UAS – the story continues Flight safety starts

UAS – the story continues Flight safety starts
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: humanfactors@casa.gov.au 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: fsa@casa.gov.au
CORRESPONDENCE
Flight Safety Australia
GPO Box 2005 Canberra ACT 2601
P: 131 757 F: 02 6217 1950
E: fsa@casa.gov.au
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 fsa@casa.gov.au
‘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.
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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:
fox@flightsafety.org . 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
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h
g
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n
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F
er th
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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
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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
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of the d
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ially in t
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e
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e
,
.
space
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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 chris.s.thomson@airservicesaustralia.com
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.
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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. airworthiness.directives@casa.gov.au
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
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ylan Jones
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S uthern Regional Officce
Southern
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eoff Butler
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Butle
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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
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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: atsbinfo@atsb.gov.au
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
tech@raa.asn 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: repcon@atsb.gov.au
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 humanfactors@casa.gov.au, 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 humanfactors@casa.gov.au, 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
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ety Seminar
Alice Spring
Springs
5 Aug
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on Safety
ty S
Seminar
min
Na
Narrabri
ri
5 Aug
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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: mail@aopa.com
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
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QUIZ ANSWERS
71
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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
info@qbeaviation.com
Safe. Secure. Strong.
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