of these candidates, they need to have training. Given the looming deadline, and to give candidates as much time as possible to prepare, this training should be underway, or begun as soon as possible. Chief flying instructors should be familiar with the requirements, and make sure their instructors are equipped to conduct this training. Human factors, and TEM in particular, are a formalisation and extension of what is known as ‘airmanship’. But because this may be a new way of looking at some familiar concepts, CASA has developed a range of guidance material and resources to assist instructors. These are listed below, and we recommend that they be tackled in the following order: Day–VFR Syllabus for aeroplanes and helicopters (containing the standards); Flight test forms; CAAP 5.59-1(0), Teaching and Assessing Single Pilot Human Factors and Threat and Error Management; Safety Behaviours: Human Factors for Pilots training resource; 65 Aeroplane and helicopter flight instructor manuals; and the Approved testing officer manual. You can obtain a copy of the Safety Behaviours: Human Factors for Pilots training resource by emailing email@example.com, or calling 131 757. All the other documents are available from the CASA website: www.casa.gov.au If you are conducting assessment for licences, you should also make sure you have planned how you will conduct these tests well before the due date. The resources above will also assist assessors. Many instructors are already teaching HF and TEM, but just haven’t formalised the processes for the benefit of less experienced staff and trainees. For example, you would already teach your students a process for identifying what could catch them out on any given flight, and taking some time to consider what they can do to avoid an incident. Those organisations who have safety managers, are putting TEM into practice any time they record incidents, monitor trends and provide feedback to their staff to improve their understanding of those issues. Generally, the aviation industry has accepted the concept of teaching HF and TEM well, but there is some understandable apprehension. Perhaps because this is something new - some also see HF and TEM as being rather esoteric and belonging to the realm of psychologists. However, as the CAAP Teaching and Assessing Single Pilot Human Factors and Threat and Error Management demonstrates, if HF and TEM are associated with airmanship and common sense, and measured against the published standards in the Day–VFR Syllabus, the task is not as daunting as it may first appear. A copy of this CAAP is included in the Safety Behaviourss training package. The CASA human factors’ team (above) and the AvSafety Advisors are also active in the field, further supporting the practical integration of the new standards. They can provide further help if you need it. HUMAN FACTORS On 1 July 2009, applicants for private or commercial pilot licences will be required, as part of the licence flight test, to be assessed in human factors (HF) and threat and error management (TEM). AVQUIZ FLYING OPS S (c) acceptable as long as they do not exceed ¼ inch in depth and are not in the outer one third of the blade radius. (d) acceptable as long as they have been filed. 6. When carrying out a series of left-hand circuits in a singleengine aircraft where both the left and right fuel tanks feed simultaneously, the fuel flow (a) from each tank will not be affected by the direction of turn provided that the aircraft remains balanced. 1. (b) from the left tank will be higher than from the right, because of the acceleration towards the centre of the turn. In the two instruments depicted, the DG has been set to the magnetic compass by the pilot. The compass reads approximately (c) from the right tank will be higher than from the left, because the right wing is higher. (d) from the right tank will be lower than from the left, because the right wing is higher. (a) 255(m) and the DG is correctly set to it. (b) 255(m) and the DG is set incorrectly to 285. (c) 285(m) and the DG is set correctly to it. 7. (d) 285(m) and the DG is set incorrectly to 255. 66 At a non-towered aerodrome where there is no discrete CTAF advised in ERSA the frequency to use (in MHz) is (a) the MULTICOM 126.7. 2. When ATS issue an initial level as part of an airways clearance the prefi x (b) the UNICOM 126.7 (c) 119.1. (a) ‘AMENDED CLEARANCE’ will be used. FSA MAY–JUNE09 (d) 123.45 (b) either ‘MAINTAIN’ or ‘AMENDED’ may be used. (c) ‘MAINTAIN’ will be used not ‘AMENDED’. 8. (d) ‘AMENDED’ will be used not ‘MAINTAIN’. 3. (a) always cause an engine over-speed (b) will show large fluctuations as speed increases and, during climb-out, the ASI will over-read. (b) result in a coarse pitch and low RPM condition,which will make it easier for the climb, but slower in the cruise. (c) may give little indication of the problem initially, but during climb-out, the ASI will under-read. (c) always cause an engine under-speed. (d) may give little indication of the problem initially, but during climb-out, the ASI will over-read. Constant speed propellers use (a) a separate oil supply to lubricate the mechanism and to change the pitch. (b grease to lubricate the mechanism, and a separate (b) accumulator to change the pitch. (c) engine pressure oil to lubricate the mechanism, and a separate high-pressur s e hydraulic system to change the pitch. (d) engine pressure oil to lubricate the mechanism and to change the pitch. 5. (a) will show large fluctuations as speed incre eases and, during climb-out, ASI will under-read. Loss of oil pressure to an engine with a constant speed propeller will (d) cause either an over-speed, or a move to coarse pitch depending on the propeller/system design. 4. During takeoff, in the case of a static system blockage, the pressure instruments Nicks in the leading edge of propellers are (a) acceptable as long as theey do not exceed 3mm depth. (b) a serious risk as they are likely to initiate a stress fracture and the loss of part of a blade. 9. In the situation described in question 8, the altimeter (a) reading would remain the same and the VSI would show a slight climb. (b) reading would remain the same and the VSI would read zero. (c) would be erratic and the VSI would show a slight descent. (d) would show large fluctuations and under read, as would the VSI. 10. Some protractors used in flight planning provide for an altern e ative method of measu a ring track, whereby the N (north) arrow is aligned along the track, and thee bearing is read on an inner secondary scale, against a meridian. On this type of protractor the inner scale (a) commences at north and increases in an anti-clockwise direction. (b) commences at south and increases in a clockwise direction. (c) is the reciprocal of the outer scale. (d) is displaced 90° from the outer scale. MAINTENANCE 1. A function of a resistor incorporated in a spark plug is to (a) automatically when the field relay is tripped. (a) reduce plug electrode wea e r due to energy stored in the capacitance in the shielded lead. (b) automatically when the main circuit breaker is tripped. (b) increase the duration of the spark. (d) by a cockpit circuit breaker operating a solenoid. (c) reduce the intensity of the spark without increasing radio interference. (c) by a cockpit switch operating a solenoid. 7. (d) increase the intensity of the spark without increasing radio interference. 2. (a) rotates, and is pow wered by the rectified output of the exciter generator rotating on the same shaft. (b) rotates, and is powered by the output of the permanent magnet generator. If a static port was blocked during maintenance when the QNH was 1020, the effect of the pressure instruments if the QNH then fell to 998, and the aircraft remained in the same location, would be that the (c) is stationary, and is powered by the rectified output of the exciter generator. (d) is stationary, and is powered by the output of the permanent magnet generator. (a) readings on all three instruments t would slightly increase. (b) readings on all three instruments would not alter. (c) ASI would show a slightly incre eased reading and the altimeter and VSI would remain the same. In a brushless aircraft AC generator, the main field 8. A vertical gyro provides information on (a) bank angle and yaw angle. (d) ASI would show a slightly incre eased reading, the VSI would show a slight climb while the pressure was changing, and the altimeter would remain the same. 67 (b) bank angle and pitch attitude. (c) pitch attitude and yaw angle. (d) rate of yaw, roll and pitch. When a helicopter is in the cruise, an advancing main rotor blade has (a) a slightly higher angle of attack than a retreating blade. (b) a slightly lower angle of attack than a retreating blade. (c) the same angle of attack as a retreating blade. 4. (a) install lock wire to ensure that the threads do not disengage due to tensile loads. (b) install lock wire to ensure that the threads do not disengage due to tensile loads. When a chevron type seal is installed in a hydraulic system the (a) open end of the ‘V’ should face the source of pressure. (c) relieve air or hydraulic pressure that may be compressed ahead of the thread during engagement. (b) open end of the ‘V’ should face away from the source of pressure. (d) to ensure that sufficient threads of an associated fi tting are engaged. (d) orientation is not critical, since the pressure difference will always tend to collapse the seal. A spiral back-up ring is installed (a) on the pressure side of the O-ring and the ramped surfaces on the ends should be facing each other. (b) on the pressure side of the O-ring and the ramped surfaces on the ends should be facing away from eacch other. (c on the opposite side of the O-ring to the pressure and the (c) ramped surfaces on the ends should be facing away from each other. (d) on the opposite side of the O-ring to the pressure and thee ramped surfaces on the ends shoul o d be facing each o ther. 6. The purpose of a safety hole in the barrel of a turnbuckle orr other fi tting is to (d) the same angle of attack as the opposite blade. (c) orientation is not critical, since the pressure will always tend to expand the seal. 5 5. 9. Whe a constant speed drive to an electrical gen When e erator is req equir uired to be disconnected in flight this is usually accomplished 10. Differential ailerons are designed so that (a) the angle by which an aileron moves upwards is greater than the angle by which the opposite aileron moves downwards, resulting in an increased tendency to yaw towards the upper wing. (b) the angle by which an aileron moves upwards is less than the angle by which the opposite aileron moves downwards, resulting in an increased tendency to yaw towards the upper win w g. (c) the angle by which an aileron moves upwards is greater than the angle by which the opposite aileron moves downwards, resulting in an increased tendency to yaw towards the lower wing. (d) the angle by which an aileron moves upwards is less than the angle by which the opposite aileron moves downwards, resulting in an increased tendency to yaw towards the lower wing. QUIZ 3. IFR OPERATIONS 3. Appr Ap proa o ch & runway lighting Would you expect this runway to have touchdown zone (TDZ) lighting, and why? (a) You cannot know without checking the aerodrome chart or ERSA for the location concerned. *Refer to the photograph of the lighting system to answer questions 1 to 6. (b) Yes, since you can see the touchdown zone markings painted on the runway for V.M.C operations and day operations. (c) Yes, since this is a category II ILS runway. (d) No, since this is not a precision instrument approach runway. 4. How can you determine what type of runway this is? (a) It is a category I ILS runway, because it has the rows of crossbar lights. (b) It is a category II ILS runway, because in add d ition to the crossbar lights, there are additional rows of lights prior to the threshold. (c) You can only determine this by checking the aerodrome chart or ERSA for the location concerned. 68 55. You are making a night straight-in approach to this runway in reduced visibility due to drizzle. What will the tower controller be expecting to hear from you as the approach continues? FSA MAY–JUNE09 (a) A request for progressive lowering of the set intensity to reduce glare, but you as the pilot do not have to know the stage numbers and values. (b) No communication, since the tower controller has set the intensity stage based on visibility. (c) A request for progressive lowering of the set intensity to reduce glare and you as the pilot must know which stage number to ask for. 6. What is the name of the lighting system to the left of the TDZ and what is it indicating? (a) It is a T-VASIS (visual approach slope indicator system) and is showing ‘on slope’ to the runway. 1. (b) It is an AT-VASIS (abbreviated T-VASIS) and is showiing low on the approach. What spacing would you expect the runway edge lighting to be, and why? (a) 90m since it is not an instrument approach runway (c) It is a P.A.P.I (precision approach path indicator) and is showing high on the approach. (b) 90m since it is an instrument approach runway (d) It is a P.A.P.I and is showing ‘on slope’ to the runway. (c) 30m since it is an instrument approach runway 2. (d) 60m since it is an instrument approach runway. For questions 7 andd 8 , refer to the Melbourne aerodrome chart page 2 to answer. What colour runway edge lighting would you expect at the final portion of the runway, and why? 7. (a) White, the standard colour for all runway edge lights. (b) Red, to ssignify the last 600m of the runway, since this is a category I ILS runway. (c) Yellow for the last 600m, since this is a category II ILS runway. If you were conducting a circling approach to runway 34, with a visibility of 4.5 km at night and the runway lighting on stage 2, you would expect the lighting to be omni-directional: true or false? (a) True (b) False If you were conducting a straight-in approach to runway 27, with a visibility of 1.5 km, what is the special feature of the runway lights and why? (a) The lights remain omni-directional in case a circling approach is required. (b) The lights are now uni-directional to the approach end because the high intensity (1-3) lighting is required with the reduced visibility. 9. What could be the reason for the discrepancy? (a) The T-VASIS is not as sensitive as the ILS. (b) The mist is causing reflection or refraction of the T-VASIS indications. (c) The T-VASIS is at a different location to the ILS glideslope position. (d) The h T-VASIS is only designed for use from 5 nm. (c) The lights are now uni-directional to the approach end because the high intensity (4-6) lighting is required with the reduced visibility, and only ‘straight- in’ would be feasible. Refer to Ballina/Byron Gateway N.S.W (YBNA) aerodrome chart for question 10. (d) The lighting has only one intensity; that is ‘medium intensity runway lights’ (MIRL) as per the aerodrome chart. 10. What is the significance of this ssy mbol near the runway thresholds? You are making a straig i ht-in visual approach at night to a runway, currently on a 6nm fi nal, with the following T-VASIS indication: (a) It is a P.A.P.I system on each runway end and is on both sides of the runway. 69 (b) It is an abbreviated P.A.P.I system on each runway end, left side RWY 24, right-side RWY 06. You receive a report from the tower controller of a shallow mist developing near the runway threshold. You note your ILS sshows ‘on slope’. (c) It is a T-VASIS system on each runway end and is on both sides of the runway. (d) It is an abbreviated T-VASIS system on each runway end, left-side RWY 24, right-side RWY 06. CHANGE ME QUIZ 8. CALENDAR 2009 Date Event Venue Organiser & More info 2-3 Jun Ju AAAA confe conference rence - (watch (watch the website for Marriott Resort & Aerial Agriculture Association Aeria A ssociation Australia Australia further urt information in atio closer clo too the date) at Spa Surfers Sp fer Paradise ar www.aerialag.com.au/ 9-11 11 Jun J Aviation Ground Avia nd S Safety Seminar ina Queenslan Queensland Bournemouth, mou England d 9 Jun Aviation Saf Safety ety Seminar Hoba t Hobart 10 Jun Ju Aviation Safetyy Se Avia Seminar Launceston ston 9 Jun un Aviation Safety Aviat afety Se Seminar Perth th 100 Jun Aviation Saf Safety ety Seminar North m Northam 11 JJun Aviation Avi on Safety ty S Seminar min W Wynyard rd 17 Jun Aviation Safety Semina Seminar Pa kes Parkes 18 Jun n Aviation ation Saf Safety Seminar eminar Port LLincolnn 188 Jun Aviation Av tion Safety ty Seminar min D Dubbo 23 Jun J Aviation Safety Semina Seminar Ma kay Mackay 244 Jun J Aviation Av on Safety ty Seminar min Ay Ayr 8 JJull Aviation Saf Safety ty Seminar Toow omba Toowoomba 8 Jul Ju Aviation Safety Semina Seminar Mi dura Mildura 8 Ju Jul Aviation Avi on Safety ty S Seminar in Ge Geraldton on 14 Jul Ju Aviation Saf Safety ety Seminar Esperance 14 Ju Jul Aviation Safety Avia afety Se Seminar Warracknabeal kna 15 Jul Aviation Safety Aviat afety Se Seminar Cessnock snock 155 Jul Aviation Saf Safety ety Seminar Alice Spring Springs 5 Aug Aviation Avi on Safety ty S Seminar min Na Narrabri ri 5 Aug Aviation Safety Semina Seminar T ora Temora 5 Augg Aviation ation Saf Safety Seminar eminar Kalgo Kalgoorlie 6 Aug Aviation ion Safety Seminar min G Gunnedah 6 Aug Au Aviation Safety Semina Seminar Forbes 111 A Aug Aviation Av on Safety ty Seminar min Yarra Valley Ya all 188 Aug Aviation Saf Safety ety Seminar Cairn Cairns 30 Sep-2 Sep Oct O RAAA C RAA Convention nvention (30th 0t anniver anniversary of Hyatt H tt Regen Regency C Coolum, olum, RAAA & 10th anniversary of the convention) convention Sunshine Coast, QLD Sep ep Greener Gr er Skiess 2009 2 Hong Kong Ho on Ve Venue/dates dat too be b confi nfirmed ed www.orientaviation.com/greenerskies08 OCT 6-8 Oct ct Safeskies eskies Conference Co enc Hyatt Hotell Canberra Canber Bienn conferenceBiennial nferenc details tails closer clos to the time e NOV 2 5 Nov 2-5 62nd annual International Air Safety Semina Seminar Kerryy Centre Hotel, Ker Hot l, (IASS) IAS Beijing, Ch Be China Flig t Safety Foundation Flight http://www.flightsafety.org/seminars.html JUN JUL 70 FSA MAY–JUNE09 AUG SEP BJ LoMastro astr BJ.LoMastro@nsc.org Aero Club lub of Southern Southern Tasmania www.casa.gov.au Tasmanian Ta ian Aero ro Club www.casa.gov.au Royal Aero Club of WA www.casa.gov.au Northam Aero N ro Club C www.casa.gov.au Wynyard Wyny d Aero ero Club www.casa.gov.au Parkes Par es Aero Club www.casa.gov.au Port Lincoln Po c Flyi Flying Club u www.casa.gov.au Dubbo Aero Clu Club www.casa.gov.au Mackay Ma kay Aero Club www.casa.gov.au Burdekinn Aero Bu A Club C www.casa.gov.au Darlingg Downs Aero Club Darlin www.casa.gov.au Mildura Mi ura Aer Aero Club l b www.casa.gov.au Geraldton nA Aero Club www.casa.gov.au Esperance Esper nce Aero Club Club www.casa.gov.au Yarriambiack Ya bia Function Fun nR Room m www.casa.gov.au Venue to be confirmed www.casa.gov.au Alice Springs gs Aero Club C www.casa.gov.au Narrabri N ri Aero ro Club C www.casa.gov.au Temora Aero Club www.casa.gov.au Kalgoorlie Ka li Boulder ould Aero Club lub www.casa.gov.au Gunnedah Aero Club Gunne www.casa.gov.au Forbes es Aero Club www.casa.gov.au Yarra Valley Ya alley Aero r Club b www.casa.gov.au Cairns Aero Club Cairn www.casa.gov.au Regional onal Avi Aviation Associa Association of Austral Australia www.raaa.com.au Key Please note: note: AvSafety Seminar Seminar calendar calendar subject to change, change, please confirm date and venue an en with th your y r local l Aero Club, lub or with CASA AS on: 131 757 57 CASA events Other organisations’ events Have you got the latest copy of the AOPA magazine? Out now! Look out for the May/June issue of Australian Pilot For pilots and aircraft owners. In this months issue: >> Self Administration – Buyer beware >> ADSB – What it really is >> Flying the beloved Connie Ph: 02 9791 9099 Email: firstname.lastname@example.org m.au Web: www.aopa.com.au QUIZ ANSWERS FLYING OPS 1. (b) A very common mistake. 2. (c) GEN 3.4 4.7.2. 3. (d) With the exception of some aerobatic aircraft, most modern singles will go to fi ne pitch; 4. (d) 5. (b) Propeller nicks have resulted in fatal accidents. 6. (a) 7. (a) ENR 1.4 4.2.1. 8. (c) 9. (b) Theoretically there would be no change in the static pressure trapped within the system, although a manometer effect can occur in the case of water in the system. 10. (a) Some protractors of later production have the reciprocal on the inner scale and can not be used in the manner described – a trap for the unwary. 5. (a) AIP AD 1.1 - 28 MAINTENANCE 6. (d) AIP AD 1.1 - 33 1. (a) 2. (c) the pitot would see the falling QNH. 3. (b) 4. (a) 5. (d) 6. (c) 7. (a) 8. (b) 9. (d) 10. (c) paragraph 5.1.2 paragraph 4.12.6 7.(a) AIP AD 1.1 - 23 paragraph 4.4.4 8. (c) AIP AD 1.1 - 28 paragraph 4.4.4. Note: the MIRL is on Where is your aircraft right now? RWY 09. 9. (b) AIP AD 1.1 - 31 paragraph 5.1.1 I.F.R. OPERATIONS note 2. Answer (d) 1. (d) AIP AD 1.1 - 23 paragraph 4.4.1 2. (c) AIP AD 1.1 - 23 paragraph 4.4.3. Note that the approach lighting array signifies this as a cat II ILS runway paragraph 4.12.5 Figure 8 3. (c) AIP AD 1.1 - 24 paragraph 4.7.1 4. (b) AIP AD 1.1 - 28 paragraph 4.12.5 figure 8 is ordinarily correct and can be used to 7 nm with glideslope backup but be wary with the mist. Note: condensation can also affect PAPI Track your aircraft in real-time with spidertracks, the world’s leading portable aircraft tracking system. + No installation required, simply plug it in and start tracking + No software to install, view all of your tracks at www.spidertracks.com + Rentals available from as little as $80 per month plus ongoing costs + Track your aircraft, manage your ﬂeet, protect your people, invest in your business + Book your FREE no obligation demonstration today. Call 1800 461 776 or email email@example.com 10. (d) YBNA aerodrome chart AIP AD 1.1 - 32 paragraph 5.1.1 P 1800 461 776 E firstname.lastname@example.org www.spidertracks.com QUIZ ANSWERS 71 Support AOPA - working for YOU On sale early May LEADING EDGE SAFETY SYSTEMS The LEADER In Aviation Safety Management Services We are a group of aviation safety specialists with previous airline, CASA and general aviation backgrounds. We offer practical and tailored services to th he aviation in ndustrry and can assist you with meeting the followin ng CASA req quirremen nts:: UÊ Ê UÊ Ê UÊ UÊ «iiÌ>Ì v ->viÌÞ >>}iiÌ -ÞÃÌiÃ "Ã nÓ°Î E nÓ°x® Õ> >VÌÀÃ /À>} >` /iV V> -Ã /-® ÃÃiÃÃiÌ "Ã nÓ°Î E nÓ°x® ÀÕ} >` V >>}iiÌ *>Ã *® >Ì}Õi ,Ã >>}iiÌ -ÞÃÌiÃ ,-® For more information on our services and to find out about us, ty.com.au please visit our website http://www.leadingedgesafety.com.au or call Dr Graham Edkins on 0410 522 541 72 9^hXdkZgi]ZCZl7gZV`i]gdj\]^cHV[Z=nedm^VIgV^c^c\VcY:meZg^ZcXZ^i[dgndjghZa[ I]ZigV^c^c\i]Vi]VhdcanWZZcVkV^aVWaZidb^a^iVgnVk^Vidgh^hcdlVkV^aVWaZidX^k^a^Vce^adihVcYV^gXgZl# FSA MAY–JUNE09 8jggZcigZ\jaVi^dchVcYdgYZghdcangZfj^gZi]ZdgZi^XVa`cdlaZY\Zdnedm^V#Cdli]ZgZ^hVegVXi^XVaZYjXVi^dcVa ]nedm^VZmeZg^ZcXZVkV^aVWaZl]^X]WddhihVlVgZcZhhVcYZVgangZXd\c^i^dcd[VYVc\Zgdjh]nedm^XZkZci"V bZbdgVWaZaZVgc^c\ZmeZg^ZcXZi]ViXdjaYhVkZndjga^[ZVcYi]Za^kZhd[i]dhZYZeZcYZcidcndj# Hnbeidbhdnedm^VVgZjhjVaangZegdYjX^WaZVcYXdch^hiZci^cZVX]^cY^k^YjVa# I]Z<D'6ai^ijYZcdgbdWVg^X]nedm^VZYjXVi^dchnhiZbegdk^YZhVhV[ZVcY^ccdkVi^kZhdaji^dc#6cVai^ijYZ h^bjaVidgVaadlhndjidZmeZg^ZcXZndjgdlc^cY^k^YjVagZVXi^dcidi]ZhjWiaZ!nZigVe^YdchZidnedm^V^cV hV[ZVcYXdcigdaaZYZck^gdcbZci# I]Z<D'6ai^ijYZcdgbdWVg^X]nedm^VigV^c^c\hnhiZb^cXdgedgViZhZYjXVi^dcVaeVX`V\Z!Xd\c^i^kZiZhi^c\!i]Z bdc^idg^c\d[e]nh^dad\^XVaeVgVbZiZghVcY[jaanVjidbViZYVcY^chiVcik^YZdVcYeg^ciZYgZedgi\ZcZgVi^dc# IdiV`ZVYkVciV\Zi]ZbdhiZ[ÒX^ZciVcYZc_dnVWaZegVXi^XVaVcY]nedm^VZYjXVi^dcXdjghZVkV^aVWaZdci]Z bVg`ZiidYVnWdd`ndjg^cY^k^YjVadg\gdjehZhh^dcdca^cZVilll#]nedm^V"ZYjXVi^dc#Xdb flightsafety safety … essential aviation reading INSIDE NEXT ISSUE Our feea attu ure e lloo oo okss at SM SMS S fr from om a sma mall lller opeer op erat era a to ator orr’ss p per e ssp er peccti t ve Six xty y yea earrss o ears on n, Mac n, acar arth thur u Job ur b com omme memo memo me mora rate ra tess te an n Ausstral trallia tr ian an ac acci cide ci deentt wit d i h less less le sson son onss fo forr to toda day da y Fliiggh ght ht Sa Safe fety y talks allks ks to a sk kyd ydiv iver iv e witth an er an Au ustrali liian ‘fi firrs rst’ rst’ And An d … a sp spec ecia ec cia i l exte ex xtte end nded e ‘cl clos osee ca os call ll’’ ll now! New hum human man facto factors ors training ning resource ource Safety S affety be behaviours: ehavvio ourss: hu human uma factors actors for p pilots lots is a new resource resourc CASA AS has designed g e speciﬁcally for f r the GA and low-capacity regular public ic transport port sectors sectors. Itt p provides rovides an a introduction i troductio to o human factors, and gives practical pra ical support for the he human factors’ tr training nin and asse assessment sm ment requirements req irement of o both oth the th new ew Day-VFR Day VF FR syllabus and CAO 82.3 amendments. ts The training package includes: a comprehensive resour resource guide id which wh h cove coverss are areass such suc ass fatigue g stress alcohol and other dru drugss c mmunica communication t amwork teamwork leadership adership situational awarenesss decision m making king threat eat and error rror management m nage em airmanship. manship a DVD DVD, incorporating nco ating th the real-life re eal-lif scena o Airtime scenario Air me, as we well a as expe expert commentary entary from rom human factors’ factors spec ali specialists workbook k – with it case a studies e and exercises exerc ses to reinforce th the hu human um n fac factors knowledge ga gained ned from the e rresource source guide and DVD,, for individual or group ro p learni learning g CD – containing CD t i electronic l t copies co es of these ese resources, esource es, as well wel as a copy p of the new w Day-VFR syllabus Day-VF s llabus CAA CAAP. For more information (CFIs and low– capacity RPT chief pilots or safety managers) P: CASA ASA Human Factors Fa tors 131 13 757 E: humanfac email@example.com ors@c sa.gov TEACH ING AND ASSESS HU ING SIN THREAT MAN FAC GLE-PIL ACT TOR OR AND OT EXTRAC ERROR S AND MANAG T FRO ROM EMENT CAAP E 5.59-1(0 ) HUM AN FAC TOR S F OR PIL OTS urs There has never been a better time to be with good people. Safe. Secure. Strong. They are the foundations of a business partnership you can rely on. QBE, good people to be with. Proud to be your NIBA General Insurer of the Year 2002-2008* 4%(,QVXUDQFH$XVWUDOLD/LPLWHG$%1$)6/LFHQFH1R 1,%$*HQHUDO,QVXUHURIWKH\HDUDZDUGHGWR4%(*URXS&RPSDQ\ Contact details for you and your broker: VIC, Asia, NZ/Pacific & Head Office Ph: (03)8602 9900 SA, WA, NT NSW Queensland Ph: (08) 8202 2200 Ph: (02) 9299 2877 Ph: (07) 3031 8588 The Day the Music Died It is over 50 years since rock and roll legend Buddy Holly lost his life in an aircraft accident in February 1959, yet the same mix of factors that caused that accident continues to cause fatalities and aircraft losses today. While the factors below are not necessarily all implicated in the accident which took Buddy Holly’s life, they give focus to some of the underlying causes of light aircraft accidents. Marginal Weather One of the least predictable variables in any flight. Weather can be hazardous in a number of ways including: 1. Reduced visibility and ceiling 2. Winds and turbulence 3. Airframe icing A finding of pilot error is common in weather related aircraft accidents. Such a finding indicates a deficiency of experience or knowledge rather than intent. However a systematic approach can be applied to manage weather conditions. This can be as simple as utilising all available information for flight preparation. High Performance GA Aircraft These demand precision. Understandably, many pilots take years before they move from single engine fixed undercarriage, fixed pitch QBE - Insure with strength propeller aircraft to more costly and sophisticated aircraft types. These more sophisticated aircraft may not always be more difficult to fly but they do demand more precision. For example, flying too fast in the circuit area or on approach is not so quickly rectified. Similarly, the pilot must be ahead of the aircraft. Organisations such as the Cessna Pilots Association and Bonanza Society regularly host pilot proficiency courses. These go well beyond a basic type endorsement or check ride and are to be highly recommended. Non Instrument Rated Low Hour Pilot The need for caution. Obtaining a licence is an accomplishment to be proud of. However, it is only the beginning of a learning curve. Experience is a valuable teacher, but as you build your hours, always ensure that your judgement in relation to VFR versus IFR errs on the conservative side. If in doubt about conditions, a 180 degree turn could be the prudent approach and save lives. Pressure From Passengers to Undertake the Flight Stay strong, safety first. Passenger pressure is an insidious factor which may play a greater role in the accident rate than is generally acknowledged. A disciplined pilot puts safety first and calmly defuses any passenger pressure. By explaining why a passenger request cannot be met without sacrificing safe flying conditions helps passengers understand operational risks. It seems to me that causes of light aircraft accidents and fatalities have not changed much in the last 50 years. Why haven’t we, as an aviation community, learned more over the past 50 years and more proactively translated that knowledge into safer flying practices? Certainly licensing, training and maintenance standards are in place. However, stronger ongoing education and training programs for light aircraft pilots play an important role in improving safe flying practices and lifting risk management awareness. The outcomes should be fewer accidents and fewer fatalities. Take every opportunity available to take part in a safety course. They are generally enjoyable and most importantly instill a culture of safety and airmanship. Garry Cook National Technical Consultant - Aviation QBE Australia firstname.lastname@example.org Safe. Secure. Strong.
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