Flight Safety Australia - Jan-Feb 2012

Flight Safety Australia - Jan-Feb 2012
‘Organised common sense’
Safety management systems
Jan-Feb 2012
Issue 84
‘That empty feeling’
Focus on fuel management
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Phone: 07 3204 0965
Fax: 07 3204 1902
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The first student to complete Bob Tait’s CPL Performance online study course
got 100% in the CASA exam!
ISSUE NO. 84, Jan-Feb 2012
John F McCormick
Gail Sambidge-Mitchell
Margo Marchbank
Robert Wilson
Joanna Pagan
Fiona Scheidel
P: 131 757 or E: fsa@casa.gov.au
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'Organised common sense'
Safety management systems take aviation to the next level
of safe operations.
20 'Some material truths' Composite materials and new generation aircraft.
26 'That empty feeling'
Running out of fuel can be more than just embarrassing.
30 'Oil and water'
Important lessons to be learnt from an avoidable tragedy.
39 'Hanging by a strand' Control cables, you are the weakest link. It’s time to go.
44 'AOC survey results'
Important information for AOC holders.
58 'When safety stalls'
Macarthur Job dissects the 2009 downfall of a Turkish Airlines
Boeing 737-800.
62 'Safety as well as service'
SMS? It’s what your cabin crew are trained in.
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 2012, Civil Aviation Safety
Authority Australia.
2 Air mail
4 Flight bytes–aviation safety news
16 ATC Notes–news from
Airservices Australia
18 Accident reports–International
19 Accident reports–Australian
31 Airworthiness pull-out section
Copyright for the ATSB and ATC supplements
rests with the Australian Transport Safety Bureau
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 design: Fiona Scheidel
46 Close calls
Average Net Distribution
1 April 2011–30 September 2011
This magazine is printed
on paper from sustainably
managed forests and
controlled sources
Recognised in Australia
through the Australian
Forestry Standard
46 Put to the test
49 Blurred strike
50 Look both ways
52 ATSB supplement
66 Av Quiz
71 Quiz answers
Graham Thomas writes
'Successful, or just
Whilst the thrust of the article on lucky?' asks Leigh Ryan
QF2 at Bangkok on January 7, 2008
was about the effects of an airline
modification that was instrumental in
facilitating a major electrical problem
in a Boeing 747-400, I wish to point out
that another very important point you
mentioned could have been explored
further - conserving battery power.
The concept of minimal crewing must
be coupled with adequate safety
coverage, which does not seem to
be the case here. There appeared to
have been no attempt to release the
deployed forward slide raft from the
aircraft: was there a positive decision
to leave it attached? A lucky ditching?
A well-publicised ditching? The most
successful ditching?
The Nov–Dec Flight Safety Australia
inspired this email, when I read on
page 64 that US1549 was ‘The most
successful ditching in aviation history’.
That's a big claim—I recognise that the
quotation marks indicate that it came
from somewhere else? But I suggest
that there was a lot of luck involved
My nomination for the most successful
As you pointed out in the article, this and a number of lessons to be learnt
ditching is the Pan Am Boeing
aircraft landed in daylight with only 16
Stratocruiser mid-ocean ditching
minutes of battery power remaining, One aspect that was troubling was
between Honolulu and the mainland
even though it had one generator that the Airbus A320 has two entry
in 1956, filmed by the crew of a US
operating. I believe that all pilots doors forward, two service doors
Coast Guard weather observation
should consider how they would bring aft, and four overwing emergency
ship, with full details of wind and sea
a long-distance flight to a successful exits—yet the aircraft was crewed by
conditions recorded. I've read claims
conclusion at night with an instrument only three flight attendants. Only one
that most of the passengers didn't
approach to the destination, in the flight attendant was located at the aft
even get wet.
unlikely event that they were reduced exits. Correct me if I'm wrong, but an
to emergency battery bus power.
A320 ditched has the rear door sills This ditching was also a lucky ditching
and learnings from it were fed back
This obviously entails pulling circuit underwater - therefore the aft flight
into the designs of the Boeing 727
breakers on the bus, using torches,
and 737. The Boeing 737-300 ditching
no public address announcements, door but to defend it from passengers
manual discusses the design basis for
switching off the radio, making an
ditching and includes mention of the
ops call periodically, and so on. This
Pan Am Stratocruiser.
is an exercise for all and maybe it will
promote some informed discussion, as
well as exploration of the emergency
electrical system.
Photo: William Simpson US Coast Gaurd
Communicate to survive,
says professional
communicator, John Clark
Bearing in mind the poor audio
quality of VHF radio compared with
mobile phones, for example, you'd
think that pilots would take more
I read the article ‘Now see hear’ with care when talking on VHF to make
interest, especially having recently sure their communication was clearly
done the trip to Marree and Lake understood.
Eyre, but I think there was one major
point missing in your discussion about The closest thing in real life to
commercial pilots’ VHF speech is the
radio procedures.
tag at the end of a political commercial
The point of making a radio call on TV, ‘This announcement was
is to communicate with other authorised by etc.’, digitally sped up
airspace users and there is a to save time since it's merely a legal
mere requirement and nobody needs to
transmission and communication! understand the content. Reporting
If nobody understands what you are your position and intentions on VHF is
communicating, what's the point in rather more important than this but in
many cases is infinitely more difficult
I don't fly for a living, but I do work to understand.
in communication. For some reason, I heard many transmissions on that
the current style or fashion of trip where the start was clipped
communication used by many pilots, by the pilot pressing the button as
frequently the professional ones, they started talking and the end
seems designed to be as difficult to garbled, clipped or thrown away,
understand as possible.
so that the most important part of
the transmission, the location of the
caller, was either missing or unclear.
Oddly enough, when two pilots were
chatting with each other, they reverted
to normal human speech patterns!
If a professional pilot disagrees with
this, I suggest that they consider how
they would talk on a 000 emergency
call. Would they speak as fast as
possible to minimise air time, or would
they speak clearly and at a normal
conversational pace to make sure that
their life or death communication was
clearly understood?
Because a VHF communication might
be just that … life or death.
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A draft report will be available on
the CASA website in early January.
Is Yours safe
Stakeholders will be notified when the
to carrY?
With Western Australia’s current report is available, and where to find
mining and resource boom, aviation it on the web.
If in doubt, asK!
traffic throughout the region has
increased, particularly in the north Stakeholders are encouraged to
dangerous goods.
west of the state. The exploration of oil provide feedback on the report to
and gas fields off the coast of Western oar@casa.gov.au. CASA will consider
Australia has also resulted in an feedback to be public information and
Newspapers reported two other
increase in helicopter traffic between will attribute feedback received.
phones catching fire in November
the mainland and offshore sites.
2011. An iPhone 3GS caught fire in
On the 28 April 2011, CASA's Director In your hot little hand
Australia, the Sydney Morning Herald
of Aviation Safety wrote to the It seems there’s a new way for mobile reported, and a charging iPhone 4
Department of Infrastructure and phones to be an aviation safety self-combusted in Brazil, Reuters said.
Transport proposing the formation hazard.
Neither of these phones was on an
of a Western Australian Air Traffic
aircraft at the time.
Task Force to review the impacts of The Australian Transport Safety
increased air activity in northwestern Bureau (ATSB) is investigating a The ATSB says it has no record of
‘smoke event’ that occurred on a Rex spontaneous self-ignition by smart
West Australia.
Airlines Saab 340B on 25 November phones or other portable electronic
comprises 2011. The incident took place at devices on an aircraft in Australia.
representatives from the Department, Sydney Airport after the aircraft The transport investigator said it was
Airservices Australia, CASA and the had landed. A passenger's Apple ‘keen to fully understand the nature
Department of Defence.
iPhone, reported by newspapers as of this event, given the increasing and
an iPhone 4, began to emit heat and widespread carriage and use of such
The initial report provides an overview
smoke. A flight attendant used a fire technology on passenger transport
of the increasing air traffic issues in
extinguisher to cool the phone and vehicles.’
Western Australia, focusing first on
everyone on board left safely.
that part of the state north of, and
including, Geraldton.
Informing and entertaining pilots for over 20 years.
$48 (1 YEAR)
Use coupon code: FSAFY
36232_2_HN Flight Safety HPH (Nov 11).indd 1
21/11/11 4:44 PM
detailed guidance on manufacturing,
initial airworthiness, licensing and
training operations, maintenance,
continuing airworthiness and safety
management. Once the advisory
material has been developed, the
Go to www.casa.gov.au/dg for more relevant regulations (Part 101 of the
information on the various categories CASR) will be reviewed.
of lithium batteries, and which
The project will also consider the
categories you can carry on board.
options for, and implications of, the
long-term integration of RPA and
RPAs guided by CASA
other aviation operations in all classes
CASA is in the process of developing of airspace.
six advisory circulars to guide both
Given the recent rapid growth in RPA
regulators and the aviation industry in
activity, the need for comprehensive
the safe operation of remotely piloted
aircraft (RPAs) - previously known as
cumbersome licensing application
unmanned aerial vehicles (UAVs), or
systems is all the more pressing.
unmanned aerial systems (UAS).
Lithium batteries, such as those in
iPhones, are classified as dangerous
goods, but small lithium batterypowered devices can be carried in
aircraft cabins.
The rules covering these systems
were first drafted almost 10 years
ago and did not detail aspects of RPA
safety such as pilot qualifications,
airworthiness and risk management.
Easy access to drug
testing information
If you send an email to drugtesting@
nata.com.au you will receive an
automated response advising you
how to search for accredited testing
laboratories, and providing a list of
companies that are able to perform
onsite workplace collection and
If you have enquiries about other
aspects of workplace drug testing,
simply email the same address
drugtesting@nata.com.au and the
manager of NATA’s life science sector
will respond promptly.
The National Association of Testing
Authorities (NATA) have made it easy
for those wanting to find organisations
The new advisory circulars will cover accredited
RPA systems in general, as well as workplace collection and screening
for drugs.
Although many companies are
accredited to perform secondary
testing in a laboratory, only a handful
so far are accredited to perform
testing and screening in workplaces,
although this number is growing.
Young guns take on
ageing aircraft
In October, two engineers from the
CASA graduate program participated
in a Bankstown ageing aircraft
awareness seminar for pilots, owners
and maintainers. Luke Webb and Tom
Wiltshire, from CASA’s Airworthiness
and Engineering Branch, also had
the opportunity to learn about
practices, preview a full glass-cockpit
version of the Bonanza II, and network
with owners, maintainers and
manufacturers’ field-support staff.
‘Coming straight from university and
working in a regulator has been a real
eye-opener,’ said Webb. ‘Seeing first
hand one of the many ways in which
CASA engages with industry was a
very valuable experience. Learning
to communicate – both listening and
speaking – is a vital skill required as
a regulator’.
Seeing CASA processes at work was
of particular interest to Tom Wiltshire.
‘It was good to see open discussions
about the issues that matter to owners
and operators,’ he said. He was
particularly keen about ‘encouraging
industry to contribute to air safety
The CASA seminar is part of a series through its continued involvement
in part of Stage 1+ of the ageing with the service difficulty reporting
aircraft management plan. The (SDR) process – an important link
seminar encourages aircraft owners, between industry and CASA’
operators, pilots and maintainers to
‘take a closer look’ at ageing issues, Webb and Wiltshire joined CASA’s
and covers basic concepts, including Airworthiness
the logic behind the ‘bathtub curve’, Branch in mid-2011, having graduated
the impact of structural fatigue, the from RMIT University with aerospace
process of wire degradation and the engineering degrees.
science of ageing.
They are among six new graduates
As newcomers to the organisation, taken on by CASA as part of the
the event was an excellent learning organisation’s inaugural graduate
opportunity for the two graduates. development program.
Tom Wiltshire and Luke Webb
EU modifies aviation
ban list
The European Union banned Rollins
Air of Honduras and part of Jordan
Aviation’s fleet from flying in the
27-nation bloc, while further easing
curbs on TAAG Angola Airlines under
the latest changes to a list of unsafe
carriers updated late in 2011.
The EU said ‘significant safety issues’
first raised by France justified the
fleet-wide prohibition on Rollins Air
and ‘numerous and repeated safety
deficiencies’ by Jordan Aviation
warranted a ban on three of its Boeing
767 aircraft. TAAG is allowed to add
two Boeing 777-300 planes to the
carrier’s aircraft permitted in the EU.
The AWPA membership
announces that applications are now open
for the 2012 Scholarships & Awards
Supported by Airservices Australia,
CASA, RAAF, Air BP, Bankstown Helicopters,
ATSB, Aero Refuellers, Champagne PC Services
and private individuals.
Over $65,000 available for 33
possible scholarships and awards.
Scholarships for flight training (licences,
endorsements, ratings), flight reviews, renewals,
theory study, human factors training, cost of
exams, maps, publications etc. Awards for high
achievements and outstanding contributions.
Applications NOW open!
Check the website for conditions and application forms
‘Safety comes first,’ the commission,
the EU’s regulatory arm, said in a
statement in Brussels. ‘We cannot
afford any compromise in this area.’
This is the 18th update of a blacklist
first drawn up by the commission
in March 2006, naming more than
90 airlines, mainly from Africa. The
ban already covers passenger and
cargo carriers from nations including
the Democratic Republic of Congo,
Equatorial Guinea, Gabon, Liberia,
Sudan and the Philippines.
Airline crashes in 2004 and 2005 that
killed hundreds of European travellers
prompted EU governments to seek
a uniform approach to airline safety
through a common blacklist. The list,
updated at least four times a year, is
based on deficiencies found during
checks at European airports, the use
of antiquated aircraft by companies
and shortcomings by non-EU airline
The students aren’t in the military,
but they’ll likely end up working
as military contractors when they
graduate. That’s where the jobs are.
Associate Professor Ben Trapnell set
up the UAS degree program here. He
used to be a Navy pilot, but he says
The state of North Dakota is trying that unmanned aircraft are the future.
to position itself to become a leader ‘And if you do any research with the
in unmanned aircraft. Two years army, the air force, there are people
ago, the University of North Dakota that will tell you they may have
became the first civilian school to produced or are producing their last
offer a four-year degree in unmanned manned fighter.’ Trapnell sees a lot
aircraft systems operations. Several more than just military applications
other schools – in Alaska, Arizona, for unmanned aircraft.
Florida – are now offering courses.
‘I’ve got about 90 different uses for
The new UAS training centre in unmanned aircraft. But some of the
Grand Forks is located off-campus, big things: agricultural uses – we can
at Grand Forks Air Force Base. The get imagery to farmers a lot faster than
centre includes a small room that’s having to wait for satellites to do the
essentially a cockpit on the ground. same thing – pipeline patrols, power
Pilots and sensor operators can watch line patrols, there’s the possibility of
what’s happening in the air through flying organs one place or another to
cameras on the plane.
get them there faster for transplants.’
North Dakota’s RPA
The undergraduate students studying
unmanned aircraft systems begin
their coursework by learning about
aerodynamics as any traditional pilot
would. Then the classes branch off
to study the specifics of unmanned
The state of North Dakota is an ideal
place to experiment with this new
technology – wide-open space and
few people.
Source: www.uasvision.com
2012 Aviation Management Scholarship
The Guild of Air
Pilots and Air
Navigators (GAPAN)
Griffith University
Applications are invited for the 2012 scholarship, established to promote aviation
management excellence. One scholarship will be awarded. This will cover tuition
fees at Griffith University for either the Bachelor of Aviation Management, the
Graduate Certificate in Aviation Management or the Master of Aviation Management.
Applications close 24th February 2012
For further details and an application form, email postgradscholarship@gapan.org.au
Matthew Pang-Way 2010 Griffith University scholarship winner and Jemma Heatley 2011 are both progressing well towards their Master of Aviation Management.
2012 CPL and ATPL Examinations Scholarship
Applications are invited for the 2011 CPL and ATPL Examinations Scholarships.
Two scholarships will be awarded. One will cover the CASA/ASL examination fees
for the complete set of CPL Examinations. The second will cover the CASA/ASL
examination fees for the complete set of ATPL examinations.
The Guild of Air Pilots & Air Navigators (GAPAN)
Assessment Services Limited (ASL)
For further details and application form visit
www.gapan.org.au or email scholarship@gapan.org.au
Applications close 26 March 2012
Mia Angus and Chris Lee were the successful GAPAN/ASL applicants in 2011. Mia has successfully
completed 4 of her ATPL examinations with an 80% average, a very creditable result for given that
she is working full time and self studying.
As well as imposing an operational
ban in Europe, the blacklist can act as
a guide for travellers worldwide and
influence safety policies in non-EU
countries. Nations that are home to
carriers with poor safety records can
ground them to avoid being put on the
EU list, while countries keen to keep
out unsafe foreign airlines can use
the European list as a guide for their
own bans.
The reams of academic words written about
safety management systems can make them seem
like a dark art. In fact, SMS is a simple but essential way
to take aviation to the next level of safety.
Contrary to what some believe, safety
management is not a Harry Potter-esque
dark art. The central concepts are simple,
although jargon and over-theorising from
some practitioners complicate it. Safety
management was succinctly described at
an International Civil Aviation Organization
(ICAO) working group late last year as
‘organised commonsense’.
In Australia, CASR part 139 (safety standards
for Australian aerodromes) came into effect
in May 2003, (with a 1 November 2005
deadline for aerodromes with international
operators; and 1 January 2007 deadline for
all other certified aerodromes).
Flight Safety Australia’s last look at SMS
was over two years ago, as high- and lowcapacity regular public transport (RPT)
operators were working through their SMS
plans before having them approved by
CASA. This SMS focus was an early policy
implementation CASA undertook from
Part 119. This process is now complete,
Peter Boyd, executive manager standards
explains, with the 32 airlines in Australia,
divided almost equally into high- and
low-capacity operators, gaining approval
for their SMS implementation plans.
‘Approvals are now done, and the operators
are proceeding to implementation, so that
SMS becomes business as usual,’ Boyd says.
‘Industry is picking up SMS more and more,
even those who are not yet required to
implement it.’
A safety
management system
(SMS): a businesslike
approach to safety—
a systematic, precise
and proactive process for
managing safety risks.
(Transport Canada)
Some sectors of aviation are relative
latecomers to the concept of managing
safety as a system. For most of its first
century, aviation safety was driven by
lessons learned from fatal accidents.
This was not an option for the more
recent petrochemical and nuclear power
industries, where a fatal accident could
involve thousands, not hundreds of
victims, and leave behind effects lasting
for centuries. These industries turned to
safety management systems (SMS), which
they have had in place for more than 20
years. Aviation SMS grew from the ground
up, as aerodromes and airports, and air
traffic management, were the first sectors
to implement SMS.
‘And this tightens the safety net’, Boyd says.
‘As a regulator, there are things we can’t cover.
The regulator deals with the common and known
hazards—training standards, airworthiness controls,
certification, operational issues such as loads and
balances, fuel management, for example. However, to
continue to improve safety, we need to identify and
manage all the other hazards which may be unique to
individual operators, because of their environment
and circumstances. That’s where safety management
systems come in.’
CASA is now working on Civil Aviation Safety
Regulations Parts 119, 121, 133 and 135, which focus
on passenger transport services. Part 119 covers air
operators’ certification and management: SMS
is at its heart. Part 121 applies to operators of
aircraft carrying 10 or more passengers; and
Part 135, operators of aircraft carrying up to
nine passengers. Part 133 applies to rotorcraft
passengers. These CASR Parts will be released
shortly for public consultation.
ICAO’s SMS framework has four major components:
Safety policy, objectives and planning
Safety risk management
Safety assurance
Safety promotion
Information is the foundation of these four
components. Information gathered and freely offered
by frontline staff; information recorded and analysed
by management (with the involvement of frontline
staff) for its safety implications; information then
widely disseminated throughout the organisation, both
to address identified safety concerns, and to develop
a safety culture. And last but not least, information on
how the safety system itself is operating. The flow of
information in an SMS is continuous and uninterrupted,
like the flow of money in an economy, or blood through
the body. Safety experts, such as Patrick Hudson, who
formalised much of the SMS used in the oil and gas
industry, stress that safety must be an integral part of
everyday management and operations.
Safety Management System
Phase 1
Phase 2
Phase 3
Safety Policy, Objectives and Planning
Management commitment & responsibility
Safety accountabilities of managers
Appointment of key safety personnel
SMS implementation plan
Gap analysis
Third party interface (contractors)
Coordination of the emergency response plan
Safety Risk Management
Risk assesment & mitigation process
Hazard identification process
hazard identification
Safety Assurance
Safety performance monitoring &
Reactive - incident &
accident investigation
Internal safety investigation
The management of change
Continuous improvement of the safety system
Safety Training & Promotion
Training & education
Safety communication
Key personnel
All safety critical
All safety critical
‘Pilots and other humans in the system
often mitigate operational risk. It’s
important to understand those positive
behaviours and to take advantage of them.’
The human element
Each of the four SMS components: safety policy,
objectives and planning; safety risk management;
safety assurance; and safety promotion and training;
has a number of elements.
CASA is working on a resource kit to assist
operators with SMS, whether updating and
improving an existing system, or developing and
implementing a new one from scratch.
It is practical, written in plain English, and takes
a jargon-busting approach. The set of booklets
outline the structure of an SMS, following the
global ICAO framework. It includes:
1. An introduction – why have an SMS?
What is the difference between an SMS
and a quality management system?
2. Four booklets covering each of the four
main parts, with the 12 elements above
3. A dedicated chapter on human factors
4. The largest section – useful checklists
and templates for operators to adapt to
their own needs.
The kit is due for release
by mid-2012, and will
be widely publicised.
Human factors gets its own chapter in CASA’s SMS
resource kit because, as Peter Boyd says, ‘if you’re not
taking human factors into account, you won’t have a
very good SMS’. Human performance and managing
human error are at the heart of safety management.
Human factors is an umbrella term for the study of
people’s performance in their work and non-work
environments. The British Rail Safety and Standards
Board has a succinct definition of human factors as:
‘all the “people” issues we need to consider to assure
the lifelong safety and effectiveness of a system or
Trying to understand all the implications of such a wideranging definition can be daunting. Perhaps because
the term is usually used following human error of some
type, you may think of it negatively. However, human
factors also includes all the positive aspects of human
performance. Human factors specialists study what
have come to be known as heroic recoveries—positive
examples of human performance—such as the semicontrolled Sioux city crash of United Airlines Flight 232
in 1989 after a hydraulic failure or the successful
landing of the DHL Airbus A300 that was hit by
a missile over Baghdad in 2003. These events
are analysed just as intensely as disasters
caused by human errors.
As Federal Aviation Administration human
factors specialist Kathy Abbot says: ‘Pilots
and other humans in the system often
mitigate operational risk. It’s important to
understand those positive behaviours and to
take advantage of them.’
Wayne Jones, CASA standards implementation manager,
emphasises that an organisation’s safety manager is
‘not the safety person, but the safety systems person’.
In other words their job is not to look after safety
themselves, but to make sure that everybody in the
organisation is looking after safety.
CASA’s forthcoming SMS toolkit says: ‘The main thing to
remember is that human factors is about understanding
humans—our behaviour and performance. Then, from
an operational perspective, we apply that human
factors knowledge to get the best fit between people
and the system in which they work, to improve safety
and performance.’
The primary focus of any human factors initiative is to
improve safety and efficiency by reducing and managing
human error, both by individuals and organisations.
ICAO uses the SHEL model to represent the main
components of human factors. SCHELL is an expanded
version of this model.
SCHELL stands for:
The SCHELL model emphasises that the whole system
shapes how individuals behave. Any breakdown or
mismatch between two or more components can lead
to human performance problems. For example, an
accident where communication breaks down between
pilots in the cockpit or engineers at shift handover
would be characterised by the SCHELL model as a
liveware-liveware problem. Situations where pilots
engineers or controllers disregarded a rule would be
characterised as liveware-software.
At its simplest, the SCHELL model provides a checklist
of five items for analysing any task or accident. But
unlike a checklist, it is a starting point for analysis.
Using it can tell you not just what happened, but why.
You then know what you have to do to make the system
work better.
S = software:
the rules, procedures and other
aspects of work design
C = culture: the organisational and national
cultures influencing interactions
Benefits of SMS
H = hardware:
the equipment, tools and
technology used in work
In a recent publication talking about the senior
manager’s role in an SMS, Bill Voss, president and CEO of
the Flight Safety Foundation argues that ‘Occasionally
a safety management system will identify a problem
that, if left uncorrected, could have killed the company,
but that is not the real pay-off. The same SMS will
constantly identify the thousands of little problems
that disrupt your operation, destroy efficiency and
affect the bottom line.’ The publication also lists nine
distinct benefits of an effective SMS:
E = environment: the environmental conditions in
which work occurs
L = liveware:
the human aspects of the system
of work
The ability to control the potential risky operations
faced by the business
A clear and documented approach to achieving safe
operations that can be understood by others
Active involvement of staff in safety
Demonstrable control for the regulator, your
customers and others that your risks are
under control
Building a positive safety culture
Reduction or removal of operational inefficiencies
Decreased insurance costs and improved reputation
A common language to establish safety objectives,
and to manage risk
The ICAO safety management working group is writing
new SMS documentation – ICAO Annex 19, which
Jones argues is the most important annex in 50 years –
because it is about the way safety is managed in all of
civil aviation.
Jones, who in a previous life dealt with composite
materials as an engineer, likens the strength of an
SMS to that of a composite material. ‘In its individual
components it is useless: in its entirety it is very
powerful.’ Safety culture is the matrix which gives
SMS strength, in much the same way that the matrix
and fibres combine to make composites strong. ‘Safety
culture starts at the top. It requires leadership, but
its potential benefit is that every member of your
organisation becomes a safety agent’, Jones says.
‘The introduction of carbon-fibre airliners is an
excellent example of why SMS and safety culture
is important,’ Jones explains. The vulnerability of
such new-generation aircraft to almost undetectable
damage highlights the importance of prompt and
honest reporting, where safety is paramount. Under
a blame culture, if someone accidentally drives a tug
or a truck into a fuselage at night, and they think they
can get away with it, they will keep quiet. Whereas
aluminium hulls would show the damage externally,
composite hulls may not. They may look OK, but fail
in flight. A robust reporting culture is more important
than ever with this technology.
SMS experts talk frequently of culture but what do they
mean? Culture is a word with many definitions, many
of them overlapping. Anthropologists have compiled
more than 160 definitions of culture. But the one that
applies to safety management is one of its four main
definitions in the Oxford English Dictionary: ‘the ideas,
customs, and social behaviour of a particular people or
society.’ The Merriam-Webster Dictionary defines it as
‘The set of shared attitudes, values, goals, and practices
that characterizes an institution, organization, or
group.’ An often-quoted colloquial definition is ‘the
way we do things round here.’
Culture is important because it can nurture or suffocate
a safety management system. ‘It’s not going to work
unless the boss is on side – there’s no point paying your
SMS lip service, if the organisation damns anyone who
reports issues,’ says an industry insider.
A macho ‘can-do’ culture where contemplation and
self-criticism are unknown words is an obviously poor
fit for the implementation of SMS. But there are other
more subtle cultural barriers. The tendency after half
a century of the regulation driven safety model is to
think in terms of process rather than outcome – to do
things by the book, without seeking to understand why.
Adopting SMS components in this manner is pointless,
warns Jones.
A potential defence from legal action.
ICAO says ‘SMS represents a continued evolution in
safety. The first 50 years of aviation safety was based
on individual risk assessment.' And Wayne Jones, who
is CASA’s representative on the ICAO working group,
argues that we then had 50 years of the traditional
compliance-based approach. SMS leverages the first
two, he says, and exploits information age processes
and management techniques to better inform managers,
allowing them to manage risk more effectively. With
increasing maturity, the time has come to further
safety by building on that strong foundation with
performance-based regulations.
The importance of being earnest
– and cultured
Using parts of an SMS without tailoring them to your
own organisation or circumstances is contrary to the
central idea of SMS. ‘Such a box-ticking exercise would
be both dangerous (thinking you are being safe when
you are not) and a waste of time,’ he says.
'Safety culture starts at the top. It requires
leadership, but its potential benefit is
that every member of your organisation
becomes a safety agent'
Box-ticking is in many ways the opposite of safety
culture. Just as with 'culture', there is no exact definition
of 'safety culture', but a 2006 ICAO document makes
a good stab when it refers to a good safety culture as
‘a corporate safety culture that fosters safe practices,
encourages safety communications and actively
manages safety with the same attention to results as
financial management.’
‘In most cases just do what you’re already doing, but
make it systematic – this means integrating the various
systems you probably already have in place,’ says
Boyd. ‘And use your data to identify and mitigate your
operating risk.’
To come back to our opening—it comes down to
organised common sense, leaving aside the objection
that common sense is not necessarily that common.
The final word comes from the Flight Safety Foundation’s
Voss: ‘Some shy away from initiating the SMS process
because it is not a pre-determined package, a turn-key
mechanism you import and adopt. To be truly effective,
it must be an organic product of your company’s culture
that takes advantage of the positive elements of that
culture already in place, but then goes beyond that
point to push higher and deeper into the firm’s psyche.
This is how SMS becomes effective and long-lasting.’
Growing … from reactive to proactive
Over fourteen years, Lindsay Evans has looked at safety
management from the viewpoint of a small, medium
and high-capacity aircraft operator. He founded Perthbased Network Aviation in 1998, with a Cessna 310
piston twin and a Cessna 441 turbine twin. The company
evolved into a turbine charter operation flying Embraer
EMB 120 Brasílias, then a jet charter operation flying
Fokker 100s, before Qantas bought it in early 2011. The
F100 fleet is planned to expand to 12 aircraft, all for flyin-fly-out routes to West Australian mine sites.
‘Looking back, we had a fairly simplistic SMS,’ Evans
says of the early days. ‘We had a good reporting culture,
but we didn’t do a lot with the information. We tended
to look at reports that came in, in isolation. We did some
trending of the data, but the whole thing was perhaps
more reactive than proactive.’
Network’s safety manager, Dan Morvell, says: ‘the amount
of communication and transparency that the system
has provided throughout the company has certainly
increased. I think that’s the most important part.‘
Sophistication came with growth, Evans says. ‘In those
days we had one safety person, now we’ve got five, and
we plan to increase that to six next year.’
‘The other thing was we didn’t do too many internal audits.
That’s certainly changed with the larger organisational
approach to safety.‘
That approach means seeing the dark, dangerous side
of opportunities. Of the planned fleet expansion Evans
says, ‘We’re very mindful of the amount of change that’s
going on and we want to make sure the foundations are
rock solid before we introduce these aircraft.’
‘In most cases just do what you’re
already doing, but make it systematic
– this means integrating the various
systems you probably already have in
place ... And use your data to identify
and mitigate your operating risk.’
The safety-minded manager’s burden of chronic unease
is one Evans accepts philosophically. He understands
that safety is a never-ending quest. In consecutive
sentences, Evans mentions that Network recently
completed a Basic Aviation Risk Standard audit with
‘zero findings’, and goes on to say that the company has
‘a way to go in changing people’s behaviour.’
Evans says integrating safety and management brings
benefits. ‘The other positive about a good SMS is
that if you take the word safety out of it, it’s a good
management system. It improves the way you manage
the business.’
For Network Aviation, the quest for safety goes on.
Evans says the greatest challenge is empowering
managers to be responsible for safety in their areas of
the business. ‘That’s challenging because, in the past,
that sort of responsibility has wrongly fallen on the
shoulders of safety managers. It’s the managers now
that are being made accountable for safety in their area
of the business,’ he explains.
Get fitted for ADS-B
Australia’s air traffic control surveillance future is tied to Automatic
Dependent Surveillance Broadcast (ADS-B) – a satellite based air navigation
system that enables aircraft to be accurately tracked by air traffic controllers,
and other pilots, without the need for conventional radar.
irservices ADS-B network is now
delivering continuous surveillance of
aircraft operations in high and low level
airspace across western, central and northern
Australia where radar coverage does not
currently exist. Substantial coverage exists at
lower levels extending to near the surface in the
vicinity of each ground station.
Airservices has had a continent-wide ADS-B
network in operation since December 2009,
deploying 29 duplicated ADS-B ground
stations nationally plus 14 ADS-B capable
multilateration sites in Tasmania and 16 sites in
the Sydney basin. A further 14 ground stations
to support the needs of airlines, regional and
general aviation are being considered.
Benefits of ADS-B include reduced radar
separation standards for equipped aircraft,
which translates to less delay, less use of
stepped climbs and descents, and more
clearances granted to fly requested routes or
levels. Clear safety benefits include lower pilot
and air traffic control workloads, activation
of automatic safety nets and increased route
flexibility in poor weather.
There is only two years to go until a December
2013 deadline for the fitment of ADS-B
equipment for operations at and above FL290
by domestic and foreign operators. Given the
timeframes associated with airframe upgrades
and equipment installation, Airservices is
encouraging all operators flying at and above
FL290 to consider ADS-B equippage in
advance of the mandate.
The safety and operational opportunities
offered by ADS-B are already being realised
in upper airspace in advance
of the mandate with operators
who have opted to equip
early reaping these
Too close for comfort managing nuisance TCAS RAs
There have been several recent instances of pilots experiencing nuisance
TCAS resolution advisories (RAs) involving aircraft climbing, descending or
maintaining a level that is vertically separated from other aircraft.
hese incidents are what ICAO calls
high vertical rate (HVR) encounters.
TCAS RA thresholds are independent of
ATC separation standards because TCAS does not
strive to ensure separation (the controller’s role) but
tries to avoid collision as a last resort.
TCAS projects the existing vertical speeds of both
an intruder and own aircraft to estimate the vertical
separation that will exist at the closest point of
horizontal approach during an encounter. TCAS
does not know intent so it cannot limit trajectory
projection on the basis of an ATC level clearance.
If this projection is less than the TCAS-desired
vertical separation (300-700ft, depending on
altitude), an RA is issued.
The performance of modern aircraft and the design
of common flight management and guidance
systems can result in vertical speeds in excess of
3,000ft per minute until aircraft are within 500ft of
the aircraft’s assigned level. In this situation, the
aircraft is less than 30 seconds away from being
at the adjacent IFR level, which may be occupied
by a TCAS-equipped aircraft flying level at that
level or approaching it in the opposite direction.
If the aircraft are horizontally within the protected
area provided by TCAS, there is a high probability
Normally the RA will be a ‘monitor vertical speed’,
‘maintain vertical speed’ or ‘adjust vertical speed’
advisory in which the TCAS itself will command an
appropriate vertical rate. In many such cases there
should be no deviation from the ATC clearances
(assuming they were correct).
Even if an advisory does not result in a deviation
from an ATC clearance, it is a reportable incident.
Lessons learned
In order to prevent HVR nuisance RAs, ICAO
recommends that a climbing or descending aircraft
should adjust its vertical rate to less than 1,500ft
per minute when 1,000ft above or below assigned
level and when the pilot is aware that there is an
aircraft at or approaching an adjacent altitude or
flight level. However, experience suggests that this
is not often done.
ICAO notes that in these situations crews can
be made aware of the presence of other aircraft
by several means, including traffic information
provided by an air traffic controller, a TCAS traffic
advisory (TA) or by visual acquisition.
If you are given traffic information in this situation,
or you otherwise become aware of vertically and
laterally converging traffic, consider whether your
vertical rate is appropriate to avoid generating a
nuisance RA.
In addition, the main TCAS thresholds are
time-based, not distance-based like most ATC
separation standards. The alerting thresholds used
by TCAS were developed to ensure that errors in
altimetry and delays in pilot responses would not
compromise the safety provided by TCAS.
that an RA will be issued just as the climbing or
descending aircraft begins to reduce its vertical
speed to capture its assigned level.
International Accidents/Incidents 4 October 2011 - 30 November 2011
4 Oct
Cessna 208B Grand
Utsingi Point, Great Slave 2
Lake, Canada
Fatalities Damage
Written off
Aircraft (first flight 1992) sustained substantial damage in an
accident en route to Lutsel K'e Airport. The aircraft was reported
overdue and was later found to have crashed, killing the pilot and
one passenger and seriously injuring the other two passengers.
13 Oct de Havilland Canada 20km south of Madang
Airport, PNG
Written off
Aircraft (first flight 1988) crashed in dense forest near the Gogol
River, killing 28 of the 32 people on board.
14 Oct Cessna 208B Grand
Xakanaka Airsrtip,
Aircraft crashed immediately after take-off en route to
Pom Pom Camp Airstrip in the Okavango Delta.The pilot and
seven passengers were killed but four passengers were said
to have survived.
18 Oct Pilatus BrittenNorman BN-2T
Turbine Islander
Dhorpatan, Baglung
District, Nepal
Written off
The Nepal Army Air Wing aircraft, on an ambulance
flight, crashed into a dense forest and caught fire, killing all
on board.
25 Oct Antonov
Al-Anad Air Base,Yemen 4
Written off
Yemen Air Force transport plane involved in an accident during
landing, killing four of the 15 occupants. Aircraft have been
withdrawn from some air bases because of confrontations
between government forces and their opponents in the vicinity.
1 Nov
Boeing 767-35DER
Warszawa Frédéric
Chopin Airport, Poland
While on approach to the aiport the crew encountered problems
in lowering the undercarriage. The aircraft entered a holding
pattern at 2750ft but the gear could not be deployed so the crew
decided to carry out a gear-up landing. Fortunately, none of the
231 occupants was injured.
8 Nov
BAe HawkT1
RAF Scampton,
Lincolnshire, UK
Pilot killed after the ejector seat was activated accidentally
on the ground and the parachute failed to deploy properly.
10 Nov Eurocopter EC130 B4 Kaunakakai, Molokai,
Written off
Tourist helicopter crashed into mountainside, killing all
on board, including a couple who had been married five
days earlier.
11 Nov Aérospatiale AS
332L1 Super Puma
Written off
Military helicopter carrying a federal government minister,
officials and three crew members crashed into a hillside in
conditions of cloud and low visibility.
16 Nov Cessna 172 Skyhawk Mt Ciremai, Java,
Written off
Training aircraft with two students and an instructor on board
went missing on a cross-country flight. The wreckage was found
on a mountainside.
21 Nov Sukhoi Su-30
Entebbe International
Airport, Uganda
Reports said a jet operated by the Uganda People's Defence
Force made a gear-up landing. This was denied by officials but
eyewitnesses described the plane as being one of the new
Su-30 jets flown by the UPDF.
23 Nov Rockwell
Commander 690A
Apache Junction,
Arizona, USA
Written off
Privately owned light turbine twin crashed and caught fire in
rugged terrain about 18.30 local time, shortly after take-off from
Falcon Field Airport. Witnesses saw aircraft fly into mountainside.
23 Nov Cessna 208B Grand
near Sugapa Airport,
Written off
The cargo plane was involved in an accident near Sugapa Airport,
killing the co-pilot. The pilot survived but was critically injured.
Reports indicated that the pilot attempted a go-around to avoid
a person walking on the runway, but crashed some distance from
the airport.
29 Nov Mil Mi-24
Pruzhany Air Base,
Written off
Helicopter gunship crashed on landing approach during
training mission.
30 Nov Aérospatiale AS
350BA Ecureuil
Matai Bay, Karikari
Peninsula, New Zealand
Written off
Helicopter went missing during a fire-fighting operation and
was later found in the sea.
near Santa Catarina
Atoyzingo, Mexico
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 not always available.
Australian Accidents/Incidents 1 October 2011 - 30 November 2011
Cessna 208B Twin
Cessna 182R
Jurka MJ-77
Cessna U206F
Tooradin (ALA), Vic
Glasflugel Libelle
Piper PA-36-300
Stonefield (NDB), 320° M
9km, SA
Deniliquin Aerodrome, 280° Nil
M 52km, NSW
Piper PA-24-250
Boeing 747-438
Marree (ALA), W M 19km,
Brisbane Aerodrome, Qld
Cessna 182P
Cessna 172G
Ayr (ALA), E M 2km, Qld
near Batchelor (ALA), NT
Grumman G-164B
20 Oct Glaser-Dirks
25 Oct Aerostar 601
Ravensthorpe Aerodrome, E Nil
M 40km, WA
Narrabri Aerodrome, 121° M Nil
39km, NSW
Bourke Aerodrome, NSW
25 Oct
Cessna 172
near Dairy Creek homestead Nil
26 Oct
Cessna 310R
near Jabiru (ALA), NT
29 Oct
Bell 206B
Cessna 210L
Maitland Aerodrome, NSW
Serpentine (ALA), WA
Parafield Aerodrome, SA
Balloons E-260
Robinson R22
Schleicher ASK-21
Alice Springs Aerodrome, S Serious
M 19Km, NT
Julia Creek Aerodrome, N M Nil
93Km, Qld
Benalla Aerodrome, Vic
Spitfire MK 26B
10 Nov Grob G-115C2
Kununurra Aerodrome, WA
Jandakot Aerodrome, WA
12 Nov Luscombe 8A
Coldstream (ALA), Vic
19 Nov Cessna 210M
Bickerton Island (ALA), NT
21 Nov Piper PA-28-181
Hamilton Aerodrome, Vic
During the landing, the aircraft ballooned before landing hard on its nose landing
gear which collapsed on impact, resulting in the propeller striking the ground.
El Questro (ALA), 060° M
28km, WA
Mundubbera (ALA), Qld
During an approach to land, the low RPM light and warning horn activated and
the helicopter made a hard landing. Investigation continuing.
The aircraft collided with terrain.
During the landing roll, the aircraft overran the runway. Investigation continuing.
1 Oct
3 Oct
4 Oct
8 Oct
8 Oct
10 Oct
13 Oct
14 Oct
15 Oct
16 Oct
18 Oct
4 Nov
5 Nov
7 Nov
7 Nov
8 Nov
Naracoorte Aerodrome,
WSW M 31km, SA
Devonport Aerodrome, Tas
Injuries Damage Description
The aircraft landed short of the runway and struck a drum that was being used
as a runway marker.
The aircraft landed heavily, resulting in a collapse of the nose landing gear.
27 Nov Robinson R22
30 Nov Amateur-built
Bede BD-4
30 Nov Cessna 210L
Kalumburu Aerodrome, WA Nil
During the approach, the aircraft's landing gear did not fully extend.
The engineering inspection revealed that the left magnetic door catch had failed.
During the approach, after a parachute sortie rejected due to weather, the C206
collided with terrain. Investigation continuing.
The glider landed heavily after a launch failure.
During spraying operations, the left main landing gear struck a mound.
The aircraft returned to the departure strip and upon landing, the left main
landing gear collapsed, causing the propeller to strike the ground.
During the flight, the engine failed. The pilot conducted an intentional wheelsup landing.
The first officer exited his aircraft via the rear stairs as a neighbouring Boeing
747-400 was taxiing away from the gate. The jet blast from the 747 blew the
stairs over and the first officer fell. Investigation continuing.
During the approach, the aircraft struck a bird that shattered the windscreen.
The pilot conducted a forced landing into a canefield. Investigation continuing.
During cruise, the engine failed. The pilot conducted a forced landing during
which the aircraft struck a log and became inverted. Due to the extent of the
damage, the cause of the engine failure could not be determined.
During a rejected take-off, the aircraft collided with a fence.
During an outlanding in a paddock, the glider's right wing collided with a contour
bank and the glider ground looped.
The pilot inadvertently landed with the landing gear retracted.
During the cruise, the aircraft's fuel supply was exhausted and the pilot
made a forced landing. During the approach, the aircraft collided with trees.
Investigation continuing.
During approach, the nose landing gear failed to extend fully. The aircraft
diverted to Jabiru and during the landing the nose landing gear collapsed.
An engineering inspection revealed a failed nose landing gear lock bar.
During the short final approach, while conducting an autorotation, the helicopter
rotated 30 degrees and landed heavily. Investigation continuing.
During the take-off, the pilot did not maintain directional control and the aircraft
collided with a tree.
During the take-off run, the nose landing gear collapsed resulting in the propeller
striking the ground and the aircraft veering off the runway.
During the landing, the balloon basket struck a dead tree due to a change in
wind direction.
During mustering operations, the main rotor blade struck the ground, resulting in
the helicopter coming to rest on its side. Investigation continuing.
During the landing, in long grass adjacent to the runway, the glider ground looped
and sustained serious damage.
During the landing roll, the aircraft ground looped, the right main landing gear
collapsed and the aircraft nosed over.
During the landing, the aircraft bounced and landed heavily, breaking off the
nosewheel and veering off the runway.
While taxiing, the aircraft's right wheel struck a pipe on the side of the taxiway.
The right landing gear collapsed and the right wing tip and propeller struck
the ground.
The pilot inadvertently landed with the landing gear retracted.
Text courtesy of the Australian Transport Safety Bureau (ATSB). Disclaimer – information on accidents is the result of a cooperative 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.
2 Nov
Bulimba (ALA), Qld
Composite materials are stronger, lighter
and longer lasting than aluminium, but
anyone who flies or works near new
generation aircraft needs to know about
their distinctive characteristics.
Source: Boeing
With all due respect to Boeing’s new 787, which
made its first flight to Australia in November 2011,
the age of composite materials in aviation is not
about to begin—it dawned many years ago.
Boeing says its new airliner promises a 20
per cent reduction in fuel consumption, fewer
maintenance inspections and greater passenger
comfort because its construction allows for a
lower (that is, higher pressure) cabin altitude and
greater cabin humidity. The 787 is approximately
50 per cent carbon fibre composite by weight. It
will be joined over the next few years by the Airbus
A350, the Russian Irkut MS-21 and the Bombardier
C Series, all of which make varying but extensive
use of composite construction.
Composite materials have been around since the
earliest days of aviation. The Wright brothers’
Flyer 1 was made of a naturally-occurring carbon
fibre composite called wood.
Aircraft engineers also call laminates, such
as plywood, or honeycomb-structure panels
sandwiched between laminates, composites,
but this article will only examine fibre/matrix
Fibreglass was developed during World War II,
and consists of glass fibres as reinforcement in
a polymer resin. Aircraft have used fibreglass
components since the late 1950s.
Carbon fibre, developed in the 1960s, is similar in
principle to fibreglass, but uses fibres made of up
to 95 per cent pure carbon as its reinforcement.
(They are derived from pyrolised polyacrilonitrile).
The crystal bond pattern that the carbon atoms
form with each other makes carbon fibre
very strong.
Carbon fibre has been used in jet engine compressors and fan blades since
the 1960s. The McDonnell Douglas DC-10 and Lockheed Tristar of the early
1970s utilised the material for rudder and aileron segments.
To make structural carbon fibre, several thousand individual fibres are
initially spun into a yarn, the yarn is woven into a carbon fibre cloth, and then
the cloth is surrounded by a polymer matrix. The result is a material with
great strength, stiffness and lightness. Carbon fibre composite is about three
times as strong, weight for weight as aluminium alloy, and four times as stiff.
Another method of creating carbon fibre involves uni-directional fibres that
are layered in different directions. The uni-directional fibres are supplied in
strips pre-impregnated with the matrix material.
Carbon fibre has an additional advantage: it can be optimally designed for
strength. Because the strength in carbon fibre lies along the axis of the fibres,
extra fibres can be placed where they are needed to increase the strength
of a component in a particular direction. Using this technique, carbon fibre
components can be many times stiffer against particular stresses than
aluminium components of similar weight.
Using this technique, carbon
fibre components can be many
times stiffer against particular
stresses than aluminium
components of similar weight.
A composite material is exactly what its name
suggests: a material made up of two parts—the
matrix material and a reinforcement fibre scattered
or layered within it. Composites are among
humanity’s oldest materials. Straw bricks, which
date from ancient Egyptian times, are a perfect
example of a composite and of its advantages.
The straw, which is stronger in tension than mud,
helps stop the bricks from cracking.
Composites used in modern aircraft include fibreglass, carbon fibre, boron
and aramid. Aramid fibres are sometimes known by the brand name Kevlar.
Aramid produces a material that is less stiff than carbon fibre, but more
impact and abrasion resistant. However, it has the inherent disadvantage
of absorbing moisture, and its use is restricted to components designed to
contain runaway engine fan blades. Aircraft interiors use another type of
composite material, a glass/phenolic fibreglass, which gives off relatively low
amounts of toxic gases in a cabin fire.
Engineers will wistfully say that the best material
to have between yourself and a fire is sheet
steel—but the only aircraft made of this are the
ones in children’s adventure playgrounds. In an
aircraft capable of flight your choice of structural
sheeting is between aluminium and carbon-fibre
Using a carbon composite for aircraft construction
can have advantages over aluminium.
For example, aluminium will melt at 660°C in
large fires. Typically, for a composite material,
the degradation temperature to cause burning
is 300°–500°C, but as the matrix burns away on
the outer surface, the remaining carbon fibre
acts as a barrier to the fire. In this way carbon
fibre maintains some structural integrity during
burning. This might save your life by giving you
a little more time to escape if you ever find
yourself in the ghastly situation of being in a postcrash fire.
Composite materials, such as glass/phenolic
(glass fibre), used in aircraft cabins, can have
excellent fire resistance properties, depending on
the additives used in the matrix.
Advanced structural composites with superior
fire properties are also under development.
They use high-temperature thermoset polymer,
thermoplastic or inorganic polymer matrices.
Another class of composites can have great
heat resistance. Aircraft brake discs are made
from carbon-carbon composites – carbon fibre
reinforcement in a matrix of graphite – that have
been in use since the technology was retrofitted
to the Concorde in the early 1970s.
Composite materials have
been around since the
earliest days of aviation.
The Wright brothers’ Flyer
1 was made of a naturallyoccurring carbon fibre
composite called wood.
There’s no getting around the fact that composite materials are a new factor
for the first responders to an aircraft crash to consider. Fire and impact can
create airborne fibres which are suspected of being a breathing hazard.
Carbon fibre composites are cured at temperatures of about 120°C. When
composites are exposed to high temperatures (300°–400°C and above), the
bonding matrix decomposes, releasing heat, soot, smoke and toxic gases.
The fibres (usually carbon, but sometimes also aramid) may also decompose,
creating dust, and adding to the heat and toxic smoke.
There does not need to be a fire for composites to be a toxic hazard. Composite
structures that have shattered in a crash can also produce respirable fibres,
that is, small enough to breathe in. These fibres or splinters are needle-sharp,
and can cause skin and eye irritation.
In a report, the Australian Transport Safety Bureau (ATSB) says: ‘Released
composite fibres are a respiratory hazard much like asbestos, and similar
safety precautions should be taken in regards to breathing apparatus,
clothing and decontamination.’
For these reasons, it is important to minimise exposure to composite dust and
smoke after a crash. This can be done by evacuating passengers quickly to
a location upwind of the accident and away from composite dust and other
debris. The burning of the epoxy matrix and carbon fibres can produce over
100 toxic gases, including hydrogen chloride, hydrogen cyanide, hydrogen
bromide and nitrogen dioxide.
The Directorate of Defence Aviation and Air Force Safety (DDAAFS) has a
policy that ‘any dust is bad dust’. DDAAFS also co-produces the Civil and
Military Aircraft Accident Procedures for Police and Personnel booklet
with the ATSB. Both the procedures and checklist are available on the
ATSB website.
However, the news is not all bad. A study on rats suggests that the lung
irritation caused by carbon fibres is not linked to disease, unlike silica,
E-glass and other advanced fibres used in composite materials. Laboratory
tests indicated that inhaling carbon fibres did not cause lung disease in
the rats. Instead, the researchers found ‘dose-dependent, transient
inflammatory responses’.
Carbon fibre, also known as carbon/epoxy or
carbon fibre reinforced plastic (CFRP) – used as
a primary structural and skin material.
Kevlar/epoxy – mostly used in military applications,
in primary structures and amour plating.
Fibreglass, also known as glass fibre – used
as a structural and skin material (on amateur-built
and GA aircraft).
Source: Boeing
Glass/phenolic (GFRP) – used in interior fittings,
furnishings and structures.
Boron/epoxy – used in composite repair patches and
older composite structures.
Source: ATSB 2006
Composite materials are very strong, and resist impacts that would crumple
steel or aluminium. Carbon fibre also has a better fatigue life than steel,
titanium, or aluminium. Indeed, correctly produced composites do not have a
fatigue life. Carbon fibre components in service on RAAF aircraft have been
tested without failure to more than 20 times the service life of the metal parts
they replaced.
But the flip side of carbon fibre’s strength is that failure, when it does occur,
is sudden and complete. As a rule carbon fibre does not bend or crumple: it
either takes an impact or load, or it breaks.
An engineer would describe the failure mode of carbon fibre composite as
brittle or, to be hypercorrect, pseudo-brittle. The material fails at the point
when its fibres and matrix separate—the fibres left carrying the original load
then fail in tension. This generally happens under a far greater stress than
steel or aluminium would bear before bending or breaking.
This makes life more difficult for crash investigators. On investigating
composite failure, the ATSB says: ‘As a result, it is inherently more difficult
for transport safety investigators to analyse failed composite structures and
clearly determine what types of loads were involved’.
However, the news on composite material strength is good. As part of its
advanced general aviation transport experiments, NASA performed a crash
test on a Lancair Columbia 300 low-wing single-engine GA aircraft.
The NASA report concluded: ‘The impact conditions of this test represented a
much higher velocity change, and possessed more than five times the impact
energy compared to the current FAA requirements for
dynamically certified seats and restraint systems.
The demonstration was successful since a survivable
cabin volume was retained and occupants survived
the test’.
As part of its certification for the 787, Boeing
conducted a drop test of a fuselage section in 2007.
A 2.5-metre section of the fuselage’s bottom half, with
full luggage containers beneath the passenger floor,
was dropped from 15 feet on to a thick steel plate.
It hit the ground at 30 feet per second, or 1800 feet
per minute, about 10 times the typical descent rate of
a typical landing, and three times the descent rate a
787’s landing gear is required to withstand.
The floor stayed intact, as did the cabin door and
its supports. Boeing said sensors on the passenger
seats showed the impact forces were survivable.
Source: Boeing
In chemical terms, joining carbon fibre to
aluminium is similar to joining dissimilar metals—it
can create galvanic (electrochemical) corrosion.
Carbon and aluminium are atomically far enough
apart to react given the right conditions. Like
dissimilar metals, they need to be separated by an
inert material to prevent this type of corrosion. If
not, the worst outcome is that aluminium becomes
the sacrificial element of the two.
Ultraviolet (UV) damage is often mentioned as a
potential problem with carbon fibre construction.
It should not be a factor in aviation-grade carbon
fibre structures in which the matrix contains
UV stabilisers. Painting any external carbon
fibre surfaces further guards against ultraviolet
degradation. Generally, airframe manufacturers
require composite structures to be painted white,
or another light colour, to reduce the heat build-up
from direct sunlight. At higher temperatures, the
matrix surrounding the fibres can approach the
glass transition temperature, a point at which the
matrix becomes softer, leading to ‘creep’ failure of
the structure.
Heat can damage carbon fibre composite structures through surface
oxidation, just as it can metal. Common sources of heat damage include
lightning strikes and hot jet exhaust.
Lightning can puncture a composite aircraft’s skin, (as it can an aluminium
skin). Lightning can also delaminate the skin and other composite structural
parts, disbond adhesives, and buckle composite panels due to magnetic
force effects. This is why all composite airframes include metallic elements
to conduct and dissipate lightning. Woven and nonwoven metallic meshes
are available for this purpose.
One property of composites that everyone who has anything to do with
ground handling of aircraft should know is that they put up a brave front.
Unlike metals, which bend and dent, composites tend not to show impact
damage from the outside. The damage on the inside of a composite fuselage
that has been hit by a service truck, for example, can be severe, but hidden
from the outside. After a blunt impact, a composite skin can pop back into
place, often leaving no evidence of the trauma beneath.
Punctures or scores on the outer surface can provide an entry for moisture
into the core of the material. Aramid fibres are particularly hygroscopic. At
altitude, this moisture accumulation can freeze, causing further delamination.
For this reason composite structures must be repaired promptly.
Boeing put a large effort into making the 787’s composite structure damagetolerant. One requirement is that barely visible impact damage, which falls into
the insidious category between obvious and insignificant damage, must not
grow by enough to reduce design strength if it occurs between inspections.
But despite conservative design, it is vital that all maintenance and other
ground personnel report any type of accidental impact on a composite
airframe, no matter how minor it may appear at the time. In this, and many
other areas, composite materials have great benefits to offer, but also require
new skills, attitudes and procedures.
Glass laminate aluminium reinforced epoxy is a
fibre-metal laminate, composed of several very thin
layers of aluminium between layers of glass fibre,
bonded together with an epoxy matrix. The glass
fibres are in uni-directional pre-impregnated sheets
which can be aligned in different directions to suit
predicted stresses on the part being made.
GLARE parts are constructed and repaired using
mostly conventional metal material techniques. It is
lighter than aluminium, has better corrosion and fire
resistance and better damage tolerance.
Source: Lockheed Martin; Photographer: David Henry
GLARE is made in one plant in Britain and is used in
the Airbus A-380.
In comparison to carbon fibre, an MMC is more
resistant to fire, does not absorb moisture, is more
conductive of electricity and heat, and is resistant
to radiation damage. MMCs are used in automotive
and aerospace applications, including cylinder
blocks and the Hubble Space Telescope, where the
MMC properties of lightness, electrical conductivity
and dimensional stability were highly useful.
Further reading
Castles, R, Maintaining ageing composite aircraft,
Flight Safety Australia July-August 2009 pp31-32,41
Croft, J, 'Boeing must prove 787 materials are safe', Flight
International, 1-7 May 2007, p6
Castles, R, Composites damage: ignore it and it will not go
away, Flight Safety Australia September-October 2010 pp39-40
AGATE Composite Airframe Impact Test Results, NASA Langley
Research Center March 2002 http://tinyurl.com/5rp7xwv
Federal Aviation Administration, October 2007, Flammability
Properties of Aircraft Carbon-Fiber Structural Composite
D. B. Warheit, J. F. Hansen, M. C. Carakostas and M. A.
Hartsky, 'Acute Inhalation Toxicity Studies in Rats with a
Respirable-Sized Experimental Carbon Fibre: Pulmonary,
Biochemical and Cellular Effects.' The Annals of Occupational
Hygiene Volume 38, Issue inhaled particles VII pp. 769-776
Australian Transport Safety Bureau, Research report April 2006
Fire Safety of Advanced Composites for Aircraft
Metal matrix composites are reinforced metals. The
metal surrounds the reinforcing fibres, in the same
way as the epoxy matrix in a carbon fibre composite.
General aviation aircraft continue to crash for
the most basic reason – running out of fuel.
One recent example is a cautionary tale about why
fuel starvation is an
insidious problem that You might have heard this story before, or
like it. One Saturday afternoon a Cessna
can strike even the one
152 was turned into an expensive pile of
most cautious pilot – scrap aluminium – for want of a few litres
of avgas. The C152, which was being used
like you.
for aerial photography, was on approach to
The Australian Transport Safety Bureau
investigation concluded that the aircraft
ran out of useable fuel despite having nine
litres of avgas remaining in its tanks. This
was substantially more than the six litres
specified in the flight manual.
‘Asymmetric fuel delivery may have led to
fuel tank outlet unporting, allowing air into
the fuel system,’ the ATSB said.
Why did this happen? The ATSB directed its
suspicions at a time-honoured but possibly
suspect tool – the wooden dipstick.
The pilot either misread the pre-refuel dipstick
reading or, due to unequal actual amounts
in the left and right wing tanks, may have
mistakenly read the first, higher, quantity
indication on the dipstick as the level in the
other tank, the ATSB said.
This may have been due to persistence of
the fuel mark on the wooden dipstick [after
dipping one tank]. Also, there is little distance
between substantially different levels of fuel
on the dipstick, making accurate readings
more difficult.
Moorabbin Airport on 7 August 2010 when
its engine stopped for the last time. After
clipping the roof of a house with its wheels,
it crashed in a nearby backyard in the outer
Melbourne suburb of Mordialloc, narrowly
missing a swimming pool.
fuel in the
tanks is a
It involves
juggling of
and flight
planning ...
The ATSB found the pilot did not conduct a
post-refuel visual check of fuel tank levels,
but did sign for the correct top-up amount
from the refueller. This may have been a
problem because the ATSB found: ‘Data in the
operator’s flight time and serviceability log
was ambiguous with respect to the amount of
fuel remaining in the tanks after each flight.’
It is tempting to be dismissive and say the
pilot was careless – tempting but wrong.
Blaming the crash pilot, in this and many
other accidents, gives other pilots an easy
mental defence: ‘I would never be so dumb’.
But that attitude is a problem because it
removes the incentive for further analysis.
Fuel starvation is more than nature’s revenge
on idiots, as all too many normally cautious
pilots have found. Keeping fuel in the tanks is
a multifaceted flight management challenge.
It involves continuous juggling of workload
and flight planning, and is affected by factors
such as aircraft load, operating altitude,
ambient temperature, mechanical condition,
instrumentation, winds aloft and pilot skill.
These are a lot of factors for any pilot to
manage. They go towards explaining why fuelrelated accidents accounted for 10 per cent of
all fatal GA accidents in the 1990s, according
to an ATSB survey. The ATSB found half of all
accidents involving flight into terrain under
partial control were fuel-related. The ATSB
euphemistically refers to this type of crash as
‘managed flight into terrain’.
To say this crash could have happened to any
pilot would be overstating the case – but it
could certainly have happened to many, and
perhaps most, pilots. The safe and easy option
of brim-filling the tanks was unavailable
because with two passengers aboard (at a
nominal weight of 150kg for both), a Cessna
152 can carry no more than 82 per cent of its
fuel load.
The problem then arises of how to work
out that 82 per cent accurately. Aircraft
fuel gauges are rightly dismissed as largely
inaccurate instruments of last resort – and
that’s when they were new. Any original
gauge on a Cessna 152 would be 26 years
old because C152 production ended in 1985.
Many gauges on American aircraft are also
calibrated in pounds or US gallons—another
potential source of confusion.
Measuring fuel level by dipstick also has
traps. Wing-mounted fuel tanks are wide
and shallow, precisely the wrong shape for
accurate measuring by dipstick. The slightest
slope in the ground on which the aircraft is
parked can distort the reading up or down.
Even when the aircraft is on level ground,
the range between empty and full amounts
to only a few centimetres, or millimetres on
some types. Then there’s the difficulty of
taking a second, lower reading if the dipstick
has already been marked by the contents of
one near-full tank.
The pilot in this case was prudent and
conservative. Although not required to, the
pilot had incorporated a variable reserve of
15 per cent of the anticipated flight fuel, along
with 45 minutes fixed reserve. After dipping
the wing tanks, the pilot had arranged for a
fuel top-up, but had not dipped them again
after signing for the fill.
CASA flying operations inspector, Stuart
Jones, agrees. ‘Many otherwise safetyconscious pilots would be tempted not to
bother with the second visual fuel check. But
despite the inconvenience it has to be done’,
he says. ‘The first, second and third rule has
to be: always dip the tanks yourself, after
every refuelling. Most of the time it will seem
like a waste of time - it will just tell you what
you already know. But the stakes are so high
that you have to do it.’
‘The first,
second and
third rule
has to be:
always dip
the tanks
after every
refuelling ...
the stakes
are so
high that
you have
to do it.’
What you can do
• Always dip your tanks after every fill.
• Park on flat ground before dipping the tanks.
• Put fuel quantity on
The ATSB noted the type of work the aircraft
your pre-start, or
the Cessna did on its last flight. Low-level
pre-flight, checklist
aerial work had used more fuel than even
the pilot’s generous estimate. Open throttle,
• Make fuel checks a
low-speed flying with many steep turns was
checklist (or every
probably one of the reasons behind the high
few minutes) item when consumption. Another could have been the
practice of selecting fully rich mixture for
flying aerial work.
low-level, high-power flight.
... a Cessna
152 can
carry no
more than
82% of its
fuel load
The message is to beware of unknown factors
in a novel flight, Jones says.
The ATSB says: ‘fuel consumption rates
determined through experience with an
aircraft over a variety of types of operation
will not necessarily be relevant to higherpowered, richer mixture and lower level
Unusually, this fuel exhaustion story had
a happy ending. The 28-year-old pilot and
70-year-old passenger climbed from the
wreckage unhurt. For obvious reasons,
there was no fire. That sort of luck cannot be
guaranteed in the deep and sudden silence
after tanks run dry and the engine stops.
Civil Aviation Advisory Publication 234-1(1) sets out guidelines to follow
in determining the fuel required for a flight; factors to consider in
determining the amount to be carried and checks to make to establish
fuel on board, including quantity cross-checking. It is available on the
CASA website: www.casa.gov.au
Preliminary analysis of fatal general aviation accidents in Australia
1991-2000 www.casa.gov.au/wcmswr/_assets/main/media/download
Starved and exhausted: fuel management aviation accidents ATSB Avoidable
Accidents series December 2011 www.atsb.gov.au
‘When you’re out on a nav you usually
consider your fuel state every few minutes,’
he says. In low-level aerial work it’s easy to be
distracted – there’s a lot happening after all,
and it makes compelling demands on your
Pull-Out Section
Oil and Water
Canada’s east coast offshore oilfields are a
vivid demonstration of the oil industry maxim
that ‘all the easy oil has already been found’.
Since the 1990s, platforms on the continental
shelf of Nova Scotia and Newfoundland
have pumped oil from beneath the bed of a
cold and stormy sea. The area is also known
as the setting for the October gale of 1991,
immortalised by writer Sebastian Junger in
The Perfect Storm.
Pull-Out Section
An offshore helicopter crash, which killed 17
people off Canada’s east coast in 2009, is a
story of several dearly bought lessons about
maintenance communication, crew resource
management and survival equipment.
Photo: Dreamstime
Pull-Out Section
A lack of flail injuries on the bodies later
recovered suggested the workers in the cabin
had braced correctly. The pilots had substantial
head injuries from the instrument panel.
Photo: Dreamstime
Like offshore platforms everywhere, the rigs of the Canadian oilfields
rely totally on helicopters. Flying conditions here are similar to those
of the North Sea, between Britain and Europe, with poor visibility,
frequent rough air, stormy seas and cold water.
This is the environment into which a Cougar Helicopters Sikorsky
S-92A took off from St. John’s, Newfoundland, with 16 passengers
and two pilots, to the Hibernia oil production platform. It was 0917 on
12 March 2009.
The passengers had been issued with Helly Hansen Nautilus E-452
survival suits. Cougar Helicopters and the suit manufacturer took cold
water safety seriously. All passengers had to undertake a five-day
survival course and all suits were inspected after every flight and
pressure tested at the factory every six months.
About 0945, at 9000ft and about 54 nautical miles from the airport,
a main gearbox oil pressure warning light illuminated. The pilots
declared an emergency, began to descend, and diverted back to
St. John’s. The descent levelled off at 800ft. The pilots had a brief
discussion about the problem, which the captain decided was due
to a faulty sensor. He declared his intention to get to shore, despite
the first officer advising that the final step in the checklist was to land
immediately. A failure of the tail rotor drive decided the issue.
At 0955, about 35 nautical miles from St. John’s, the crew reported
that they were ditching. The helicopter was clear of cloud, with good
flight visibility, in daylight. The wave height was about 2.5 metres and
the water temperature was 0.3 degrees Celsius.
The helicopter struck the water in a slight right-bank, nose-high
attitude, at low speed and a high rate of descent. The Transportation
Safety Board of Canada (TSB) found its vertical speed was ‘somewhat
less than 5100ft per minute,’ (about 26 metres per second or 93 km/h).
The flight data recorder had been interrupted shortly before the crash.
One of its final readings was main rotor rpm at 81 per cent and falling.
Among the last recorded words of the first officer were his advising
the pilot of the falling rotor rpm.
The fuselage fractured horizontally and sank quickly in 169 metres
of water. Its emergency floats did not inflate, but everyone on board
survived the crash, seven of the passengers with no significant
injuries, thanks in part to impact-absorbing seats.
But only one person was found alive. He was
seriously injured and had spent about 80
minutes in the water before rescue. A 26-yearold rig kitchen worker also made it out of the
helicopter but was dead when picked up. She
had drowned, as had the other 16 people who
remained in the helicopter. Cold-water shock
probably reduced the time they were able to
hold their breath to about 15 seconds. Those
who were unconscious would have drowned
immediately from the gasping reflex stimulated
by immersion in very cold water. The TSB
subsequently recommended that the survival
suits incorporate portable air supplies to allow
more time for evacuation.
Nothing was heard from the emergency locator
transmitter or the personal locator beacons
worn by the occupants of the helicopter.
The helicopter was raised from the sea bed a
week after the crash. A preliminary examination
quickly found the cause of the gearbox failure.
Two of three studs used to hold the oil filter
housing onto the transmission had failed.
The studs were titanium, which is light and
corrosion resistant, but relatively soft. They had
worn prematurely because of a greater than
expected number of transmission oil changes.
Once worn, the nuts on the studs were not able
to be done up as tightly as they should have
been and the studs experienced greater loads
in flight, leading to their sudden failure.
Sikorsky had issued an alert service bulletin
on 28 January, 2009, which recommended
that the titanium stud be replaced with a steel
stud within one year, or 1250 flight hours of the
bulletin’s date. The bulletin was in response to a
total loss of oil and resulting emergency landing
of an S-92 in Broome, Australia, in August 2008.
However, the Sikorsky service bulletin had been
only the latest in a series of communications to
S-92 operators about titanium gearbox studs.
These had included a webcast (Sikorsky and
S-92 operators conduct weekly webcasts) in
August 2008, six weeks after the Australian
incident. Cougar Helicopters had participated
in that webcast, but the Australian incident had
A preliminary examination quickly found the cause of the gearbox failure. Two of three
studs used to hold the oil filter housing onto the transmission had failed.
not been considered a cause for concern as it
was believed to have resulted from a field repair
the Australian operator had made on the stud.
Moreover, the S-92 had been flying for five years
with more than 100,000 hours as a type, with no
similar incidents.
Retired Canadian judge, Robert Wells, conducted
the public inquiry into the crash. He was critical
of Sikorsky’s response to the Australian incident.
However, Cougar Helicopters did respond
promptly to the January 2009 service alert. It
ordered the replacement steel studs in February
2009. They were to have been sent in the next
parts shipment.
Urgent action did come after the crash. Within
days of the revelation about the titanium studs in
Cougar 91, the US Federal Aviation Administration
issued an airworthiness directive, a special
airworthiness information bulletin and, finally,
an emergency airworthiness directive that
required the studs be replaced immediately with
steel ones.
The unanticipated failure of the studs had made
other mechanical defences irrelevant. The S-92
was designed to comply with the US Federal
Aviation Administration’s requirement [FAR Part
29.927(c)(1)] for a 30-minute run dry requirement,
unless the possibility of gearbox oil loss was
‘extremely remote’.
Although the similar gearbox of the Sikorsky UH60 Black Hawk passed the 30- minute test, the
S-92 gearbox lasted only 11 minutes before the
tail rotor drive failed.
(The test assumed 60 per cent of oil had
been lost). Leakage from the oil filter had
not shown up as an issue in the Black HellyNautilus E-452 suit
Hawk gearbox. Taking all known factors into
account, Sikorsky and the FAA concluded that other types of gearbox
failure were ‘extremely remote’.
Data from its flight data recorder and the health and usage monitoring
system indicated the loss of transmission oil in Cougar 91 had caused
the tail rotor to fail after 10 minutes. The helicopter hit the water a
minute after that.
The inquiry found that ambiguities in the flight manual had contributed
to a misdiagnosis of the situation by the pilots, who had concluded
that they were dealing with a faulty oil pump or sensor. They
were expecting to see an increase in oil temperature, as a sign of
impending transmission failure. This rise didn’t happen because there
was almost no oil left in the transmission.
The inquiry found the captain’s decision to carry out pilot flying duties,
as well as several pilot not flying duties, resulted in an excessive
workload that delayed checklist completion and prevented the
captain from recognising critical cues available to him. It noted that
the captain was perceived to have a strong personality. In contrast,
the first officer lacked assertiveness, the report said.
The main rotor rpm loss that caused the helicopter to plunge over its
final 160ft of descent was found to have been caused by the throttles
being shut off before lowering the collective after the tail rotor failed.
The sole survivor’s survival suit was found to be one size too big. He
had been fitted with a large suit for comfort; he should have worn a
medium. There were no lessons to be learned from his suit because
it had been destroyed by paramedics. Concerned at the greater than
predicted drop in the survivor’s core temperature, Helly Hansen
redesigned the E-452 suit.
The crash of Cougar 91 happened on the other side of the world
in a very different climate. But the climate of aviation is the same
everywhere. There are lessons for Australians who maintain, manage
or fly fixed- or rotary-wing aircraft. The story of how maintenance
communication was insufficient is a parable for all LAMEs. The story
of how cockpit communication broke down should concern all who
fly in multi-crew operations, and the way that survival suit fitting
was allowed to drift should be of concern to anyone who manages
safety systems.
In October 2008, Sikorsky issued a safety
advisory to inform operators of changes to the
aircraft maintenance manual that would include
an enhanced inspection procedure for removal
and installation of the oil filter bowl assembly.
As the subsequent TSB investigation found,
there was no record that Cougar Helicopters
had implemented this enhanced inspection
Hibernia oil platform
Pull-Out Section
‘Coming events cast their shadow,’ Wells told
the 2011 Safeskies conference in Canberra.
‘The shadow from the Broome incident was a
long shadow, but it seems nobody grasped the
significance of it.’
In response, Sikorsky added a bypass
valve to isolate the oil cooler, from which it
expected the overwhelming majority of leaks
would come. (This conclusion was based
on Black Hawk service history). When the
bypass valve was shut promptly the S-92
transmission could run for up to three hours
after an oil leak in the cooler or its hoses.
16 Sept – 18 Nov 2011
Note: Similar occurrence figures not included
in this edition
Airbus A320232 APU start/ignition system
O-ring damaged. SDR 510013694
Fumes in cabin during descent. Investigation found
the APU starter O-ring seal cut and leaking. P/No:
M832481034. TSN: 14,602 hours/15,317 cycles.
Pull-Out Section
Airbus A320232 Cargo station equipment
power drive unit failed. SDR 510013644
Rear cargo hold power drive unit (PDU) failed.
Unit overheated (too hot to touch) and smoking.
P/No: 1291009.
Airbus A320232 Equipment/furnishings wiring
incorrectly routed. SDR 510013668
RH forward and RH aft passenger door escape slide
electrical wiring incorrectly routed. Routing was for
LH door installation.
Airbus A320232 Fuel crossfeed switch
incorrectly fitted. SDR 510013819
Fuel crossfeed overhead switch incorrect part.
Switch located below the crossfeed switch was
meant to be changed but was inadvertently installed
in crossfeed switch position.
P/No: ABS0951 C3LM004.
Airbus A320232 Pneumatic system
compressor faulty. SDR 510013649
Electrical burning smell in cabin. Smell traced to a
faulty air compressor. P/No: 8378M12.
Airbus A320232 Trailing edge flap position
indicating pick-off unit contam-water.
SDR 510013792
Flap asymmetric position pick-off unit (APPU) faulty
due to water contamination.
P/No: 9028A000401. TSN: 6,067 hours/3,114 cycles.
Airbus A321231 Fuel boost pump incorrect
part. SDR 510013577
Pre-mod fuel pump P/No: 568-1-27202-005 fitted
at FIN location 25QA. Part number does not comply
with the requirements of either SB A320-28-1159
or AD/A320/192.
P/No: 568127202005.
Airbus A330202 APU smoke/fumes.
SDR 510013714
Strong oily smell evident on flight deck.
Suspect faulty APU.
Airbus A330202 Fuel storage cap missing.
SDR 510013585
RH wing fuel access panel found to be open with
the panel hold-open rod broken and latch damaged.
Investigation also found the refuel manifold
caps missing.
Airbus A330303 Air distribution fan faulty.
SDR 510013699
Fumes and burning electrical smell in cabin. Initial
investigation found the LH recirculation fan circuit
breaker FIN 1 HG 1 had tripped. Suspect caused by
seizure of the fan rotor ball bearing.
Airbus A330303 Brake rotor failed.
SDR 510013772
No. 2 main wheel brake rotor broken. Investigation
found additional cracks in broken rotor as well as
adjacent rotors.
P/No: 215782.
Airbus A380842 Crew oxygen bottle
discharged. SDR 510013749
Forward crew oxygen bottle discharged.
Investigation continuing.
P/No: B435705.
Airbus A380842 Passenger oxygen system
PSU leaking. SDR 510013743
Passenger service units (PSUs) leaking oxygen.
A total of 47 PSUs with 16 different part numbers
were found to have significant leaks. Found during
inspection iaw EA SM07622 and AMM 35-20-00720-807. Investigation continuing.
Airbus A380842 Potable water system water
tank leaking. SDR 510013715
Potable water tank leaking. Investigation continuing.
Airbus A380842 Wing, rib/bulkhead rib
cracked. SDR 510013633
LH wing lower boom ribs cracked on feet. Cracking
found on forward hybrid rib 11/Str 7, rib 12/Str 2 and
rib 14/Str 7. Investigation continuing.
BAE 146300 Aircraft lightning strike.
SDR 510013600
Aircraft suffered a lightning strike. Investigation
found a hole at a rivet position on the edge of the
RH airbrake petal and a burnt section at the rear
of the RH lower pitot probe. BAE 146RJI00 Hydraulic main filter leaking.
SDR 510013849
Green hydraulic system pressure filter leaking
from union.
BAE JETSTREAM3206 Aileron control heavy.
SDR 510013828
Aileron control system heavy in operation. During
landing, the flaps were oversped. Investigation
of the aileron system and flap system found nil
BAE JETSTREAM3206 Pitot/static system
FOD. SDR 510013880
Pitot/static system FOD. Investigation found the
remains of two insects partially blocking system.
Boeing 717200 Hydraulic system, main fitting
leaking. SDR 510013611
RH main landing gear door retraction actuator
bottom fitting leaking due to extruded O-ring seal.
Loss of hydraulic fluid.
Boeing 717200 Main landing gear strut/axle/
truck link separated. SDR 510013760
RH main landing gear brake line scissor links and
ground sense link disconnected from lower strut.
Suspect caused by link arm coming adrift and
affecting proximity sensor.
Boeing 737376 Fuselage main, frame fuselage
frame cracked. SDR 510013705
Fuselage frame cracked in three places in wire
penetration holes located between stringer 20 and
stringer 21. Found during eddy current inspection
iaw EI 733-53-0373. List of cracks: 1) BS500B
LH - aft side of frame cracked. Crack length
approximately 7.6mm (0.300in). 2) BS500D LH aft side of frame cracked with crack running into
inboard radius. 3) BS500C RH - aft side
of frame cracked. Crack length approximately
3.81mm (0.15in).
Boeing 737476 Air distribution cooling fan
failed. SDR 510013889
Strong sulphur-type smell in cabin. Investigation
found avionics equipment cooling fan had failed. P/
No: 65771. TSN: 539,765 hours. TSO: 27,134 hours.
Boeing 737476 Flight compartment light
smoke/fumes. SDR 510013813
Smoke observed coming from under glareshield on
first officer's side. Investigation found background
light assembly faulty.
P/No: 16471.
Boeing 737476 Galley station equipment
system oven suspect faulty. SDR 510013698
Smoke/fumes in forward galley. Investigation could
not confirm the source but it was found that the
smell intensified with oven C206 operating.
Oven replaced and smell did not occur again.
P/No: GENM2585015. TSN: 55,545 hours. TSO:
13,885 hours.
Boeing 737476 Trailing edge flap position
indicating switch faulty. SDR 510013724
Trailing edge flap up limit switch S245 failed.
P/No: 426EN108.
Boeing 7374L7 Fire detection module
faulty. SDR 510013706
Fire warning on landing and shutdown. Nil other
indications. Investigation found a faulty fire/
overheat module.
P/No: 659401.
TSN: 52,194 hours. TSO: 42,063 hours.
Boeing 7374L 7 Fire detection system suspect
faulty. SDR 510013741
Engine fire warning on take-off. System checked
but nil faults found although lamps were changed
as a precaution.
Boeing 73776N APU start/ignition system
starter-generator failed. SDR 510013688
APU starter-generator failed to restart following
shutdown. Caused by diode failure.
P/No: 28B5457. TSN: 6,216 hours/5,785 cycles.
Boeing 7377FE Landing gear position and
warning system light worn. SDR 510013596
LH main landing gear warning light base assembly
had worn pins and contact preventing secure
connection and causing light to flicker.
P/No: 3181001032.
Boeing 7377Q8 Drag control system cable
broken. SDR 510013847
Spoiler cable WSB2 broken and lying on No. 2 flap
track fairing. Investigation found wing spoiler panels
No. 2 and No. 3 not sitting flush.
P/No: BACC2C3D04062FG.
Boeing 7377Q8 Pneumatic distribution system
line broken. SDR 510013835
Bleed air rigid supply line located between 9th
stage supply duct and BAR/PCCV broken. Duct union
nipple also worn in flared section.
P/No: 332A2350l2.
Boeing 7377Q8 Trailing edge flap control
system connector damaged. SDR 510013592
(photo below)
Alternate trailing edge flap operating system
connector D46036P internally short circuited and
pins burnt. Connector located in LH main wheel
well ceiling.
P/No: D46036P.
Boeing 737838 Fuel boost pump relay failed.
SDR 510013784
RH fuel boost pump relay R937 failed.
Boeing 737838 Landing gear position and
warning system PSEU faulty. SDR 510013702
LH forward and aft overwing door lights illuminated.
Inspection found door locks OK. Investigation found
a faulty proximity sense electronic unit (PSEU).
P/No: 285A16005.
TSN: 30,889 hours. TSO: 30,889 hours.
Boeing 737838 Leading edge channel
damaged. SDR 510013739
LH edge slat downstop gang nut channels for No.1
leading edge slat inboard track inboard channel and
No. 2 leading edge slat inboard track outboard
channel deformed. Found during inspection iaw
EI N37-57-0070.
Embraer ERJ190100 Flight compartment
window cracked. SDR 510013651
LH direct vision window outer pane cracked in two
places along forward edge approximately 200mm
(8in) from the forward LH corner. Crack lengths
approximately 25.4mm (1in). Inspection of the
cracks suggests that the cracking was caused by
impact damage.
P/No: 17028299413.
Boeing 737838 Throttle suspect faulty.
SDR 510013738
No response to engine thrust lever movement.
Investigation continuing.
Embraer ERJ190100 Fuel storage vent
suspect faulty. SDR 510013662
LH and RH wing tanks venting overboard.
Suspect caused by design of fuel vent system.
Boeing 7378FE Landing gear retract/extension
system suspect faulty. SDR 510013584
Landing gear failed to retract. Investigation could
find no cause for the problem but it was reported
that the landing gear manual access door was
opened and closed prior to departure as rain had
leaked into the flight deck and needed to be cleaned
up. Maintenance personnel were able to simulate
the fault by closing the access door but not latching
it fully, but the crew stated the door was checked
closed before take-off as per their checklists.
Fokker F28MK0100 Drag control actuator
cracked. SDR 510013869
LH No. 5 lift dumper actuator outer body cracked
circumferentially. Investigation continuing.
TSN: 100,965 hours/l00,751 cycles.
Boeing 7378FE Wheel failed.
SDR 510013846
No. 4 main wheel hub failed. Nil damage to axle.
P/No: 277A6000204. TSN: 13,215 hours/5,757
cycles. TSO: 2,805 hours/261 cycles.
Boeing 747438 Aircraft structures drain
blocked. SDR 510013602
Aircraft canted pressure deck drain blocked at
Stn 1240 LBL12-RBL12 WL69.
Boeing 767336 Escape slide reservoir
low pressure. SDR 510013716
Emergency exit door escape slide reservoir
pressure low.
Boeing 767338ER AC regulator controller
failed test. SDR 510013703
LH hydraulic motor generator (HMG) controller failed
operational test due to frequency out of limits.
Boeing 767338ER Hydraulic main filter
separated. SDR 510013586
Centre hydraulic system pressure filter separated
from filter module causing major hydraulic leak.
Investigation found the case to be cracked in the
threaded area before failure.
P/No: 271 T00424.
Bombardier DHC8103 Hydraulic system ‘B’
nut loose. SDR 510013805
No. 1 hydraulic system ‘B’ nut loose in RH wing root
area. Loss of hydraulic fluid.
British aerospace BAE1251000 Pressure
control system suspect faulty. SDR 510013692
Pressurisation system control faulty. Investigation
could find no faults but it is suspected that poor
seating of pneumatic line connection between the
pressurisation controller and outflow valves may
have been the cause of the defect.
Embraer EMB120 Main landing gear strut/axle/
truck bearing unserviceable. SDR 510013750
Main landing gear strut tubular bearing severely
corroded. Oleo seals also leaking.
P/No: 2164300001. TSN: 22,174 landings.
TSO: 8.360 landings.
Embraer ERJ170100 Engine oil pressure
indicating system faulty. SDR 510013670
Engine oil pressure system faulty. Pressure
fluctuating during flight. Investigation continuing.
Fokker F28MK0100 Fuselage main frame
cracked. SDR 510013708
Fuselage cracked at Stn 3845 and Stn 4150 stringer
37 and stringer 38. Crack progressed along a butt
joint of two mating upper skins. Crack length
158.75mm (6.25in).
Fokker F28MK0100 Landing gear retract/
extension system bushing cracked.
SDR 510013795
LH main landing gear downlock lower toggle
link lug bushing cracked and loose in housing.
Investigation continuing.
TSN: 27,953 hours/21,225 cycles.
TSO: 2 hours/2 cycles.
Beech 200 Vertical stabiliser spar cap
corroded. SDR 510013658
Vertical stabiliser LH and RH rear spar caps
contained excessive exfoliation corrosion.
P/No: 10164001010. TSN: 8,607 hours.
Beech 300 Horizontal stabiliser angle
corroded. SDR 510013825 (photo below)
LH horizontal stabiliser rear spar lower spar
cap angle contained exfoliation corrosion located
at HSS 65. Investigation also found slight
exfoliation corrosion just inboard of HSS 17.
P/No: 1016200144. TSN: 8,491 hours/5,404
cycles/5,404 landings.
Fokker F28MK0100 Windshield rain/ice
removal system transformer burnt.
SDR 510013870
LH windshield heat transformer burnt and
arcing at terminal point GS0242. Skin and wire
in area damaged.
Aircraft BELOW 5700kg
Beech 200 Cargo station equipment section
latch pin faulty. SDR 510013775
Wing locker latches failed to lock correctly
with inadequate lock pin engagement. Suspect
due to misalignment and/or lack of lubrication.
P/No: 853520092.
Beech 200 Elevator hinge corroded.
SDR 510013659
LH and RH elevator outboard hinges contained
excessive exfoliation corrosion.
P/No: 1016200113. TSN: 8,607 hours.
Beech 200 Fuselage/stabiliser attach fittings
angle cracked. SDR 510013623
LH fin to fuselage fillet angle cracked through
a previous patch. Investigation found RH fin to
fuselage fillet angle also cracked.
Beech 200 Nacelle/pylon, frame/spar/rib rib
corroded. SDR 510013647
LH nacelle outboard side rib badly corroded and
adjoining bracket cracked.
P/No: 1019800132. TSN: 22,485 hours 117,652
cycles 117,652 landings/396 months.
Beech 200 Rudder structure bearing cap
failed. SDR 510013802 (photo following)
Lower rudder bearing failed/collapsed allowing
rudder control horn to rub on the bearing support.
Suspect caused by excessive shimming between
rudder torque tube and control horn.
P/No: MS289135C55301002770. TSN: 13,098
hours/15,701 landings.
Boeing 747438 Flight compartment windows
window cracked. SDR 510013701
First officer's No. 1 windshield cracked in vinyl
interlayer. Window initially failed to heat before
cracking. Window heat controller also changed.
Fokker F28MK0100 Drag control system
actuating rod cracked and corroded.
SDR 510013881
RH No. 3 lift dumper door actuator rod cracked
and corroded. Further investigation found the LH
No. 4 lift dumper door actuating rod also cracked.
Investigation continuing.
Beech 200 Tyre balance weight disbonded.
SDR 510013727
Nose wheel tyre internal balance weight
disbonded and separated from tyre, causing out
of balance condition. Balance weight was 56gm.
P/No: 265F868.
TSN: 482 hours/567 landings/3 months.
Pull-Out Section
Boeing 737838 Leading edge nut loose.
SDR 510013787
Loose nut found in No. 8 leading edge slat inboard
track cavity canister. Nut held in with grease.
Investigation could not find the origin of the nut.
No. 1 leading edge slat outboard track guide channel
forward anchor nut retaining clip dislodged and
found in guide channel. Found during inspection iaw
EI N37-057-0070.
Beech 300 Rudder control system nut loose.
SDR 510013641
Rudder post to rudder horn attachment bolts
and fitting loose.
P/No: 130909N32.
Beech 95B55 Wing spar cap corroded.
SDR 510013871 (photo below)
LH wing upper spar cap corroded in area located
at approximately WS 54. Area of corrosion
approximately 63.5mm long by 19mm wide by
1.9075mm deep (2.5in long by 0.75in wide by
.075in deep).
P/No: 501100032. TSN: 6,449 hours/5l2 months.
DHav DHC2 Elevator structure corroded.
SDR 510013878
LH elevator front spar, end rib and upper and lower
skin internal surfaces corroded.
Beech E33 Elevator control cable broken.
SDR510013965 (photo below)
Elevator down cable broken at pulley P/No. 187546. Cable is located forward of the instrument
panel. Following discovery of the failed cable, an
inspection on a similar type aircraft (Beech A36)
found the same part number (PNo 36-524000-23)
cable frayed and ready to fail.
P/No: 33-524000-63. TSN: 4,610 hours
Diamond DA42 Nose/tail landing gear torque
link cracked. SDR 510013589
Lower nose landing gear torque link cracked through
lower RH lug.
P/No: D6032231053. TSN: 880 hours/19 months.
Pull-Out Section
Giplnd GA8 Pitot/static anti-ice system
connector loose. SDR 510013758 (photo below)
Pitot tube heater P50/150 connectors loose causing
overheating. P/No: P50150.
Cessna 172S Rudder control system cable
worn. SDR 510013693 (photo below)
Rudder cables P/No 05101-369 and P/No 05101-338
worn in area of idler pulleys located at bulkhead at
the rear of the baggage bay.
P/No: 05101369. TSN: 5,844 hours.
Cessna 172M DC power distribution system
wire burnt. SDR 510013755
Feeder cable from alternator to bus burnt for
approximately 50mm (1.9in). Burnt area was where
the feeder cable was secured to the artificial horizon
inlet air hose by a cable tie. It is suspected the cable
tie vibrated and wore through the insulation. P/No:
S153489. TSN: 7264 hours
Cessna 402B Main landing gear strut/axle/
truck torque link disconnected. SDR 510013704
RH main landing gear upper and lower torque links
disconnected allowing wheel assembly to rotate 90
degrees. Suspect caused by incorrect installation of
washer in torque link centre pivot as referenced in
AWB 32-020 issue 1.
Cessna 402C Passenger/crew door faulty.
SDR 510013710
Upper passenger door opened in flight. Investigation
found door handle loose not stowing correctly.
P/No: 521119024.
Cessna 404 Rudder control system rod
end broken. SDR 510013867
Rudder trim actuator rod end failed at start
of threaded area.
TSO: 32 months.
Cessna 441 Instrument wiring harness worn.
SDR 510013808
RH annunciator panel wiring harness chafed against
rear of Comm 2 controller. Circuit breaker tripped.
TSN: 9,644 hours.
Cessna 441 Trailing edge flap skin separated.
SDR 510013860
RH outboard flap lower skin separated.
TSN: 17,875 hours.
Cessna 208 Nose/tail landing gear bolt failed.
SDR 510013855
Nose landing gear spring fork to shock strut LH
attachment bolt failed. RH bolt and support bearing
assembly migrated through the fork allowing the
shock strut to separate from the fork. Suspect
bolts inadequate size for application along with
attachment point for operations on unsealed landing
strips. TSN: 164 hours/284 landings.
Cessna 210F Elevator spar/rib nut cracked.
SDR 510013580
Elevator torque tube nut cracked. Suspect cracking
due to hydrogen embrittlement.
P/No: MS2l042L4.
Cessna 210L Landing gear wiring worn and
damaged. SDR 510013642
Landing gear power pack wiring chafed and
short circuited causing landing gear pump to
run continuously.
Cessna 305A Elevator structure
unserviceable. SDR 510013833
(photo following)
Centre elevator pivot bracket failed.
P/No: 0632106.
Cessna 550 Rudder tab control system
cable failed. SDR 510013684
Following rudder removal and replacement, the
rudder system operation was checked. Rudder trim
was hard to move through full range and some
resistance was felt during rudder operation
followed by something giving way. Investigation
found the rudder trim cable had failed and the
cable had bird-nested between the rudder pulley
and pulley support bracket.
P/No: 656501010CR.
TSN: 17,174 hours/10,459 cycles.
Child S2CPITTS Landing gear retract/
extension system strap broken. SDR 510013853
(photo below)
Main landing gear over extension strap
pulled through Nicopress sleeves.
TSN: 600 hours.
Gulfstream 500S DC generator-alternator
terminal faulty. SDR 510013762
LH alternator terminal poorly fitted resulting in wire
becoming loose. Investigation found insufficient
insulation stripped from wire for a good contact at
the terminal and the terminal had been crimped
with what appears to be pliers. Terminal was also
an automotive part.
P/No: Unknown automotive.
Gulfstream 500S Hydraulic pump main fitting
failed. SDR 510013812
RH hydraulic pump fitting failed and separated.
Loss of hydraulic pressure.
P/No: MS208226D.
Pilatus PC12 Brake system master cylinder
failed. SDR 510013604
RH brake master cylinder failed.
P/No: 9594751132.
TSN: 2,647 hours/2,277 landings.
Piper PA28161 Main landing gear oleo strut
cracked. SDR 510013779 (photo below)
RH main landing gear oleo strut cracked in lower
torque link outboard attachment lug. Crack length
approximately 25.4mm (1in) long by 6.35mm
(0.25in) deep.
P/No: 78738803. TSN: 8,401 hours.
Piper PA28R201 Hydraulic main power pack
intermittent. SDR 510013661
Hydraulic power pack intermittent in operation.
P/No: HYC5005. TSN: 513 hours 10 months.
TSO: 513 hours 10 months.
Piper PA31350 Landing gear position and
warning microswitch failed. SDR 510013789
RH main landing gear downlock microswitch failed.
P/No: 1CH214.
Piper PA31350 Main landing gear torque link
broken. SDR 510013655
RH main landing gear upper torque link broken and
upper and lower torque link bolts had sustained
severe loads.
P/No: 4025700.
Piper PA44180 Hydraulic pressure sensor
switch faulty. SDR 510013616
Landing gear hydraulic power pack pressure
switch faulty.
P/No: 587847. TSN: 7,922 hours/400 months.
Jabiru3300 Reciprocating engine cylinder
bushing contaminated. SDR 510013803
Rocker bushes deteriorated/breaking down.
Bushes manufactured from plastic/nylon material.
TSN: 25 hours. TSO: 25 hours.
Swearingen SA227DC Landing gear
nosewheel steering system failed.
SDR 510013610
Nose wheel steering system failed. Aircraft left the
runway at low speed. Investigation continuing.
Jabiru3300 Reciprocating engine cylinder
bushing failed. SDR 510013707 (photo below)
Rocker bushings (9off12) failed within two hours
of fitment. Oil feed blockages caused damage to
rocker shafts and bushes. Rocker shaft bushes are
manufactured from plastic/nylon material. Aircraft
registered with Recreational Aircraft Australia.
TSN: 2 hours.
Vulcan P68C Elevator tab control system trim
system slipped. SDR 510013689
Elevator trim system slipping when operated
electrically, reducing the amount of trim available.
Lycoming IO540AE1A5 Engine exhaust system
holed. SDR 510013626
Exhaust muffler to tailpipe assembly junction holed.
P/No: C16932. TSN: 508 hours.
Lycoming IO540AE1A5 Engine muffler
damaged. SDR 510013628
Muffler/tailpipe junction blown out.
P/No: C16932. TSN: 503 hours.
Continental IO520L Engine fuel pump seized.
SDR 510013765
Engine driven fuel pump P/No: 646212-23A
seized and driveshaft P/No: 631683 sheared.
P/No: 64621223A.
Lycoming IO540E1B5 Reciprocating engine
crankshaft failed. SDR 510013607
Crankshaft failed due to cracking in the area of
No. 3 main bearing radius.
P/No: 75079. TSN: 28,100 hours. TSO: 1,209 hours.
Continental IO520L Magneto/distributor
bearing seized. SDR 510013768
LH magneto cam end bearing seized. Suspect
lack of lubrication. Metal contamination of engine.
P/No: 10353060. TSN: 159 hours.
Lycoming IO540K1A5 Engine fuel pump
fluctuates. SDR 510013685
Engine driven fuel pump pressure fluctuating.
P/No: RG 17980DM. TSO: 39 hours.
Lycoming IO540K1A5 Reciprocating engine
failed. SDR 510013733
Engine failed resulting in an emergency landing.
Initial investigation on site found the engine seized
and a pool of oil under the aircraft. The crankcase
was also ruptured. Investigation continuing.
TSN: 1,764 hours. TSO: 1,764 hours.
Continental O300C Reciprocating engine
piston pin unserviceable. SDR 510013681
Piston pins (2 off) unserviceable. Piston pin surface
covered in ‘heat check’ indications. P/No: 530830.
Lycoming IO540K1A5 Reciprocating engine
piston ring broken. SDR 510013664
No. 6 cylinder piston oil regulator ring broken into
several pieces.
P/No: 14H21950. TSN: 1,894 hours.
Continental TSIO520C Reciprocating engine
valve lifter corroded. SDR 510013646
Inlet and exhaust valve lifter faces corroded with
one lifter having heavy pitting. Nil damage to
camshaft. Nil metal contamination of oil filter.
P/No: 653877. TSO: 617 hours/138 months.
Lycoming IO540K1A5 Reciprocating
engine cam follower spalled. SDR 510013686
(photo below)
Metal contamination of engine oil system.
Investigation found cam follower faces spalled.
TSN: 403 hours.
Jabiru2200 Reciprocating engine power
section bolt broken. SDR 510013748
Two crankcase through bolts broken. Aircraft
registered with Recreational Aviation Australia.
TSN: 21 hours.
Jabiru3300 Reciprocating engine failed.
SDR 510013752
Engine loss of power. Aircraft clipped power line
and was damaged during forced landing. Aircraft
registered with Recreational Aviation Australia.
P/No: 3300. TSN: 60 hours.
Agusta-Bell A109E Landing gear retract/
extension system hose broken. SDR 510013864
RH main landing gear actuator flexible hydraulic
hose broken and leaking.
P/No: 01501B22C073UREVM.
Bell 206B3 Horizontal stabiliser tube corroded.
SDR 510013680
Horizontal stabiliser tube severely corroded.
P/No: 206020120011.
Bell 206B Engine/transmission coupling worn.
SDR 510013854
Engine/transmission driveshaft inner couplings worn
beyond limits. Outer couplings serviceable. Found
during inspection following overtemp indication.
P/No: 206040117001. TSN: 5,532 hours.
Bell 412 Main rotor gearbox transmission
contam-metal. SDR 510013608
Transmission had minor vibration in cruise. After
approximately 10 minutes, the vibration increased
followed by chip detector illumination. Investigation
found metal contamination. P/No: 412040002103.
TSN: 10,642 hours. TSO: 4,823 hours.
EUROCOPTER BK117C2 Tail rotor control rod
cracked. SDR 510013636 (photos below)
Yaw smart electro-mechanical actuator (SEMA)
control rod cracked on upper end. Crack confirmed
using x10 magnifying glass and subsequent dye
penetrant inspection. P/No: B673M4004101.
Lycoming IO540E1B5 Reciprocating
engine crankcase cracked and leaking.
SDR 510013656
Engine crankcase cracked and leaking through
oil gallery in area located forward and above
No. 2 cylinder.
Hamilton Standard 14RF9 Propeller control
actuator unserviceable. SDR 510013673
LH propeller actuator unserviceable. LH propeller
failed to fully feather. P/No: 7902016.
TSN: 8,999 hours/8,021 cycles/80 months.
Pull-Out Section
Continental GTSIO520M Reciprocating engine
cylinder failed. SDR 510013614
RH engine failure. Bulk strip and investigation found
the cause of the failure was detonation in the
No. 5 cylinder. TSO: 815 hours.
Continental IO520M Reciprocating engine
valve lifter faulty. SDR 510013742
Investigation of vibrating engine found five valve
lifters out of adjustment and not pumping up.
Three exhaust valve lifters and two inlet valve
lifters affected.
P/No: 646277. TSN: 1,075 hours.
Lycoming TIO540AH1A Engine fuel pump drive
shaft sheared. SDR 510013783
Engine-driven fuel pump driveshaft sheared.
Pump was still free to rotate and was not seized.
P/No: 200F5002R. TSN: 540 hours/3 months.
Lycoming TIO540AH1A Reciprocating engine
drive gear tooth missing. SDR 510013816
Crankshaft accessory drive gear tooth missing.
TSN: 1,260 hours 12 months.
Piston Engines
Continental IO520F Reciprocating engine
cylinder failed. SDR 510013865 (photo below)
Engine cylinder head separated from barrel.
P/No: 10520. TSN: 495 hours. TSO: 46 hours.
Lycoming O540F1B5 Reciprocating engine
cylinder unserviceable. SDR 510013590
No. 2 and No. 6 cylinders unserviceable, with
inlet valves sticking and burnt/eroded. Further
investigation found the inlet valves on the other
cylinders were rough in operation, as well as
carbon build-up on the valve stems.
P/No: LW13870. TSN: 274 hours.
Pull-Out Section
Eurocg BK117C2 Tail rotor gearbox damaged.
SDR 510013786 (photo below)
Tail rotor gearbox chip detector illuminated.
Investigation found a piece of metal missing from
one tooth on the bevel gear.
TSN: 1,931 hours. TSO: 130 hours.
Eurocopter AS350B2 Main rotor head
frequency adaptor cracked. SDR 510013665
(photo below)
Main rotor head red blade frequency adapter aft
face cracked. P/No: 704A33640088. TSN: 3,056
hours/3,907 landings/66 months.
Robinson R44 Main rotor gearbox contammetal. SDR 510013627
Main rotor gearbox chip detector light. Investigation
found metal contamination of the chip detector plug.
The chip detector was cleaned and rechecked with
more metal present. Further investigation found the
hard facing coming off the gears.
P/No: C0065. TSN: 503 hours.
SCHWZR 269C Main rotor blades debonded.
SDR 510013851
Main rotor blade outboard leading edge abrasion
strip debonding. A small crack was also found in
the abrasion strip in debonded area.
P/No: 269Al1851. TSN: 2,742 hours.
Eurocopter AS365N Main rotor blade
debonded. SDR 510013605
Main rotor leading edge abrasion strips debonding
at joggle joins. Blade had debonded and been
repaired approximately 71 hours previously.
P/No: 365Al1005004. TSN: 1,614 hours.
MDHC 369E Tail rotor blade debonded.
SDR 510013769 (photo below)
Tail rotor blade leading edge debonding in
area near blade tip.
P/No: 500P3100105. TSN: 1,522 hours.
Turbine Engines
Garrett TPE33110UA Fuel control unit
unserviceable. SDR 510013796
LH engine power lever stiff in operation.
Suspect fuel control unit (FCU) internal failure.
P/No: 8978017. TSO: 2,711 hours.
PWA PT6A42 Fuel control unit arm
contaminated. SDR 510013756
RH engine fuel control unit interconnect arm dry
and dirty causing power lever to stick in flight idle.
TSN: 1,064 hours.
PWA PW120A Fuel control system EECU
suspect faulty. SDR 510013824
No. 1 and No. 2 engines reverted to manual during
approach. Engine electronic control unit (EECU)
suspect faulty. Investigation continuing.
P/No: 7898426009.
PWA PW150A Engine fuel system O-ring
deteriorated. SDR 510013818
Fuel transfer tube to fuel/oil heat exchanger O-ring
seals P/No: M83461-1-116 and P/No: AS3209-126
deteriorated and leaking.
PWA PW150A Fuel control system FADEC
failed. SDR 510013723
No. 2 engine full authority digital engine control
(FADEC) failed. Investigation continuing.
P/No: 8193007009. TSN: 7,013 hours/8,130 cycles.
GE CF680El Fuel control FADEC faulty.
SDR 510013798
No. 1 engine rollback. Suspect full
authority digital engine control (FADEC) fault.
Investigation continuing.
Rolls-Royce RB211524G Engine fuel
distribution tube worn and damaged.
SDR 510013843
No. 2 engine main fuel delivery tube suffered
extensive chafing damage due to contact with
adjacent oil vent tube. Wear was for approximately
50% of wall thickness (limit is 0.1016mm - 0.004in).
Investigation continuing.
P/No: UL37972.
GE CFM567B Fuel pressure indicating
switch suspect faulty. SDR 510013576
No. 2 engine fuel filter bypass light illuminated.
Bypass switch P/No: QA07995 and fuel filter
P/No: 65-90305-88 changed.
P/No: QA07995.
Rolls-Royce RB211524G Turbine engine failed.
SDR 510013718
No. 3 engine exceeded EGT limits during take-off.
Initial investigation found metal on the chip detector
and in the tailpipe. Investigation continuing.
IAE V2527A5 Engine fuel/oil cooler housing
leaking. SDR 510013640
No. 1 engine leaking from fuel diverter return valve
to fuel-cooled oil cooler tube seal housing P/No:
5W820 1. Leakage from between the seal housing
and pipe. P/No: 5W8201.
Rolls-Royce RB211524G Turbine engine failed.
SDR 510013872
No. 4 engine had sparks coming from exhaust during
take-off. Engine operated normally during flight.
Boroscope inspection found major damage to IPC
6 and HPC 1. Downstream blades also damaged.
Investigation continuing.
IAE V2527A5 Engine air starter sparking.
SDR 510013844
No. 1 engine pneumatic starter sparking during
start. Investigation continuing.
P/No: 790425A6. TSO: 6,180 hours/3,220 cycles.
Robinson R44 Engine exhaust system holed.
SDR 510013626
Exhaust muffler to tailpipe assembly junction holed.
P/No: C16932. TSN: 508 Hours.
PWA PT6A41 Turbine engine power section
failed. SDR 510013781
Engine power section failure.
P/No: PT6A41. TSN: 6,486 hours/4,120 cycles.
TSO: 3,697 hours/1,760 cycles.
PWA PW123D Fuel control system EEC suspect
faulty. SDR 510013678
No. 2 engine failed to accelerate. Replaced suspect
faulty engine electronic control and engine operated
OK. TSN: 11,050 hours/2,569 cycles.
GE CF680C2 Thrust reverser shaft damaged.
SDR 510013773
No. 1 engine thrust reverser LH side
electromechanical brake flexible shaft sheared.
P/No: 3278500X.
Robinson R44 Engine muffler damaged.
SDR 510013628
Muffler/tailpipe junction blown out.
P/No: C16932. TSN: 503 hours.
IAE V2533A5 Engine low power.
SDR 510013814
RH engine low power. Investigation could find no
definitive fault.
Rolls-Royce Trent97284 Turbine engine oil
system pipe loose. SDR 510013842
No. 4 engine oil feed pipe P/No: FW48295 loose
and leaking. Deflector lockwire also broken.
Loss of engine oil. Investigation continuing.
P/No: FW48295.
CALL: 131
02 6217 1920
or contact your local CASA Airworthiness Inspector [freepost]
Service Difficulty Reports, Reply Paid 2005, CASA, Canberra, ACT 2601
Online: www.casa.gov.au/airworth/sdr/
Hanging by a strand
A narrow escape for an obser vant pilot and
his lucky passengers highlights an important
maintenance issue
This story nearly made it into the tabloid papers. Had the elevator cable broken a
The up elevator cable failed in a Beechcraft
B33 during the final ‘full and free movement’
control check, just before take-off. The aircraft
had already had its prescribed daily/pre-flight
inspection that day, where no problem had
been found.
There was another Beechcraft, an A36, at
the aerodrome, which was also due to do
children’s joy flights that day. The owner of
this aeroplane had its elevator cables inspected
as soon as he heard of the E33’s failure.
A quick blind feel behind the instrument panel
about where the E33 cable had failed found an
extensively frayed control cable in the same
place on the A36.
The damaged cables were found in Beech
Debonair/Bonanza aircraft made with the
single-pole control system. (Early Barons also
use it.) This was a system used by Beechcraft
aeroplanes in which the yokes were mounted
on a beam that slides in and out of the centre
of the instrument panel.
‘What’s frightening is that the E33 and A36, like all the Bonanza family, have a downward spring load on the elevator
system in order to provide pitch stability in cruise,’ says Roger Alder, CASA senior engineer, maintenance. ‘If the
cable had broken in flight, the spring-loaded elevator would have immediately put the aircraft into a dive. These
aircraft were designed before it was a requirement to have a back-up system of elevator control – typically trim.
There would have been little chance for the pilot to recover.
As the pilot was doing the control checks at the
holding point, he reported feeling something
strange in the elevator controls and decided to
return and have it checked out. It is fortunate
that he did: the up elevator cable had failed
where it ran between (over and under) two
forward pulleys in the elevator control circuit,
ahead of the instrument panel, where the cable
changes direction from horizontal to vertical.
Pull-Out Section
minute later, or the pilot not made a final check, you would be reading about the death
of a special needs child, carer and pilot soon after take-off.
‘The other thing is the pilot said he knew his aircraft and doubted that a
less-experienced pilot would have appreciated the subtle change in how the
controls felt.’
‘The area of the cable
Both Beechcraft had been maintained to CASA Schedule 5.
difficult to inspect
Pull-Out Section
‘Schedule 5 says to inspect the cable – but how do you do that?’ says Alder.
‘The area of the cable system that suffered the failure is very difficult to
inspect properly using visual means alone when the cable is in situ.’
system that suffered
the failure is very
properly using visual
means alone when
the cable is in situ.’
In response to the defect report of this incident CASA immediately sent an
email to Hawker Beechcraft, Beechcraft type clubs and major maintenance
facilities. In the email CASA strongly suggested that they should replace
all flight control cables that have been installed for 15 years or more. For
all other cables, CASA advised that they perform a close inspection of the
entire control system cable run for wear and fatigue, particularly at the
location identified in the defect report.
One inspection technique is to move the elevator control all the way through
the full control movement while using some means of physical contact with
the cable, such as a rag or card, to detect cable fraying.
The two aircraft had much in common in terms of their age, but little in
terms of hours. The one in which the cable broke was 40 years old, while
the one in which it frayed was 30, but at 8000 hours had about twice the
flying time of the older Beech.
But flight control cables will degrade in a variety of ways on any aircraft.
CASA’s recent airworthiness bulletin 27-001, issue 2, of October 2011
applies to, ‘All aircraft flight control cable terminal fittings over 15 years old
made from stainless steel specification SAE-AISI 303 Se, including, but not
limited to, standard terminal part numbers AN669 and MS21260.’
The bulletin followed reports of cable failures in Australia and the United
States in which the metal terminal on the end of the cable snapped.
The only solution for terminal failure of these types of cable is to replace
the entire cable assembly. Internal corrosion in cable terminals cannot be
detected by eye.
AWB 27-001 says: ‘An inspection for pitting on the terminal surface is not
considered adequate to determine the extent of the intergranular corrosion
that may exist beneath the surface of the terminal, because with this form
of corrosion, in this material, the terminal may be close to failure and may
even fail, with no visible pitting on the surface.’
The cables involved in the stainless steel terminal failures had been in place
for 15 years or longer.
‘Operators seem to have two approaches to cables,’ says Alder. ‘One is to
replace them systematically as part of major maintenance – just pull the old
ones out and fit new ones. The other extreme is the wait-and-see approach.
But you have to ask, “what are you waiting for, and what will be the first
sign that you’ve waited long enough?”’
CASA airworthiness bulletin
27-001 issue 2
APPROVED Airworthiness Directives
19 - 22 September 2011
Eurocopter AS 332 (Super Puma)
series helicopters
2011-0180-E – Equipment and furnishings - hoist
cable. Identification, removal, installation prohibition
Eurocopter EC 225 series helicopters
2011-0180-E – Equipment and furnishings - hoist
cable. Identification, removal, installation prohibition
Below 5700kg
TECNAM P2006T series aeroplanes
Dassault Aviation Falcon 2000
series aeroplanes
2011-0192-E - Fire protection - engine fire
extinguisher system. Modification
2011-0193 - Wings - main landing gear
crashworthiness. Modification
Eurocopter BK 117 series helicopters
Fokker F28 series aeroplanes
2011-0149R1 - Electrical power - generator control
unit. Identification, replacement
2011-0184 - Fuel quantity indication system.
Inspection, modification (fuel tank safety)
Eurocopter EC 120 series helicopters
Fokker F100 (F28 Mk 100) series aeroplanes
AD, EC 120, 19 - Emergency flotation gear.
2011-0183 - Electrical power - galley power
supply wiring. Modification
2011-0185 - Equipment and furnishings emergency flotation gear. Inspection, modification
Turbine engines
Eurocopter EC 135 series helicopters
2011-19-03 - Installation of accessory gearbox (AGB)
axis-A oil slinger nut
2011-0111R1 - Air conditioning - mechanical air
conditioning system. Inspection, deactivation
Above 5700kg
Eurocopter EC 225 series helicopters
Airbus Industrie A319, A320 and A321
series aeroplanes
2011-0189-E - Fuselage - intermediate gear box
(IGB) fairing. Inspection, replacement
2011-0176 - Fuselage - forward fuselage frame
(FR) 35 circumferential junction. Inspection, repair
Eurocopter SA 360 and SA 365 (Dauphin)
series helicopters
Airbus Industrie A330 series aeroplanes
2011-0154 (correction) - Rotor flight controls collective pitch lever restraining tab. Inspection,
AD, A330, 32 Amendment 4 - main landing gear
retraction actuator piston rod. CANCELLED
2011-0173 - Power plant - engine air inlet cowl
acoustic panels. Inspection
2011-0177 - Doors - forward and aft cargo doors.
Inspection, replacement
2011-0179 - Landing gear - main landing gear
retraction actuator piston rod. Inspection,
CF-2010-24R1 - Hydraulic accumulators - screw
cap, end cap failure
CF-2011-36 - Main landing gear - retraction
actuator corrosion
Piston engines
Lycoming piston engines
2011-18-09 - Crankshaft inspection for improper
counterweight washers
Below 5700kg
Piper PA-23 (Apache and Aztec)
series aeroplanes
2009-13-06R1 - Forward baggage door locking
mechanism. Inspection, modification
AD, ARRIUS, 16 Amendment 1 - Engine fuel and
control - P3 air pipe. CANCELLED
2011-0182 - Engine fuel and control - P3 air pipe.
Inspection, modification
7 - 20 October 2011
Agusta AB139 and AW139 series helicopters
2011-0205 - Stabilisers - tail fin assembly. Inspection,
Kawasaki BK 117 series helicopters
TCD-7698A-2011 - Rescue winch system - flight
manual supplement. CANCELLED
2009-13-06R1 - Forward baggage door locking
mechanism. Inspection, modification
Piper PA-42 (Cheyenne III) series aeroplanes
Below 5700kg
2009-13-06R1 - Forward baggage door locking
mechanism. Inspection, modification
Cessna 525 series aeroplanes
Above 5700kg
Airbus Industrie A319, A320 and A321
series aeroplanes
Turbine engines
Pratt and Whitney Canada turbine engines PT6A series
2011-0188-CN - Goodrich carbon brake - Reduction
of performance
2011-20-51 - Failure of first stage reduction sun gears
Airbus Industrie A330 series aeroplanes
Rolls Royce turbine engines - RB211 series
2011-0177 (Correction) - Forward and aft cargo doors.
Inspection, replacement
2011-21-51 - Electrical power - to prevent potential
battery fault that could lead to aircraft fire
Diamond DA40 series aeroplanes
2011-21-10 - Removal of the VCS compressor and
mount - FAA STC SA03674AT
Piper PA-23 (Apache and Aztec)
series aeroplanes
AD, PA-23, 93 - Nose baggage door. CANCELLED
Piper PA-31 series aeroplanes
AD, PA-31, 131 - Nose baggage door. CANCELLED
AMD Falcon 50 and 900 series aeroplanes
Piper PA-42 (Cheyenne III) series aeroplanes
23 September - 6 October 2011
2011-0193 - Wings - main landing gear
crashworthiness. Modification
Above 5700kg
Boeing 737 series aeroplanes
Agusta AB139 and AW139 series helicopters
AD, AB139, 3 Amendment 1 - Fin assembly.
2006-0358R1 - Stabilisers - fin assembly.
Inspection, replacement
Eurocopter AS 332 (Super Puma)
series helicopters
2011-0189-E - Fuselage – intermediate gear
box (IGB) fairing. Inspection, replacement
2011-18-10 - Engine mount. Inspection
2011-20-10 - Inspection of wire bundle at left
forward rudder quadrant
Bombardier (Canadair) CL-600 (Challenger)
series aeroplanes
AD, CL-600, 63 - Life-limited landing gear parts.
CF-2003-18R2 - Life-limited landing gear parts
not serialised
Eurocopter AS 350 (Ecureuil)
series helicopters
CF-2003-20R1 - Life-limited landing gear parts
not serialised
AD, Ecureuil 136 - Emergency floatation gear.
CF-2003-21R2 - Life-limited landing gear parts
not serialised
2011-0185 - Equipment and furnishings emergency flotation gear. Inspection, modification
TCD-7705A-2011 - AFM amendment. CANCELLED
TCD-7733A-2011 - Flight manual supplements for
optional equipment and special operations for which
Category A operations (VTOL) are not approved.
Piper PA-31 series aeroplanes
AD, A320, 130 Amendment 3 - Goodrich carbon brake
take-off, landing performance reduction. CANCELLED
2011-0175 - Engine fuel and control - full authority
fuel controller (FAFC). Modification
Turbomeca turbine engines - Arrius series
AD, PA-42, 26 - Nose baggage door. CANCELLED
Airbus Industrie A319, A320 and A321
series aeroplanes
AD, A320, 187 Amendment 1 - Nose landing gear
steering. CANCELLED
2011-0201 - Nose landing gear, braking and steering
control unit. Inspection, replacement
2011-0202 - Landing gear control and interface unit
(LGCIU) wiring. Modification
2011-0203 - Navigation - angle of attack (AoA)
probes. Replacement
Airbus Industrie A330 series aeroplanes
2011-0196 – Fuel - main transfer system - rear and/or
centre tank fuel pump control circuit. Modification
2011-0197 - Hydraulic power - ram air turbine (RAT)
pump - anti-stall device. Inspection, replacement
2011-0204 - Hydraulic power - ram air turbine
actuator. Identification, replacement
Bombardier (Canadair) CL-600 (Challenger)
series aeroplanes
2011-0190 - Fuselage - fuel draining system.
General Electric turbine engines - CT7 series
Pull-Out Section
2011-0153R1 - Landing gear - emergency accumulator
for landing gear (LG) extension. Inspection,
modification, replacement extension. Inspection,
modification, replacement
Eurocopter AS 355 (Twin Ecureuil)
series helicopters
APPROVED Airworthiness Directives ... CONT
BAe Systems (Operations) Jetstream 4100
series aeroplanes
Bombardier (Canadair) CL-600 (Challenger)
series aeroplanes
2011-0194 - Fire protection - toilet vanity unit fire
extinguisher. Modification
AD, CL-600, 71 Amendment 2 - State of design
airworthiness directives
Boeing 737 series aeroplanes
CF-2011-37 – LH engine fuel control input
lever jamming
2011-18-10 (Correction) - Engine mount. Inspection
Boeing 767 series aeroplanes
AD, B767, 227 - Bulkhead structure at STA 1809.5.
2011-14-02 - Bulkhead structure at STA 1809.5
Boeing 777 series aeroplanes
2011-21-03 - Electrical power connectors
Pull-Out Section
21 October - 3 November 2011
Agusta AB139 and AW139
series helicopters
2010-26-52 - Tail rotor blades
Eurocopter BK 117 series helicopters
2011-0208 - Electrical power - generator control
unit. Identification, replacement
2011-0222-E - Engine – crankshaft. Inspection
Turbine engines
2011-23-13 - Power turbine governor
AD, HS125, 57 - Flight manual - change to metric units.
General Electric turbine engines - CF6 series
Turbine engines
AD, CF6, 36 Amendment 1 - Forward engine mount
assembly. CANCELLED
AlliedSignal (Garrett, AiResearch) turbine
engines - TPE 331 series
2011-23-04 - Forward engine mount assembly
2011-18-51R1 - PMA main shaft bearings
General Electric turbine engines - CT7 series
2011-21-17 - Fuel filter differential pressure switch
Bell Helicopter Textron 205
series helicopters
Bell Helicopter Textron 412
series helicopters
Rotax piston engines
British Aerospace BAe 125 series aeroplanes
Bell Helicopter Textron 205
series helicopters
Bell Helicopter Textron 212
series helicopters
Piston engines
AlliedSignal (Lycoming) turbine engines LTS 101 series
4 - 17 November 2011
2010-26-52 - Tail rotor blades
2011-0219 - Flight controls - stall warning
identification system. Replacement
CF-2011-39 - Failure of main landing gear side
brace fitting shaft
2011-0207 - Hydraulic systems - operational
checks, replacement
2010-26-52 - Tail rotor blades
CF-2011-38 - LH engine fuel control input
lever jamming
SAAB SF340 series aeroplanes
2011-23-02 - Main rotor blades
Bell Helicopter Textron Canada (BHTC)
206 and Agusta Bell 206 series helicopters
CF-2011-43 - Main rotor blade
Bell Helicopter Textron 212
series helicopters
Rolls Royce (Allison) turbine engines AE 3007 series
2011-22-03 - Compressor wheel inspection
Rolls Royce turbine engines - RB211 series
2011-0221 - Engine - intermediate pressure
compressor rotor shaft and balance weights.
Inspection, modification
Turbomeca turbine engines - Arriel series
2011-0218 - Engine - module M04 (power turbine),
power turbine blades - life limit. Replacement
2011-23-02 - Main rotor blades
17 November - 1 December 2011
Bell Helicopter Textron Canada (BHTC)
407 series helicopters
CF-2011-42 - Longeron cracking
Bell Helicopter Textron Canada (BHTC)
206 and Agusta Bell 206 series helicopters
Eurocopter BK 117 series helicopters
CF-2011-44 - Main rotor blade
Below 5700kg
2011-0214 - Electrical power - generator control unit.
Identification, replacement
Above 5700kg
Cessna 525 series aeroplanes
Eurocopter EC 135 series helicopters
2011-21-51 - Electrical power - to prevent potential
battery fault that could lead to aircraft fire
AD, EC 135, 17 Amendment 1 - Main gearbox oil
sampling and analysis. CANCELLED
DHC-3 (Otter) series aeroplanes
2009-0106R1 - Main rotor drive - main gearbox (MGB)
oil sampling and analysis program. Amendment
Sikorsky S-92 series helicopters
2011-16-04 - Maximum rolling ground speed limitation
2011-12-02 (Correction) - Airspeed limitations
for aircraft with a Honeywell TPE331-10 or -12JR
turboprop engine installed as per supplemental
type certificate (STC) SA09866SC
Above 5700kg
Airbus Industrie A330 series aeroplanes
AD, A330, 97 - Main landing gear bogie beam.
Airbus Industrie A380 series aeroplanes
Below 5700kg
Cessna 150, F150, 152 & F152
series aeroplanes
2009-10-09 R2 (Correction) - Rudder limit stops
Above 5700kg
Airbus Industrie A319, A320 and A321
series aeroplanes
2011-0206 - Fuselage - section 19 frame 101 upper
cross beam. Inspection, repair
2011-0155R1 - Time limits and maintenance
checks - fuel airworthiness limitations - ALS Part 5.
Airbus Industrie A330 series aeroplanes
Airbus Industrie A380 series aeroplanes
2011-0199 - Auto flight, flight control primary
computer (FCPC). Modification, replacement
2011-0215 - Wings - movable flap track fairing number
3 (MFTF #3) and 4 (MFTF #4) bracket assemblies and
fasteners. Inspection, replacement, modification
2011-0211 - Main landing gear (MLG) bogie beam.
Inspection, repair
2011-0212 - Main landing gear (MLG) bogie beam life limit
Boeing 737 series aeroplanes
AD, B737, 354 Amendment 1 - Forward cargo
compartment frames and frame reinforcements.
2011-20-07 - Power control relays in the P91 and
P92 power distribution panels
2011-23-05 - Forward cargo compartment frames
and frame reinforcements
2011-0217 – Nacelles, pylons - engine pylon forward
fairing access panels. Modification
British Aerospace BAe 146 series aeroplanes
2011-0216 – Equipment, furnishings – galley stowage
installation. Modification
2011-0220 - Hydraulic fluid containment system.
Embraer EMB-135 and EMB-145
series aeroplanes
2011-11-01 - Tail boom lightning protection
Gulfstream (Grumman) G1159 and G-IV
series aeroplanes
2011-24-02 - Fire extinguisher bottle - fixed
Piston engines
Rotax piston engines
2011-0224-E - Engine - crankshaft. Inspection
Teledyne Continental Motors Piston Engines
2011-25-51 - Replacing CMI starter adapters due to
fractures in shaft gears
Turbine engines
AlliedSignal (Lycoming) turbine engines ALF502 and LF507 series
2011-24-11 - Removal of second stage high-pressure
compressor (HPC2) discs due to cracking
General Electric turbine engines - CF6 series
AD, CF6, 74 Amendment 1 - High-pressure compressor
spool shaft Stage 14 disc
Rolls Royce turbine engines - RB211 series
2011-0221R1 - Engine - intermediate pressure
compressor rotor shaft and balance weights.
Inspection, modification
Seats and berths
2011-008-E - Inspection of ejector seat drogue shackle
connection to scissor shackle
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ever had a
Write to us about an aviation incident or
accident that you’ve been involved in.
If we publish your story, you will receive
Write about a real-life incident that you’ve been involved in, and send it to us via
email: fsa@casa.gov.au. Clearly mark your submission in the subject field as ‘CLOSE CALL’.
Articles should be between 450 and 1,400 words. If preferred, your identity will be kept confidential. Please do not submit articles regarding events that are the
subject of a current official investigation. Submissions may be edited for clarity, length and reader focus.
Cabri G2
AOC Holders’ Safety SURVEY
Each year CASA conducts a survey of air operator certificate (AOC) holders to collect important information on
their activities during the preceding year and their expectations of the year to come. In 2011 the information
collected was extended from being activity-based to include a wider range of topics.
Each point on this map represents an AOC holder
by the postcode of its main base, and by their broad
operational category. As expected, RPT and passenger
charter operators tend to be located along the coastline
in Australia’s more densely populated areas, while other
operators are further inland, probably due to the nature
of their business.
In early 2011, the AOC survey was launched and responses
were received from 813 operators about their activities
in 2010. A huge thank you to all AOC holders for your
valuable responses.
Questionnaire results
Arafura Sea
The 2011 survey provided a picture of the breadth and size
of AOC holder operations. Of the 813 respondents, 725
operated using their AOC in 2010 and a further 16 AOC
holders were identified as new entrants to the industry.
The information collected presents an interesting picture
of the diversity between the many small operators and
the few large operators.
Interestingly, sole operators with one aircraft operating
from one base comprise nearly one in 10 active AOC
holders. Although they are small organisations they are a
vital part of the Australian aviation industry.
Timor Sea
Port Moresby
Gulf of
Coral Sea
Nothern Territory
Western Australia
South Australia
AOC holders reported employing a total of 56,283 staff in
2010. Two-thirds of organisations reported employing 10
ange in pilots or
(FTE)staff, while 79 per cent of staff are employed by
the 10 largest AOC-holder organisations.
ed FTE
As is clear from the location of AOC holders’ primary bases,
a large proportion of aviation in Australia is conducted
in rural/remote areas. Around half of passenger charter
respondents reported that the majority of their flights
were to, from, or between, rural or remote locations.
This distribution is similar for the number of aircraft
used by AOC holders in 2010. The 725 active operators
reported using a total of 4121 aircraft throughout 2010,
or about a third of all civil aircraft on the Australian VH
register. More than half of operators reported using five or
less aircraft in the year, while only 11 operators used 40
or more. Of all the aircraft reported, around five per cent
were used by multiple operators in 2010.
Fifty-seven per cent of operators reported flying fewer
than 1000 hours. This was slightly less than the proportion
in 2009, when 60 per cent of operators reported flying
fewer than 1000 hours. There was a substantial decline
in the number of hours reported for training operations,
down 12 per cent from the hours reported for 2009.
High risk
Medium risk
Low risk
Don’t know
New South Wales
AHSQ responses by operations type
Charter (427)
New entrant (16)
Non-charter (269)
RPT (29)
Tasman Sea
Proportion of hours by operation type
Other non-AOC hours
Other aerial work
Scenic charter
Transport charter
Stability of operations
The survey collected information regarding the stability
For 2011, a majority of RPT operators expected an increase
of AOC holders’ operations, such as the turnover of key
in workload compared to 2010 and an increase of more than
personnel, the ability to hire pilots and the changing workload
200 pilots was anticipated across RPT organisations.
conditions across the industry. Information regarding the
stability of the industry is important for providing insights
Net change in pilots 2010 (FTE)
into potentially increased risks associated with change.
-220.0 2010 (FTE)
Net change in pilots
More than half of operators reported that the ability to hire
Regular public transport
suitably qualified staff was either a high or medium risk to
aviation safety. Whilst most operators
reported that the time
Regular public transport
Passenger charter
taken to recruit pilots was ‘about average’, more than half of
aerial work operators reported that it was
Passenger charter
Other operators
These operators also reported the greatest increase in pilots
employed during 2010.
Other operators
Decreased FTE
Decreased FTE
Increased FTE
Increased FTE
Perceived safety risks
Coming up in early 2012
Operators were asked to rank a list of possible risks to
aviation safety from high to low. The risks ranked by industry
were similar to the results from the 2010 survey; however
the risk due to ‘economic conditions and profitability’ is now
the second highest ranked risk (it was the highest-ranked in
2010). ‘Unsafe operators allowed to continue operating’ is
now the highest-ranked risk.
The 2012 AOC Holders’ Safety Questionnaire will be
distributed to industry in the first quarter of 2012,
so watch your email inbox for further information.
Any questions? Contact: AOCSurvey@CASA.gov.au
High risk
Medium risk
Low risk
Don’t know
per cent of operators thought CASA had not been helpful on
these issues.
Over two-thirds reported that CASA had been helpful in
providing ‘guidance on how to either set up your organisation’s
safety management system or improve its effectiveness’.
Similarly, over 90 per cent of organisations found the CASA
website helpful.
In addition to the small sample of the results from the
2011 AOC Holders’ Safety Questionnaire offered above, the
extensive information collected has provided CASA with a
wealth of valuable information relating to many potential
aviation safety issues. Your participation in the 2011 survey
has been greatly appreciated.
Unsafe operations allowed to continue to operate
The AOC survey also provides AOC holders with an
opportunity to provide feedback on their perception of CASA.
In the 2011 survey 46 per cent of participants reported that
CASA had been either extremely, or very, helpful regarding
the provision of ‘support in the interpretation and operation of
aviation regulations’ and for ‘information on local operational
matters (including aerodrome and airspace)’, while only eight
Aircraft characteristics
Economic conditions/profitability
Aircraft characteristics
Lack of industry knowledge regarding human factors
Economic conditions/profitability
Lack of industry knowledge regarding regulations
Lack of industry knowledge regarding human factors
Lack of industry understanding about safety management systems
Lack of industry knowledge regarding regulations
Local operational issues (inc aerodrome airspace)
Lack of industry understanding about safety management systems
Unsafe operations allowed to continue to operate
Local operational issues (inc aerodrome airspace)
Satisfaction with CASA
Ability to hire suitably qualified staff
Ability to hire suitably qualified staff
Overall, 53 per cent of Australian operators believe the
industry is either extremely or very safe, with only two
per cent of operators believing it is either not very or not at
all safe.
Put to
the test
Flying lessons and a general attitude
passed on to him from a wise instructor
made a night engine failure survivable,
Terry Anderson says.
I was to to ferry a Cessna 182, fresh out of a 100-hourly
inspection, from Bankstown to Moruya via Goulburn to be
ready for a weekend’s skydiving. I love my flying and get quite
a buzz from flying at night. For this reason I elected to wait
until it was dark before departing from Goulburn for the final
leg to Moruya. I expected a dark night with little wind below
3000ft, and was really looking forward to this sector.
Flying for me started back in 1976. I was a teenager when I
was introduced to hang gliding, instantly falling in love with
the sport. I pretty much taught myself to fly because in those
days there weren't too many experienced pilots around.
anyone can learn to fly an aeroplane, but when it all goes
pear-shaped can you handle it? Then you will know if you
are a pilot.’
Looking back, I don't know how I survived those formative
years. Many people died, some of whom were my friends.
On 29 April 1978, I added a new dimension to my flying and
began learning to fly aeroplanes. I had a brilliant instructor
in Corinne Nugent. What I remember best is her dictum that
‘anything man-made is prone to failure’.
That saying created an attitude. While thoroughly enjoying
my flying, I would always plan for the worst. For example,
before I line up and roll I know where I want to put her down if
the engine goes at 300ft.
I am fortunate to have accumulated 1500 hours of throwing
people out of aeroplanes. In my limited experience, flying for
skydive operations is just about the most fun thing you can
do with an aeroplane. It provides the unique opportunity to
land every 25 minutes. I might do this 20 times a day and I
don't waste this valuable resource. I practise engine-out
approaches (yes, I do watch shock cooling), really long
straight-ins, or sometimes, more conventional scenarios
within the circuit pattern. I change the scenarios to hone
my judgement, but I never change the spot − it's always the
threshold. In the event of a real engine out I can put that spot
anywhere I want.
With checks complete and a clear plan to gain extra height
before departure in my head, I lined up on 22. Corinne taught
me many years ago that if you are going to have an engine
failure Murphy says it will be during the first four minutes of
take-off. The only height you can't use is that above you, so
I always make sure I have height to spare before departing
at night.
As I throttled up I became aware that the engine sounded
different, but all the numbers were good so I put it down to the
new gel cups on my headset. I continued to rotation.
I planned high, and Melbourne Centre subsequently gave me
a clearance to enter the control area. On track for Moruya
and still climbing, with Goulburn around six or 7nm behind
me, I heard a loud bang followed immediately by very strong
vibrations. At first I thought part of the prop had fractured,
causing the imbalance, but I very quickly realised I had
suffered engine failure. That, on a black night in a single, is a
pilot's nightmare.
I know all my emergency drills instinctively, but I knew I
wouldn't be able to fix this. So my first drill was to soil myself
(gotta keep a sense of humour). I immediately came about and
pointed the nose to Goulburn.
By June 1998, I had accumulated 22 years of experience,
where every out landing I did in a hang glider was a forced
landing. You don't have the luxury of a go-around if you get it
wrong. Over those years I became quite skilled at moving with
and through the magical three-dimensional ocean of air.
At Bankstown that day I bought some new gel cups for my
headset. The first leg was uneventful. My wife Jacqueline met
me at Goulburn Airport, where we shared dinner just before
sunset. I wanted genuine night VFR so I waited a good 90
minutes until it was truly dark.
I was pumped, shaking from pure adrenalin ... All the values
I had absorbed about being professional, being precise,
uncompromising and critical of myself had saved my life.
I was in controlled airspace and when established in a stable
glide I called Centre to advise them of the emergency and
asked them to stand by while I assessed my options.
I remember feeling great fear; something I thought would
never happen to me. I have been placed in harm's way many
times in my life and I have always kept a level head. Panic
was a new experience for me. I quickly became aware I was
hyperventilating. The truth is I was thinking, ‘this is it. I'm
going to die tonight!’
Then something clicked and I took control. I told myself out
loud: ‘Aviate, you can do this. fly it to the ground. Just breathe.’
I remember that vividly. I could still see the runway lights in
the distance. My breathing slowed, but the lights really were
a long way off. The picture was tight. I remember saying to
myself ‘what are you worried about, it's just a big glider?’
From that point on I was in charge and not the aeroplane.
I decided the field was achievable.
This all happened, I guess, in the first 30 seconds, but it felt
like forever. The initial fear had gripped me round the throat,
but I got on top of it quickly.
Melbourne asked how I was going and whether I wanted
services - Police, ambulance, fire brigade, mortician, let the
guys at the drop zone know I wouldn't be in tomorrow, feed my
dog? It felt that to accept would be to admit I might not make
it. My answer was ‘no. I will be fine.’ I wanted no doubt in my
mind that I would make it. In hindsight, I should have said yes.
I had a parachute but I had put it in the back; too uncomfortable.
But I did give serious consideration to donning it and going for
help. Exiting an aircraft at night under canopy holds no fear
for me: I have done it many times for fun. I couldn't guarantee
where the aircraft would end up though, so I dismissed
that option.
Now focused on the glide, my sole purpose was to make the
runway move under the initial angle of its first sighting from
the established glide (arrive high) and keep it there. The best I
could do however was to keep the runway at almost the same
relative position within my field of vision. Unless I struck a
stronger headwind (and I knew that wouldn't happen) I would
only scrape in by the skin of my teeth.
I remember feeling confident during the glide and I relaxed
into it making over the top with 900 feet, setting up finals on
04 rather than 22 (fewer obstacles). This would not have been
possible if I hadn't gained extra altitude before departure
(thank you Corinne). Touchdown was half way down 04 and I
had just enough speed to roll onto the apron. When I stopped I
called Centre and told them I was down safely and the runway
was clear.
I was pumped, shaking from pure adrenalin. Everything I
had ever done in an aeroplane, hang glider or in freefall,
and even the time I spent in the army reserve as an infantry
section commander learning to work under extreme stress,
had brought me to this point. All the values I had absorbed
about being professional, being precise, uncompromising and
critical of myself had saved my life.
I was truly humbled by the experience. Corrine once said
words to the effect of, ‘anyone can learn to fly an aeroplane,
but when it all goes pear-shaped can you handle it? Then you
will know if you are a pilot.’
After all these years, I am still learning.
Anything man-made is prone to failure.
Your life and your passengers’ lives depend on you
understanding this.
I ducked my head and instructed the training pilot to continue to
land because I thought a last-minute go around could have made the
situation worse. I had my hands lightly on the controls in the event that
a window did come in.
As the cloud base was quite high he elected to
conduct a GPS arrival, which was the correct
decision for the conditions. On a successful descent
and getting the PAL (pilot activated lighting) on,
the pilot commenced a normal circuit to land on
runway 27 at Wynyard.
Flying down the T-VASI on slope at about 200ft I
noticed a little bit of a white blur on the runway,
but not really knowing what it was, we continued.
At 100ft the white blur, now more visibly reflecting
off the runway lights, become airborne. By
the time we both realised what it was, we were
prepared to flare and land.
It was a big flock of gulls sitting on the touchdown
markers. I estimated that there were more than
a hundred birds. Remembering a previous article
in a magazine about a Cessna Caravan’s window
coming in from the impact of hitting an eagle,
We heard and saw birds hitting the windows, props and fuselage. Then
the wheels touched down and we imagined it was all over. Another
100 metres down though we encountered a smaller flock, again sitting
along the centreline, for round two. As we were already safely on the
deck we maintained centreline.
After landing we de-briefed on the incident and inspected the aircraft
for damage. There were four engine-cowling holes on the Chieftain,
with three birds sitting in them. Other than that, no damage at all −
just a huge mess. We thought that being an RPT aerodrome it would
be a good idea for us to clear up the runway that night.
We found seven more birds, making a total count of 10. After unloading
the freight we headed to our pilot quarters for the night.
The next morning the ground agent came over after his inspection to
say ‘gee, you boys had a busy time last night’.
Our reply was: ‘yeah, 10 gulls in one hit’.
‘Ten? No way! I’ve found 33 carcases, scattered over a 100-metre
After some amendments to our ATSB report and the rest of our tour
that day we signed off. From then, on my training procedures have
always included a mention of how many gulls can congregate in white
blurs on runways after heavy downpours at coastal aerodromes.
In hindsight, I don’t think we would have changed any of the actions
we took, thinking that a go-around might have ended up worse if a
window had come in, an engine had failed, the gear wouldn’t go up, or
there had been a cooling problem in the engines, with birds stuck in
front of the cylinders.
In the early months of Spring 2006, my routine
freight flight to Tasmania as pilot in command
could have had a considerably less desirable
outcome. When receiving the weather before
top of descent, the pilot in command under
supervision noted the passing showers and rainfall
of the previous ten minutes.
The company I work for operates five Cessna
441 Conquests on charter operations. These,
to me, are fantastic aircraft. Nine-passenger
capability, armchair comfort, air conditioning,
pressurised to 35,000ft, with the capability to
climb straight to 33,000ft with a full load! Not
bad for a propeller!
This aircraft was limited to 22,500 hours by
CASA. Aircraft over this time were grounded.
Before this time all C441s were required to
undergo a supplementary inspection program
within a year. This meant about three months
out of service while it was carried out.
On this particular day I was scheduled to test
fly a Cessna 441 after it had completed the
program. I had about 6,500 hours on the
Conquest and 18,500 hours in total.
I started the engines, checking the NTS
(negative torque sensing) and completed a
manual mode over speed governor check,
in accordance with the pilot’s operating
handbook. All was normal.
I completed the pre-take-off checks during
taxi, which included making sure that the
controls were full and free.
I applied full power for the take-off and this was
normal. I rotated and was about to select gear
up at 110kt (my decision speed), but I felt that
the aileron control was not fully functional.
The left wing was lowering and application
of right control wheel made no difference. I
increased this until I had full right wing down
control! It made no difference. I immediately
checked the aileron trim – it was central, so I
applied full right aileron trim – it made little
Look bot
Assumptions, even if they seem reasonable can be the
road to a crash, as pilot Rob Wicks discovered
The daily
testing of the
panel, fuel
shutoff and
other things.
The aircraft was to be checked to ensure
engine feathering was operating within limits.
This meant the left and right engines had to be
shut down. A ‘computer set-up’ also had to be
done. This ensures power levers are matched,
red line exhaust gas temperature (EGT) is
attained and also the sink rate is within limits
when in flight idle. All other systems were also
to be checked.
I carried out a thorough pre-flight inspection
of the aircraft, paying particular attention
to trim settings. No anomalies were found.
I checked the MR and all was in order, no
defects. The daily inspection includes testing
of the annunciator panel, fuel system, firewall
shutoff and oxygen system, among other
things. These were all checked and were
functioning properly.
difference. I looked at the left aileron – it was
fully down, as it should be, yet there was no
roll! I applied rudder to counteract the left
wing low and also used differential power to
control the aircraft.
What a puzzle! The ailerons were apparently
working, but nothing was happening. I applied
full left and then full right aileron control.
There was no response, even though I could
see the left aileron was moving correctly.
Without aileron control I had to make an
immediate decision – to continue the climb
out (that is, to somehow try to turn the
aircraft around) and suffer possible disastrous
results, or abort. I chose the latter. I looked
at the runway ahead … I thought there was
insufficient remaining.
I was at only 300ft, but I stuck with my choice,
feeling that even if I overran the runway it was
still the safest option.
Using rudder and differential power, I was able
to manoeuvre the aircraft as best I could to realign with the runway. I reduced power to flight
idle, creating a lot of drag – just what I needed
– and the aircraft made a steep descent,
thanks to the fixed-shaft turbine engine.
I quickly checked the gear was still down and
continued to fly the aircraft using power and
rudder. I was in a serious situation – trying to
control the descent to land before overrunning
the runway and with no aileron control.
I managed to re-align with the runway and
flared, thinking we might just make it before
overrunning the runway.
I had only checked that the left aileron was
in the correct sense, as it was difficult to see
the right aileron with the engineer next to me.
I had heard of ailerons operating in reverse
but I had never imagined them operating in
the same sense. Indeed, it was deemed by
engineers to be impossible!
My conclusion?
Never assume anything!
I had paid particular attention to the left aileron
as part of my pre-take-off checks to ensure it
was operating in the correct sense. I assumed
(incorrectly) that that the right aileron was
doing the opposite.
rudder and
power, I
was able to
the aircraft
as best I
could to realign with
the runway.
Fortunately full reverse (thanks Mr Garrett)
provided instant propeller braking, and with
maximum disk braking, we stopped well
before the end of the runway! What a relief.
None of the engineers on board had any idea
about what had happened, and neither had I.
As I taxied in, I appreciated the quick response
of the tower in hitting the crash button. Now,
what had happened? I looked at the ailerons
- they were working OK; but wait a minute –
they were both moving in the same direction!
That is, control wheel left, both ailerons
went up; control wheel right, both ailerons
went down!!
This obviously created different aerodynamic
situations, as well as controllability issues with
the aircraft.
The Cessna abbreviated checklist has ‘Controls
- check’ as one of the checks to be completed
before take off – which, indeed they were.
The expanded checklist says ‘Controls – full,
free and correct sense’.
The Cessna pilot operating handbook also
states that where controls have been removed,
an entry indicating this should be made in the
maintenance release. There was no such entry.
Pilots need to be familiar with the vital
information in Cessna’s expanded checklist.
Control removal requires a dual inspection
by engineers, but two engineers had failed to
complete this check correctly. We need to be
able to have faith in our colleagues. After all,
not every aircraft allows us to check the sense
of its controls!
th ways
The Australian
R22 drive belt concerns
Commissioner’s message
The ATSB recently published
the Annual Report for 2010-11,
our second as an independent
statutory agency. The report
looks back on a year in which
we consolidated the ways
that we conduct transport
safety investigations. It was
also a year characterised by
important expansion in our
safety research, analysis and education functions.
We completed 113 aviation accident and incident
52 investigations in 2010-11, several of which attracted
s a result of several accidents and incidents involving Robinson
R22 helicopter V-belts, the ATSB has initiated a safety issue
investigation into the reliability of Robinson Helicopter R22
drive belt systems.
An update posted on the ATSB website (AI-2009-038) reports that no
significant safety issues have been identified to date in the manufacture
or design of the drive belts that might present an airworthiness issue
for continued safe operation of the Robinson R22 helicopter fleet.
However, the update stresses that the belts represent a critical link in
the main rotor drive system and, failures are often rapid and may be
preceded by the onset of vibration or the smell of burning rubber.
substantial national and international interest. Among
these was the investigation into the uncontained
engine failure on an Airbus A380 aircraft over
Batam Island, Indonesia on 4 November 2010 which
identified fatigue cracking within a stub pipe feeding
oil into one of the engine’s bearing structures. As a
result of this work, safety actions were immediately
undertaken by Qantas, CASA, Airbus, Rolls-Royce
plc, and the European Aviation Safety Agency,
enabling the resumption of safe flight by aircraft
equipped with this engine type.
Some of the factors that can influence the reliability of the R22 drive
system are:
Other investigations identified safety issues
relating to the protection of Boeing 747-438 aircraft
systems from liquids, potentially unreliable airspeed
indications in Airbus A330 and A340 aircraft, the
supervision of agricultural pilots, training and
supervision of charter pilots, potentially hazardous
helicopter winching procedures, turbulence caused
by buildings at airports, airspace design and
management and problems with the management
by air traffic control of compromised separation of
Environment: Operating the helicopter in environments where dust
and grit can contaminate the drive system, or where the ambient
temperature is high, can also influence the service life of the belts and
Another satisfying development has been our
expansion in research, analysis and education. As
well as improving the quality and usefulness of our
statistical publications, we are turning good research
into practical education material.
The ATSB Annual Report for 2010-11 is available at
Martin Dolan
Chief Commissioner
Regular inspection: Any form of drive belt damage such as blistering,
cracking and tie band (webbing) separation indicates that the belts
require replacement.
Operation: Pilots must monitor Manifold Air Pressure (MAP) to avoid
exceeding the placarded power limits, as listed in the Robinson R22
flight manual. Exceeding the drive system limitations may result in
sudden belt failure
Sheave alignment: Correct sheave alignment after installation of the
drive belts is critical in ensuring the belt longevity.
High gross weight operation: Pilots must ensure that the approved
gross weight limits are not exceeded while operating the helicopter.
Clutch actuator: Robinson Safety Notice SN-33 suggests that a
problem with the drive belts may be imminent if during flight the
clutch light flickers or stays on for longer than normal.
Under these circumstances the pilot is advised to land immediately.
Following a fatal, a fatal Robinson R22 accident on 6 July 2011
(AO-2011-060) that occurred near Julia Creek, Queensland, where it
is suspected that the helicopter sustained an in-flight failure of the
drive belts, the ATSB issued a Safety Advisory Notice that urged pilots,
operators and maintainers to pay particular vigilance to the R22
helicopter drive belt system.
A final report on the safety issue investigation is expected to be
released in the first quarter of 2012. ■
Aviation Safety Investigator
Pilot unknowingly affected by hypoxia
he Australian Transport Safety
Bureau has issued a safety advisory
notice reminding pilots about
the dangers of hypoxia, and urging all
operators of single-pilot, turbine-powered
pressurised aircraft to install aural cabin
altitude pressure warning systems. This
warning comes as a result of an ATSB
investigation into an air system event that
occurred in Western
reading on the outer scale (measuring
cabin altitude) of 20,000 ft. He felt some
concern at this, but found he could not
reason out a solution to alleviate that
concern. Subsequently, he became fixated
on the distance-to-run figures on the
GPS display, convinced those figures
represented the aircraft’s groundspeed. As
a result, he believed that the aircraft was
Once he realised what was happening, the
pilot descended further before landing
safely at his destination.
accidents and incidents
have long been a matter
of concern for the
ATSB, with a number
of investigation reports,
research publications
and safety actions having
been published on the
topic. In general, there
is a high chance of
surviving a pressurisation
system failure, provided
that the failure is
recognised and the
corresponding emergency
procedures are carried
out expeditiously. Flight
crews should maintain a high level of
vigilance with respect to the potential
hazards of cabin pressurisation system
failure. Auditory warnings have proven
particularly effective in eliciting responses
from pilot. There is an immediacy to
an auditory warning that may not be
apparent with visual warnings, and an
auditory warning allows events both in
and outside a pilots’ field of view to be
The investigation report, and the Safety
Advisory Notice warning pilots of the
need for aural cabin altitude pressure
warning systems, can be found on the
ATSB website: www.atsb.gov.au ■
The incident occurred
on 16 July, 2009, when
the pilot of a Beechcraft
King Air C90,
registered VH-TAM,
departed Perth Airport
on a flight to Wiluna,
Western Australia,
carrying one passenger.
Unbeknownst to the
pilot, however, the left
landing gear squat
switch was operating
only intermittently. As
a result, the aircraft
was prevented from
Photo of VH-TAM courtesy of Carsten Bauer
pressurising in flight. To
being subjected to an unexpected
make matters worse, the cabin altitude
100 kt headwind and, with permission
warning system was not operating,
from ATC, he descended to escape the
thanks to the incorrect connection
of the switch wiring during previous
After the plane had been cruising at
FL150 for a significant period of time, the
As the aircraft climbed towards the
pilot realised that he had been affected
planned cruise altitude of flight level (FL)
by hypoxia. Hypoxic hypoxia is a result
210, the pilot undertook the schedule
of inadequate oxygen being available
checklist items. During the Transition
to the lungs, which in turn decreases
checks, however, the pilot’s attention
the amount of oxygen available to the
was divided, as the aircraft encountered
arterial blood and so to the body tissues.
rough weather moderate turbulence. In
Some of the subjective symptoms of
addition, he was having some difficulties
hypoxic hypoxia include euphoria, light
with aircraft’s autopilot.
headedness, dizziness and feelings of
Those autopilot difficulties continued
warmth. Hence, hypoxic hypoxia can
once they reached FL 210. When the pilot
also create a false sense of well-being,
checked the dual altimeter, he noted a
even as it is in the process of degrading
the subject’s mental and physical
performance. In most cases, the initial
signs of hypoxia are subtle and the pilot
has limited time to recognise the signs,
make decisions, and carry out the actions
to rectify the situation.
Starved and exhausted
afe flight depends on reliable
power. If an engine does not get
the fuel it needs, the results are
often not good. The latest publication in
the Australian Transport Safety Bureau’s
Avoidable Accidents series, titled Starved
and exhausted: Fuel management aviation
accidents, addresses the issues of fuel
exhaustion and fuel starvation, describes
several fuel-related accidents and serious
incidents, and discusses procedures that
pilots can use before and during a flight to
help them be absolutely sure that they will
have sufficient fuel flowing to the engine
to land at their destination airport with
fuel reserves intact.
‘The two main reasons that fuel stops
getting to an engine during flight are
fuel exhaustion and fuel starvation,’
explains Michael Watson, Aviation
Safety Investigator. ‘Fuel exhaustion
happens when there is no useable fuel
remaining to supply the engines. Fuel
starvation happens when the fuel supply
to the engines is interrupted, although
there is still sufficient fuel on board.
Together these are what we refer to as fuel
mismanagement events.’
It is actually quite difficult to make a
realistic assessment of how widespread
fuel mismanagement events are in
Australia. On average, the ATSB
is notified of 21 fuel exhaustion or
starvation occurrences each year.
However, for every occurrence when
power fails because fuel is no longer
getting to the engine, it is likely that
there were many occurrences when there
was less fuel available than there should
have been. It is also likely that not all fuel
mismanagement occurrences are reported
to the ATSB.
Nevertheless, the existing data indicates
that fuel mismanagement is threetimes
more likely to involve fuel starvation
than exhaustion, and is mostly likely to
occur in private operations and charter
operations. In addition, there can be
serious consequences. Of the reported
fuel exhaustion occurrences from 2001
to 2010, 82 per cent led to a forced or
precautionary landing off an airport
or ditching (but luckily no fatalities or
serious injuries). In contrast, for reported
fuel starvation occurrences, only 46 per
cent led to a forced or precautionary
landing or ditching, while 22 per cent
led to a diversion to another airport or a
return to the takeoff airport. However,
11 (7 per cent) led to collision with
terrain, and there were 10 fatalities and 18
serious injuries in the 10 years.
Starved and exhausted outlines important
messages to ensure accurate fuel
On average, the ATSB is notified of
21 fuel exhaustion or starvation
occurrences each year.
‘It starts with knowing exactly how
much fuel is being carried at the
commencement of a flight,’ notes Watson.
‘This is easy to know if the aircraft tanks
are full, or filled to tabs. However, if the
tanks are not filled to a known setting,
then a different approach is needed to
determine an accurate quantity of usable
‘It also relies on an accurate method
of knowing how much fuel is being
consumed. Many variables can influence
the fuel flow, such as changed power
settings, the use of different fuel leaning
techniques, or flying at different cruise
levels to those planned.’
‘Finally, keeping fuel supplied to the
engines during flight relies on the pilot’s
knowledge of the aircraft’s fuel system
and being familiar and proficient in its
use. Adhering to procedures, maintaining
a record of all fuel selections during
flight, and ensuring the fullest tank is
selected before descending towards your
destination will lessen the likelihood of
fuel starvation at what may be a critical
stage of the flight.’
Starved and exhausted: Fuel management
aviation accidents, along with the rest of
the Avoidable Accidents series, is available
for free download from the ATSB website
www.atsb.gov.au ■
Investigation briefs
Fuel exhaustion
Investigation AO-2010-025
In April 2010, a Victa Airtourer 115 was
conducting a private visual rules return
flight from Cambridge Airport Tasmania.
This was its fifth flight since refuelling. At
about 1020, after the pilot commenced the
return to Cambridge, the engine suddenly
lost all power. The pilot conducted a
forced landing onto a road, resulting in
substantial damage to the aircraft but no
injury to the pilot, the only person on
The subsequent investigation found that
the power loss was due to exhaustion
of the aircraft’s fuel supply. Exhaustion
occurrences are normally either the
result of a gross error in the fuelling of
an aircraft before flight, or the result of
a number of seemingly minor aspects in
fuel planning and management during
the flight.
an interruption of the fuel flow, and the
loss of engine power about 42 seconds
before impact.
Incidences of fuel exhaustion are often
seen to happen close to the flight’s
destination and if it occurs when the
aircraft is close to landing, it may offer
the pilot less time and opportunity to
successfully manage the situation. ■
The aircraft had been equipped with four
fuel tanks, two main tanks (one in each
wing), and one tip tank in each wing,
with the use of the tip tanks restricted
to level flight only. There was evidence
from the wreckage that there had been
sufficient fuel in each of the main tanks.
The pilot had a written fuel log indicating
the left tip tank had been selected on
reaching cruise altitude, and the right
tip tank selected when the left tip tank
was nearly empty. It is likely that the
pilot omitted to select a main tank before
descending from cruise altitude, and the
right tip tank ran dry at a low altitude
with insufficient time available to restore
fuel supply to the engine.
Investigation 200603140
In June 2006, a Beechcraft A36 Bonanza
was conducting a private flight from
Kununurra, Western Australia to
Bathurst Island in the Northern Territory.
Airtrafficservices data recorded the
aircraft overflying the airport and that the
pilot joined the circuit on left downwind
for a landing on runway 15. The aircraft
impacted terrain 2.4 km north-west of
the airport. The pilot, who was the sole
occupant of the aircraft, sustained fatal
The ATSB investigation assessed the
aircraft as being intact prior to the impact
with terrain. The investigators did not
identify any anomaly that could have
affected its normal operation. However,
data recovered from an onboard engine
data recording system was consistent with
Although the tip tanks had been used
during the cruise and the fuel log
confirmed that fact, the use of a predescent checklist to ensure that the
correct tank was selected well before
approaching the ground could have
reduced the likelihood of this starvation
event. Running dry at a low altitude
reduced the opportunity to recover from
the power loss. ■
Accident site and surrounds of the Beechcraft A36 Bononza
In this case, a number of safety
issues were identified concerning the
measurement of the quantity of fuel on
board, and consumed before and during
the flight. Those issues contributed to
the pilot’s belief that there was more fuel
on board the aircraft than was actually
the case. The pilot had used a dipstick
to assess that there was sufficient fuel
for the flight, and that the fuel quantity
indicator provided a similar indication of
fuel quantity, showing the tank was about
half full. Unfortunately, the pilot used an
incorrect (but not uncommon) method of
using the dipstick that resulted in an overreading of the fuel onboard. Furthermore,
a close inspection of the aircraft’s flight
and fuel log would have revealed that the
fuel gauge and the dipstick indications
showed a fuel usage that was half the
expected usage. Cross-checking the
dipstick reading against the fuel gauge
indication was the correct thing to do,
however a quick mental calculation would
have shown a significant discrepancy
between the indicated fuel quantity and
the expected fuel usage. The discrepancy
could have alerted the pilot that
something was wrong with the available
fuel quantity information
Non towered aerodromes an on-going concern
erodromes with control towers
form a substantial part of the
Australian aviation landscape.
This is not only because the majority of
Australian aerodromes do not have an air
traffic presence, but because they cater to
such a wide and varied body of aircraft.
At any one time, non-towered aerodromes
can have a mix of passenger-carrying
aircraft, instrument or visual flight rules
aircraft, smaller general aviation aircraft
or amateur-built aircraft, agricultural or
military aircraft, helicopters, balloons,
and gliders all operating.
In addition, the traffic density can be
intense. The aerodromes at Broome (WA),
Kununurra (WA), Wagga Wagga (NSW),
Wollongong (NSW), Toowoomba (Qld),
Horn Island (Qld), Bathurst (NSW),
Geraldton (WA), and Port Macquarie
(NSW) aerodromes all have over
20,000 movements per year. At some
of these (and many other) non-towered
aerodromes, there are a significant
number of passenger transport flights
utilising large jet and turboprop aircraft,
as well as recreational and general
aviation aircraft.
As a result of this significant role in
Australian aviation, safety at non-towered
aerodromes has long formed a part of
the Australian Transport Safety Bureau’s
focus. The ATSB has produced a research
report, a guide for pilots and a safety brief,
all focussing on the unique challenges and
dangers that are present. Still, despite the
efforts of the ATSB, safety issues continue
to crop up at non-towered aerodromes
with concerning frequency.
In the years from 2003 to 2008, the ATSB
was notified of 709 airspace-related
safety occurrences at, or in the vicinity
of non-towered aerodrome. Of these 60
were considered serious incidents and six
constituted accidents. The ATSB urges
patrons of non-towered aerodromes to
read the free publications on the ATSB
website www.atsb.gov.au, and apply the
lessons to their own flying.
You can find the booklet ‘A pilot’s guide
to staying safe in the vicinity of
non-towered aerodromes’ on the ATSB
website, at www.atsb.gov.au. The guide
has been released in association with a
larger and more detailed report into nontowered aerodrome operations, and aims
to provide pilots with an appreciation
of the types of safety events that are
associated with operations at non-towered
aerodromes, and provide education on
expected behaviours to assist pilots in
being prepared for the risks. ■
A warning regarding PT6A engines
CASA has released an Airworthiness
Bulletin (AWB 72-005), alerting all
operators and maintainers of PT6A
engines of the potentially dangerous
installation of FAA PMA T-102401-01 compressor turbine blades in
unapproved PT6A engine variants andto
raise awareness of the restrictions placed
on the use of these blades.
This Bulletin comes as the result of an
ATSB investigation into the total power
loss suffered by a Cessna 208 aircraft in
Queensland. On 31 December 2009, the
Cessna 208 was engaged in parachuting
operations from Cairns Airport,
carrying the pilot and 15 parachutists
were on board. While climbing through
12,500 ft in preparation for a parachute
drop, the engine lost all power. The pilot
performed an initial check and scan of
the engine instruments, and advanced
the emergency power lever, but the
engine remained unresponsive. The
parachutists exited the aircraft and the
pilot completed a glide approach for an
uneventful landing at Cairns Airport.
The ATSB investigation found that the
failure of the Pratt & Whitney PT6A-114
engine had probably been precipitated
by fracture of the compressor turbine
blades. Separation of the hot section
revealed significant damage to the
compressor turbine rotor assemble. All
of the blades were fractured through
the airfoil section; the majority of
them close to the blade platform. Many
of the blade sections exhibited the
Compressor turbine rotor assembly
deformation, cracks and nicks associated
with impacting circulating blade debris.
The compressor turbine shroud and vane
ring had also sustained extensive impact
damage and gouging.
The FAA parts manufacturing approval
information indicated that part number
T-102401-01 compressor turbine blades
that had been installed in the engine
during the most recent overhaul were
not approved for the PT6A-114 model.
A review of the operating parameters
indicated that PT6A engine variants
not approved for installation of the
T-102401-01 blades typically exhibit
maximum operating temperatures
higher than the other engine variants
that were approved from the PMA
CASA recommended that operators
and maintainers of PT6A check their
engine maintenance logs to ensure
that the compressor turbine blade part
number(s) installed are correct for the
engine variant according to FAA PMA
approval information. ■
REPCON briefs
Australia’s voluntary confidential aviation reporting scheme
REPCON allows any person who has an aviation safety concern to report it to the ATSB
confidentially. All personal information regarding any individual (either the reporter or any
person referred to in the report) remains strictly confidential, unless permission is given by
the subject of the information.
The goals of the scheme are to increase awareness of safety issues and to encourage
safety action by those best placed to respond to safety concerns.
REPCON would like to hear from you if you have experienced a ‘close call’ and think others
may benefit from the lessons you have learnt. These reports can serve as a powerful
reminder that, despite the best of intentions, well-trained people are still capable of making
mistakes. The stories arising from these reports may serve to reinforce the message that we
must remain vigilant to ensure the ongoing safety of ourselves and others.
Air traffic controller fatigue
Report narrative:
The reporter expressed a safety concern
regarding air traffic controllers regularly
falling asleep at the console while
operating single person nightshifts.
Airservices has a number of towers
(TWR) and Terminal Control Units
(TCU) with low air traffic levels that
operate single person operations at night
time, including Cairns TWR and TCU,
Adelaide TWR and TCU and Perth TCU.
Airservices considers the welfare of our
controllers operating in this environment
Airservices conducted a review on night
shift staffing, following a decision by
the Federal Aviation Administration
(FAA) in regards to single person night
operations. This review resulted in
the implementation of a standardised
approach to manage these operations.
Currently, Airservices has personal duress
alarms at locations where single person
night shifts operate. The activation of the
alarms alerts the nearby TCU or Tower
and security at Melbourne or Brisbane
Centre. If contact cannot be established,
security staff at Melbourne or Brisbane
will take action as per standardised
Furthermore, during low traffic periods
when there are no arrivals or departures,
coordination between the TWR and TCU,
or interaction with the Eurocat system for
one hour or more, an intercom call will
be initiated by the respective units. The
one-hour period is determined through
console timers. If the TCU or TWR fails
to respond to the intercom call within
5 minutes, additional actions are taken
until contact is re-established. These
actions include repeated intercom checks,
attempts to contact via telephone and
requesting the Aviation Rescue and Fire
Fighting (ARFF) unit to attend to the
relevant unit.
In addition, fatigue management of
controllers on night shifts in the Brisbane
and Melbourne ATS (air traffic services)
Centres is managed within the team
environment utilising short breaks and
24-hr supervision. Rest breaks are part
of Airservices fatigue management
system and are designed to minimise
the likelihood of a controller becoming
Finally, Airservices regularly reviews and
continuously improves upon its Fatigue
Risk Management System (FRMS) to
ensure the highest possible protection
for our staff and the travelling public.
As a current priority, Airservices is
REPCON supplied CASA with the
de-identified report and a version of
the operator’s response. The following
is a version of the response that CASA
CASA has reviewed this REPCON and
notes the response from Airservices.
Exceedance of takeoff weight
Report narrative:
The reporter expressed a safety concern
regarding the aircraft’s possible
exceedence of the maximum take-off
weight (MTOW).
The reporter stated that the Piper
Chieftain departed with 10 people plus
baggage on board for a 1.5 to 2 hour
flight. At no time was the pilot observed
weighing the passengers or weighing the
Reporter comment: I believe that a Piper
Chieftain with 10 passengers, on a 1.5 to
2 hour flight would be approaching
MTOW, without factoring in baggage.
Response/s received:
REPCON supplied CASA with the
de-identified report. The following is
a version of the response that CASA
CASA found no evidence of the operator’s
aircraft flying in excess of maximum
take-off weight. CASA will continue
to monitor the operator through
surveillance and audit activities.
How can I report to REPCON?
Online: www.atsb.gov.au/voluntary.aspx
Telephone: 1800 020 505
Email: repcon@atsb.gov.au
Facsimile: 02 6274 6461
Mail: Freepost 600
PO Box 600, Civic Square ACT 2608
Response/s received:
REPCON supplied the operator with the
de-identified report. The following is a
version of their response:
checklist to determine the welfare of the
controller. These alarms are tested weekly
as part of facility testing.
updating its FRMS. The renovated
FRMS will include new work scheduling
principles, education programs, incident
investigation requirements and a new
fatigue reporting system.
When safety stalls
From the routine, pre-landing announcement ‘cabin crew, take your seats’ to the impact with a damp
Dutch field took just 19 chaotic seconds, during which autopilot disconnect and stick shaker sounds,
and the ominous computer-generated phrases ‘sink rate!’ and ‘pull up!’ filled the flight deck.
But Macarthur Job, looking at the Dutch Safety Board’s report, finds the seeds for this crash had
been sown much earlier.
On 25 February 2009, a Turkish Airlines Boeing 737-800, operating a scheduled daytime flight from
Istanbul to Amsterdam, crashed on its approach to Schiphol Airport. Four crew (including the three
pilots) and five passengers were killed. Three other crew members and 117 passengers were injured.
The wreckage came to rest 1.5 kilometres from the runway threshold.
Schiphol runways
Turkish Airlines TK1951 crash site
pre-landing announcement ‘cabin crew, take your seats’
The flight was a ‘line flight under supervision’, to give
the first officer experience of the route, with the captain
acting as his instructor and a second first officer on
the flight deck as a safety pilot. There were also four
cabin crew members and 128 passengers on board. The
Schiphol weather at the time was overcast, with total
cloud cover at 1000 to 2500ft, some heavy cloud at 800ft
and lighter cloud at 700ft. Visibility was 4500 metres.
Shortly after the accident, it was found that the Boeing’s
left radio altimeter had passed an erroneous reading of
minus eight feet to the auto throttle system.
During the approach, the left radio altimeter displayed
the incorrect height of minus eight feet on the captain’s
primary flight display but the first officer’s primary flight
display was indicating the correct height. Yet the lefthand radio altimeter system failed to record any error,
so there was no transfer to the right-hand system. The
erroneous reading thus continued to affect the various
aircraft systems, including the auto throttle.
When the aircraft began following the glidepath,
because of the incorrect altitude reading, the auto
throttle moved into the ‘retard flare’ mode. This is
normally only activated in the final phase of the landing
below 27ft, but was now possible because other
required landing conditions had been met, including
selecting the flaps to the minimum landing setting of
Meanwhile, with the right-hand autopilot receiving
the correct altitude from the right-hand system, it was
attempting to keep the aircraft on the glide path. As a
result, the attitude of the aircraft continued to steepen
to maintain lift as the airspeed reduced.
Initially, the pilots’ only indication that the auto throttle
would no longer maintain the selected approach speed
of 144kt was the RETARD display. But when the speed
fell below this at a height of 750ft, the fact would have
been evident from the airspeed indicators on both
the primary flight displays. And when the airspeed
decayed to 126kt, the frame of the airspeed indicators
would have changed in colour and begun flashing. The
artificial horizons would also have shown the aircraft’s
nose attitude was becoming excessive. Yet the crew
failed to respond to any of these indications.
Indeed, the loss of airspeed and steepening pitch
remained unrecognised until the stick shaker stall
warning went off at an altitude of 460ft. If the prescribed
recovery procedure—selecting full engine power
and lowering the nose—is implemented immediately
this occurs, normal flight will be regained. Boeing’s
procedures also prescribe pushing the throttle levers
fully forward.
The first officer did respond immediately to the stick
shaker, pushing both the control column and the throttle
levers forward. But the captain intervened, taking over
control of the aircraft. The result was that the first officer’s
selection of thrust was interrupted, and with the auto
throttle not yet disconnected, it immediately retarded
the throttle levers again to ‘flight idle’. Once the captain
had full control, the auto throttle was disconnected, but
still no thrust was selected. It was another nine seconds
before the throttle levers were pushed fully forward. But
it was too late—the aircraft had already stalled and its
height of 350ft was insufficient for recovery.
computer-generated phrases ‘sink rate!’ and ‘pull up!’
The Boeing 737-800 is fitted with two radio altimeter
systems. In principle, the auto throttle uses altitude
provided by the left-hand radio altimeter system, and
only if an error is automatically detected in this system
will the auto throttle use the right-hand radio altimeter
system. The first officer was flying the aircraft from the
right-hand seat, so his primary flight display showed
the readings of the right radio altimeter, and after ATC
provided the crew with the heading and altitude to be
flown, the autopilot was selected to the ‘altitude hold’
flaps 15. The thrust on both engines was accordingly
reduced to ‘flight idle’, this mode being shown on the
primary flight displays as ‘RETARD’.
Non-stabilised approach
The radio altimeter
Up to the point when the stick shaker activated, the
crew, somewhat under pressure because of the
reduced visibility, were still carrying out their landing
checks. But Turkish Airlines’ standard operating
procedures prescribe that, in reduced visibility, all
these actions should be completed by the time the
aircraft has descended to 1000ft. If the checks have
not been completed by then, and the approach has not
been stabilised, the crew should execute a go-around.
This provision is not confined to Turkish Airlines, but is
a general airline rule. Although the crew acknowledged
passing through 1000ft, they did not initiate a go-around.
The Dutch Safety Board’s (DSB) investigation could
not uncover a reason for the left radio altimeter system
indicating incorrectly. A few days after Schiphol,
the DSB warned Boeing of the circumstances of the
accident, and Boeing, after consultation with the Board,
immediately sent a notice to all Boeing 737 operators.
The crew also called passing through 500ft. A goaround is required at this altitude if the aircraft is not
stabilised, in conditions of good visibility. Again, this
did not result in a go-around, despite the fact that the
landing checklist had not been completed and the
approach was still not stabilised. The captain evidently
did not regard continuing the approach below 1000ft, or
even when the aircraft passed through 500ft, as a threat
to a safe landing.
Interception of the ILS
The localiser signal of the instrument landing system
is the first to be intercepted. Then, during a normal ILS
interception, the glide path is intercepted from below.
ATC however, had instructed the crew to maintain
2000ft. This resulted in the aircraft intercepting the
localiser signal at 5.5nm from the runway threshold.
But according to ATC procedures, for an aircraft at
2000ft, this should have occurred by 6.2nm to enable it
to intercept the glide path from below. ATC’s approach
instruction, without also instructing the aircraft to
descend, resulted in the glide path having to be
intercepted from above.
When the thrust levers moved to ‘flight idle’ as a result
of the auto throttle’s ‘retard flare’ mode, the aircraft
reacted as expected. But because the pilots were
expecting the aircraft to descend to intercept the glide
path, and to lose speed for the selection of flaps 15 and
then flaps 40, this masked the fact that the auto throttle
had moved into ‘retard flare’ mode. And when the
airspeed fell below the final approach speed, followed
by the increase in aircraft pitch and the flashing of the
airspeed box, both pilots were busy with the landing
checklist and its related actions.
The problem is not an isolated one, and the failure of
radio altimeter systems in Boeing 737 aircraft has a long
history. It has happened not only to Turkish Airlines,
but also to other airline companies. Turkish Airlines
had been bringing the problem to Boeing’s attention
since 2001, as it had occurred at various times and in
various ways over those years. Turkish Airlines had also
sought all manner of technical solutions to reduce the
likelihood of corrosion, cited as a possible cause of the
poor performance of radio altimeter systems.
Given that the problem had also manifested itself in other
airlines, the primary responsibility for solving it clearly
lay with Boeing as the designer and manufacturer of the
aircraft. Though Boeing receives around 13,000 reports
each year regarding technical problems with the B737,
comparatively few relate to the radio altimeter systems
affecting the automatic flight system. And only in some
cases did these concern activation of the auto throttle’s
‘retard flare’ mode.
Although there were relatively few occurrences, the
Dutch Safety Board believed Boeing should have had
a greater appreciation of the problem—particularly
its effect on the auto throttle—and its possible safety
consequences. Analysis of the problems with the radio
altimeter system (and its effects on the systems that
used radio altimeter data) would therefore have been
appropriate. It also would have been helpful to inform
airlines of the problems and their possible implications.
The Board reached this conclusion for two reasons.
A question from an airline company in 2004 about the
flight crew operations manual led to the inclusion of a
warning that, with a radio altimeter inoperative before
the flight, the associated autopilot or auto throttle should
not be used for approach and landing. Boeing was thus
aware of possible inadequacies in the radio altimeter
system. However, this did not result in any procedures
for situations where problems with the radio altimeter
system developed during flight.
Secondly, two incidents discussed in Boeing’s Safety
Review in 2004, in which the ‘retard flare’ mode was
activated at 2100ft and 1200ft respectively, as a result of
negative radio altimeter readings, also showed Boeing
was aware of the possible consequences that followed
in the Schiphol accident. Even so, after statistical
analysis and flight simulator tests, Boeing concluded
it was not a safety problem—pilots obtained adequate
warnings and notifications in time for them to intervene,
recover the situation and land safely. However, the
Board believed that an additional warning to ensure
pilots intervened in time would certainly not have been
out of place.
Operating procedures
Line flying under supervision
The first officer had joined Turkish Airlines several
months before the accident, after serving in the Turkish
Air Force, where he had gained some 4000 hours of flying
experience. The accident flight was his seventeenth
line flight under supervision, and his first to Schiphol
Airport. Line flying under supervision is designed to
familiarise a pilot with the operational aspects of airline
flying, and on the first 20 such flights for Turkish Airlines,
an additional pilot on the flight deck acts as an observer
and safety pilot.
The captain acts as an instructor on this type of flight,
meaning that he has instructional duties additional to
his command responsibilities. With the captain under a
greater operational load than usual, one of the functions
of the safety pilot is to warn the crew if anything is
overlooked. But in this case he did not do so when the
airspeed fell below the selected value.
Possibly the safety pilot was also distracted. Shortly
after the pilots selected flaps 40, the cabin crew
informed him that they were ready for landing.
Approach-to-stall training
European pilot training requirements applying to Turkish
Airlines only prescribe approach-to-stall training in
the context of aircraft type qualification—the training
required for crewing a particular aircraft type. The first
officer had recently undergone his type qualification
training, and this could explain his rapid reaction to the
stick shaker.
There is no prescribed training for recovery-after-a
stall-warning in any recurrent training syllabus.
Apparently the thinking behind this is that approachto-stall situations are unlikely, and that pilots know
how to deal with them. Furthermore, all communication
and coordination procedures for monitoring flight path
and airspeed are aimed precisely at avoiding such
The Board concluded that the training requirements
were inadequate. It noted that in some cases, such as
for a captain, there were no provisions for practising
or revising approach-to-stall situations, and this might
apply for many years. But the fact that an approach-tostall warning is a last opportunity to recover control in an
immediate and acute emergency means that it is crucial
for the flight crew to be able to respond effectively. ‘The
Board accordingly considers that recurrent airline
training should include approach-to-stall training,’ the
report concluded.
The various factors outlined in this accident review, and
even a combination of some of them, will occur frequently
in airline operations somewhere in the world. What was
unique about this accident was the coincidence of all
the factors at a critical stage of the aircraft’s approach
to land. These factors—the erroneous radio altimeter
reading, its effect on the auto throttle system, the pilots’
failure to notice the fall in airspeed and the aircraft’s
increasing pitch, and finally the safety pilot’s failure to
warn the crew of the developing situation—all reached
their peak just before the onset of the stall warning. The
result was that the aircraft’s airspeed and attitude were
not being closely monitored at the point when it was
most necessary, and a tragedy resulted.
Standard operating procedures in aviation are safety
barriers designed to ensure that flight safety is not
compromised. An example is the Turkish Airlines
procedure, that if the approach is not stabilised by 1000ft,
no attempt should be made to land. Being stabilised
early on an approach is important, not only to ensure
the aircraft is in the correct configuration and power
selection for landing, but also to provide pilots with a
chance to comprehensively monitor every aspect of the
final approach. As demonstrated by the chain of events
during flight TK1951, the importance of these standard
operating procedures cannot be underestimated.
He passed this to the captain, and shortly before the
stall warning activated, he was conveying the captain’s
advice of the impending landing back to the cabin. He
did warn the captain of the exceedingly low airspeed
when the stick shaker activated, but the Board believed
the safety pilot system did not work as well as it should
have done.
as well as
Cabin crew are naturals
when it comes to safety
management. They’ve
been doing it since before
the term was invented.
Safety management in the cabin is not really
all that complicated. It is what cabin crew do
all the time.
Once the doors are closed, armed and cross
checked there is nothing more important
than the safety of everyone on board, and
cabin crew are responsible for protecting
hundreds of lives on a daily basis. They check
the cabin for hazards, perform a silent review
before take-off, are alert to unusual sounds or
smells, and prepare themselves for something
that everyone hopes will never happen.
As CASA safety systems inspector, Leanne
Findlay says, ‘There is a vital interdependency
between safety and cabin crew. The entire
work shift of cabin crew (and others) has
the potential for recognising and reporting
hazards and incidents before they happen.
' ... Cabin crews are important ... They are safety
professionals who remain situationally aware ...'
Cabin crews are important 'eyes and ears'
even before they step on board the aircraft.
They are safety professionals who remain
situationally aware and whose skills are
honed to clearly communicate safety-related
information to those who need it, either
verbally, or in written or electronic reports’.
Safety management systems (SMS) are an
attempt to manage human performance and
risk by establishing systems for identifying,
reporting, analysing and mitigating hazards.
No two safety management systems are the
same, but the term ‘formalised common
sense’ describes what all of them aim
to produce.
Cabin safety
The IATA (2005) Cabin Operations Safety
Programme pointed out that a cabin crew
member’s duty is not limited to in-flight
service and post-accident evacuation. The
aim of cabin safety is to reduce the number
of incidents, accidents and significant costs
to airlines in injuries and material damage.
When it comes to an SMS for the cabin, ‘There
is a difference between flight deck and cabin
perspectives on safety’, Adrian Young, of
Denim Air in the Netherlands, told the recent
European Cabin Safety Conference.
‘Equally, maintenance looks at safety in a
different light to the cabin. Cabin safety is, in
many operations, something that is explicitly
addressed prior to flight and is then put to
one side, so to speak, until a situation calls
for it again. Cabin service is an activity that
demands the attention of the cabin crew
in a way that flight crew and engineers are
not similarly “distracted”. When considering
CASA’s cabin safety inspectors spend months
of every year in the air carrying out inspections
and audits with a focus on aircraft occupant
safety. They read the company’s operations
manuals and monitor compliance with them
and the SMS, as well as providing training
and education on all aspects of cabin safety,
including aircraft design, configuration,
operations and maintenance.
Management commitment
The provision of cabin service is often
viewed as a marketing function, but cabin
safety is clearly an operational function,
and airline policies should reflect this.
Ideally, management also demonstrates
its commitment to cabin safety with more
than words.
In aviation, in other forms of transport, and in
life in general, lapses in human performance
are behind the majority of incidents and
accidents. Whenever and wherever humans
and mechanical systems interact, mistakes
can and will be made.
an SMS for the cabin, this potential conflict
of interests needs to be addressed,’ added
Systems safety expert, Professor Patrick
Hudson, says ‘An SMS is not sufficient to
guarantee sustained performance. What is
also needed is an organisational culture that
supports the management system and allows
it to flourish, and is also worthwhile, both in
terms of lives and in terms of profits. First
and foremost, top management commitment
is a fundamental and necessary requirement
of building a safety culture’.
Hudson’s ideal culture contrasts with the
experience of some dedicated cabin crew. An experienced cabin crew member told
Flight Safety Australia, ‘when it involves
passengers, and how much they can bring
on board, and how we deal with things that
breach the rules ... all I can say is that not all
crew practise what management preaches in
its guidance material. Sometimes the smallest
hazards have measures for avoidance, but
the biggest hazards (such as giant carry-on
bags) are overlooked. A frustrating issue that
is far too big for little me on my own.’
Safety risk management and
safety assurance
Reporting mechanisms
Safety performance can be monitored by:
establishing an effective hazard and
occurrence reporting system for crew
and supervisors to monitor day-to-day
daily inspections (formal or informal) of
all safety-critical areas
using safety surveys
systematically reviewing and following up
on all reports of identified safety issues
systematically capturing daily
performance data in consistent
regular internal and external operational
regularly communicating safety results to
all crew members
The challenge is to establish a set of risks and
risk management processes that are suitable
and relevant, but not so long or complex that
they cannot, or will not, be used.
As Adrian Young said in his presentation,
‘once a company has selected the risks that
will be monitored, the key to success is being
able to integrate the process into day-to-day
activities – getting people to do the work
required without really noticing it.’
Extremely improbable
Risk matrix – courtesy of Denim Air
operational quality assurance =
continuous improvement
Do not proceed until risk is reduced to a value below 14.9
Proceed with caution. Additional measures may still be needed
Risk level is acceptable
Federal Aviation administrator, Robert A.
Sturgell, summed up the importance of
reporting to safety management in a hardhitting speech in 2007:
‘Aviation is no longer in the business of
combing through ashes and wreckage to
find answers,’ he declared. The way to
greater future safety is to identify hazards,
rather than the causes of actual accidents.
Reporting was central to this. ‘Even small bits
of information can point to a larger problem
before that large problem can become
catastrophic,’ Sturgell concluded.
All well and good, but after a 14-hour shift
are members of the cabin crew too tired
to report? Having forms and codes that
are unnecessarily complicated is also a
A cabin safety officer from a major Australian
airline told Flight Safety Australia that they
have three types of safety reports: for
hazard events (the most extensive), fatigue
and injury/illness. These are submitted via
the intranet or ‘good ol’ fax’, reviewed (on
weekdays) by investigators in the safety
department, risk rated and assigned to
someone for action if necessary.
‘The forms are on the aircraft and on the
intranet. While the reporting system is good,
it could be better. We would love to create an
app or simply have them accessible via the
internet as opposed to the intranet, so that
the crew could submit their reports more
‘The other issue in our (obviously confidential)
system is in the lack of feedback. Crew would
love to receive feedback for each and every
report, but there are simply not the resources
to do so. As a cabin safety officer, I'm there to
assist the safety team by providing them with
an insight as to what happens on board and
how to achieve improvements. If someone
approaches me regarding a certain issue or
report, I try to give them the feedback they
require. If I don't know, I find out.
‘Distributing feedback will stop the
speculation and the 'crew-mours' from
arising. It will also help build a trustworthy
safety culture.’
Measure the
of operational
safety objectives
by ensuring that
they are
Another experienced domestic cabin crew
member said: ‘We previously had forms for
injuries to people/crew, and a separate one for
safety hazards, but now there’s a combined
form, with all sorts of options to choose
from. When they released the new form they
believed they had covered every scenario,
but it didn't take long for them to realise it
couldn't possibly cover every occurrence. It
will probably be adjusted eventually.’
‘ ... First and
foremost, top
commitment is
a fundamental
and necessary
of building a
safety culture’.
e : co
ht Luft
Adrian Young argues that competent operators
have already done much of the groundwork
of safety management. ‘Implementing an
SMS is not as large a task as some will tell
you. There is lots of good guidance material
available and many operators will already
have some elements in place.’
Cabin safety is an integral part of the safe
operation, Young says. But it must not be
thought of as an add-on. ‘It needs to be
properly integrated into the processes that
constitute the SMS. If the training provided,
personnel involved and the different variables
that are likely to occur are all properly
considered, a risk model can be developed.’
Young argues for a balance between the use
of structured tools and experience-based
judgement to determine what is safe in each
individual company. ‘People can do safety
work without realising it,’ he says.
Airline passengers rely on the knowledge and
experience of their cabin crew every time they
fly. Introducing, implementing and resourcing
a safety management system is just one way
in which they can be supported in doing what
they do best – saving passengers, as well as
serving them.
Further reading
Hudson, P. (2000). Safety Management
and Safety Culture: The long and winding
road. Centre for Safety Research, Leiden
University, the Netherlands.
Stolzer, Halford & Goglia, (2008). Safety
Management Systems in Aviation. Ashgate,
Aldershot, UK.
Reason. J. (2001). ‘In search of resilience’.
Flight Safety Australia, September–October
2001 http://www.casa.gov.au/wcmswr/_
M easurable,
A chievable,
R ealistic, and
have a specified
T imeframe
within which
they must
be achieved.
1. Carburettor heat is provided to combat icing within the
carburettor and induction system and directs heated air into
the carburettor inlet. The alternate air control is
(a) usually provided on fuel injected engines and offers an
alternative source of air that is not prone to obstruction
by either a filter or airframe icing.
(b) usually provided on fuel injected engines and serves
exactly the same function as carburettor heat on an
engine fitted with a carburettor.
(c) provided to select filtered air in dusty conditions.
(d) provided as a second source of static air to the
pressure instruments.
2. Buys-Ballot’s law states, for the southern hemisphere, that if
you stand with your back to the wind, the low pressure area
will be:
(a) on your left.
(b) on your right.
(c) behind you.
(d) in front of you.
3. A straight track line drawn on a WAC chart is actually:
(a) a rhumb line track which is the shortest distance.
(b) a great circle track which has a constant angle with
the meridians.
(c) a rhumb line track that theoretically requires a constant
change of heading in order to follow it.
(d) a great circle track that theoretically requires a constant
change of heading in order to follow it.
4. In a forecast, cloud cover described as scattered (SCT) and
broken (BKN), means:
(a) 1-2 OKTAS and 3-4 OKTAS respectively.
(b) 3-4 OKTAS and 5-7 OKTAS respectively.
(c) 1-2 OKTAS and 5-7 OKTAS respectively.
(d) 3-4 OKTAS and 4-5 OKTAS respectively.
5. If, during a pre-flight engine run-up, the engine RPM
increases when carburettor heat is selected, this:
(a) is normal on any aircraft.
(b) will normally happen on particularly hot days.
(c) might indicate a partially blocked air filter.
(d) indicates that the ignition timing is too far advanced.
6. Diethylene glycol monomethyl ether is used in aviation as:
(a) a fuel additive used to inhibit ice formation in fuel.
(b) a coolant in liquid-cooled engines.
(c) an ice inhibitor applied to external aerofoil surfaces.
(d) a cleaner for acrylic windows.
7. The pumping energy for an ejector pump in a fuel system is
derived from:
(a) compressor bleed air.
(b) ram air.
(c) the output of the submerged boost pump before the fuel
reaches the main engine-driven pump.
(d) returned fuel from the engine-driven pump.
8. The declared summer density altitude:
(a) provides a conservative means of calculating aircraft
performance at a given location by using data published
in a CAO.
(b) is the worst-case density altitude as calculated
seasonally by the Bureau of Meteorology for each
forecast area.
(c) is the worst-case density altitude at a particular
aerodrome on a given day as calculated from the
area forecast.
(d) is the worst-case density at a particular aerodrome on a
given day as calculated from the terminal area forecast.
9. If, during a daily inspection, you find that a considerable
quantity of water has accumulated in the rudder, the
immediate airworthiness consideration is that:
(a) a drain hole is probably blocked but there are no other
airworthiness considerations.
(b) the water will alter the centre of gravity of the rudder
and potentially increase the tendency for flutter.
(c) the water will move the centre of gravity of the
rudder forward.
(d) the water will move the centre of gravity of the
aircraft forward.
10. One potential hazard of making a landing approach over
trees is that:
(a) it is extremely common for pilots to underestimate the
height of dead tree branches.
(b) it is extremely common for pilots to overestimate the
height of dead tree branches.
(c) trees can cause an updraft immediately downwind.
(d) trees can cause a downdraft immediately upwind.
1. Surface conversion coatings on aluminium alloys:
(a) are used to inhibit corrosion and increase electrical
conductivity by increasing the depth of the natural
oxide coating.
(b) rely on the process of converting the magnesium
element of the surface metal to a more stable chromate
(c) rely on the process of converting the metal surface to
a more stable zinc compound.
(d) rely on the process of converting the metal surface to
a more stable phosphate compound.
5. One potential safety issue relating to water entering a
composite structure is that:
(a) if the structure freezes at altitude, the ice expands and
causes further damage.
(b) if the structure freezes at altitude, the ice contracts and
causes further damage.
(c) corrosion of the structure may occur due to the low pH
of the trapped water.
(d) corrosion of the structure may occur due to the high pH
of the trapped water.
2. A voltage regulator ‘hard’ failure is where the generator/
(a) output is reduced slightly and the power available may
not be sufficient to supply all the electrical loads.
(b) output is reduced sufficiently for no power to be available
to supply the electrical loads.
(c) is driven to maximum output and will result in a trip of the
field or alternator circuit breaker.
(d) is driven to maximum output and can result in melting of
the battery and damage to the entire electrical system
due to over-voltage.
3. On a three-phase AC generator (alternator), a ground fault
within the generator is detected by comparing:
(a) the balance of the three output currents.
(b) the balance of the three output voltages.
(c) the three currents to the star point within the generator
with the three currents at the output of the generator.
Copyright Lufthansa. Pho
tographer: Gregor Schlaeg
4. Compared to avgas, jet fuel has a:
(a) higher viscosity and greater ability to hold contaminants
in suspension.
(b) lower viscosity and greater ability to hold contaminants
in suspension.
(c) higher viscosity and reduced ability to hold contaminants
in suspension.
(d) lower viscosity and reduced ability to hold contaminants
in suspension.
6. When burnt, carbon fibre structures:
(a) present an extreme health hazard regarding both inhalation
and skin contact.
(b) present an extreme health hazard, but only if inhaled.
(c) present an extreme health hazard, but only on
skin contact.
(d) are totally benign from a health perspective once their
adhesives have been burnt.
7. Depleted uranium, as used for mass balances on some aircraft,
has a density approximately:
(a) 55 per cent greater than lead.
(b) 68 per cent greater than lead.
(c) 150 per cent greater than lead.
(d) 201 per cent greater than lead.
(d) the sum of the total leakage to ground of the generator
8. The purpose of mass balancing of an aerofoil control surface
is to move the centre of gravity of the surface further:
(a) rearwards to decrease the distance from the centre of
pressure to reduce the amount of force required to
move the surface.
(b) rearwards to decrease the distance from the centre of
pressure to improve the stability of the control.
(c) forwards to increase the distance from the centre of
pressure to reduce the amount of force required to
move the surface.
(d) forwards to increase the distance from the centre of
pressure to improve the stability of the surface.
9. MS28778 refers to:
(a) a gasket, annular, copper-asbestos.
(b) an O-ring, tube fitting boss.
(c) a grommet, elastic.
(d) a plug, square head.
10. The purpose of a bimetallic strip in a mechanical altimeter
is to compensate for:
(a) variation from the ISA temperature.
(b) variation from the ISA pressure.
(c) variation in stiffness of the capsule and other temperature
effects within the instrument.
(d) changes in the outside air temperature (OAT).
You are tracking along W595 at A080 in cloud between Katoomba
(KAT) and Orange (ORG). (Refer to ERC 3 dated 17 November
2011). Your aircraft (category B) is equipped with 2 ADF (fixed
card), 1 VOR/ILS and an approach-approved GNSS with current
database. You are current on each of these NAV AIDS.
The following questions relate to the enroute tracking and descent
for the landing at YORG.
You passed overhead KAT at 1830Z, with an estimate for LOWDI
at 1845 and an ETI LOWDI to ORG of 11 minutes.
1. If the position report was required at KAT, on what
frequency would this be given and what is the correct
content of this call?
(a) 124.55 “SY CEN (aircraft call sign) KAT at 30, 8000,
LOWDI at 45.”
(b) 135.25 “ML CEN (aircraft call sign) KAT at 30, 8000,
LOWDI at 45.”
Photo: copyright Ces
(c) 118.5 “ML CEN (aircraft call sign) KAT at 30, 8000,
ORG at 56.”
Passing 7 GPS inbound in cloud and descending through 4400 a
RAIM loss occurs.
(d) 135.25 “ML CEN (aircraft call sign) KAT at 30, tracking
276, 8000, ORG at 56.”
4. What will your immediate actions be?
At 1845 HDG is 285M with ADF 1 (on ORG) reading 352 R and ADF
2 on BTH.
2. If at this time the aircraft is at position LOWDI what would be
the reading on ADF 2?
(a) 090 R
(b) 270 R
(c) 082 R
(d) 098 R
You copy the YORG AWIS and plan an enroute descent procedure.
You conduct a GNSS RAIM prediction. The GNSS unit indicates
no outages at the time.
3. Which of the following is the correct GPS arrival and what is
the MDA to which you may descend?
(a) Sector A. MDA 3820 with a 2.4km visibility.
(b) Sector A. MDA 3720 with a 2.4km visibility.
(c) Sector B. MDA 3720 with a 2.4km visibility.
(d) Sector C. MDA 3970 with a 2.4km visibility.
(a) Maintain 4400 and track to the ORG NDB.
(b) Climb to the MSA of 6100.
(c) Follow the GPS arrival missed approach procedure by
turning right now to track 005 and climbing to 5200.
(d) Climb to the LSALT of 5200 whilst continuing to track
to the ORG NDB.
You now consider your options for other instrument approaches
into Orange.
5. What other forms of instrument approach are available
should the RAIM warning remain active?
(a) Orange NDB-A only.
(b) Orange NDB-A, RNAV RWY 11, RNAV RWY 29 and Sector
C GPS arrival, having positioned the aircraft to return to
ORG on a TR of 080.
(c) Orange NDB-A and the Sector B GPS arrival, having
positioned the aircraft to return to ORG on a TR of 030.
(d) Orange NDB-A and the CUDAL (YCUA) to ORG GPS
arrival, having positioned the aircraft inbound to ORG
on a TR of 098.
Now approaching overhead ORG NDB, having climbed to
5500, you decide to conduct the NDB-A approach. Your heading
is 280M.
6. What sector entry will you conduct?
You conduct the appropriate sector entry then intercept the initial
approach TR of 208 for category B aircraft.
8. What is the speed range for this portion of the approach?
(a) 120 to 140kt
(a) Sector 1 only
(b) 120 to 180kt
(b) Sector 2 only
(c) 85 to 130kt
(c) Sector 1 or 3
(d) 90 to 140kt
(d) Sector 2 or 3
The date is July 25. You are overhead YORG at 1900Z.
7. Which of the following is correct concerning the requirement
for P.A.L?
Now established on the final approach TR of 010 you descend to
the minima.
9. What is the minima for your category B aircraft?
(a) DA 3810 with 2.4km visibility.
(a) Not required since the arrival is after dawn.
(b) MDA 3810 with 2.4km visibility.
(b) Required since the arrival is 1hr 33mins before dawn EST.
Activated on 119.0 by 3 times 3-second transmissions
within a 25-second period.
(c) MDA 3710 with 2.4km visibility.
(c) Required since the arrival is 1hr 30mins before dawn EST.
Activated on 119.0 by 3 times 1-second transmissions
within a 25-second period.
(d) Required since the arrival is 1hr 33mins before dawn EST.
Activated on 119.0 by 3 times 1-second transmissions.
(d) DA 3710 with 2.4km visibility.
You level out at the minima on a HDG of 360 to hold the final
approach TR.
Cloud break occurs with 2 miles to run to the ORG NDB.
The latest AWIS copied indicated wind at 270/20.
10. Which of the following indicates the most practical
manoeuvring you could use to set up for the landing?
(a) Break left for a right base runway 11.
(b) Break right for a left downwind to base runway 29.
(c) Overfly for a right downwind to base runway 29.
(d) Position for a left downwind runway 22.
Copyright Lufthansa. Pho
tographer: Udo Kröner
Calendar 2012
19 - 21
Bahrain International Airshow
Aircraft Showcase Day - 'Australian Made'
Delegate Seminar
Sakhir Airbase, Bahrain
Temora Aviation Museum, NSW
Bankstown, NSW
25 - 26
Aerial Firefighting International Airshow
and Conference
Sacramento, USA
AvSafety Seminar
Professional Development Program for ATOs
Singapore Airshow
AvSafety Seminar
AvSafety Seminar
Professional Development Program for ATOs
RAAF Museum Air Pageant
AvSafety Seminar
AvSafety Seminar
Nowra, NSW
Brisbane, Qld
Changi Exhibition Centre, Singapore
Goondawindi, NSW
Moree, NSW
Melbourne, Vic
Point Cook, Melbourne, Vic
Bairnsdale, Vic
West Sale, Vic
European Aviation Safety Seminar
Dublin, Ireland
Adelaide, SA
Parafield Airport, SA
Cairns, Qld
Certification Flight Testing Seminar
Melbourne, Vic
AViCON Aviation Disaster Conference
New York, USA
14 - 19
22 - 23
29 March 1
28 - 29
Professional Development Program for ATOs
The Internode Parafield Airshow
Professional Development Program for ATOs
18 - 19
Please note that some CASA seminar dates may be subject to change.
Please check the Education and Avsafety sections of the CASA website for
final details and booking arrangements.
CASA events
Other organisations' events
Become an AOPA member and start receiving your free copies
of the Australian Pilot magazine among other benefits!
Join online today at www.aopa.com.au
Flying ops
1. (a)
2. (b)
3. (d)
4. (b)
5. (c)
6. (a)
7. (d)
8. (a)
9. (b)
10. (a) beware of dead trees on
the approach.
References and notes
1. (b) AIP GEN 3.4 – 106, and ERC 3. Note: Answer (d) is a
departure report content.
2. (c) LOWDI is abeam BTH (90˚ to the KAT/ORG TR) thus a
TR to BTH of 277 + 90 = 007. Now, HDG 285 + 82 = 007.
3. (b) DAP – GPS Arrival procedure (YORG) page 1. Note:
AWIS allows MDA reduction of 100’ AIP ENR 1.5 – 33
PARA 5.3.2.
4. (d) AIP ENR 1.5 – 48 PARA 11.2.2 f.
5. (a) YORG approach plates. Note: All the other GNSSrelated approaches will require RAIM and therefore will
not be available in these circumstances.
6. (c) YORG NDB – A approach plate AIP ENR 1.5 – 23
PARA 3.3.1.
7. (d) Dawn at YORG on July 25 is 0633 EST. ATA is 1900Z +
1000 = 0500 EST, therefore lights required. AIP GEN 2.7
– 4 and 2.7 – 7. ERSA INTRO – 13 PARA 23.5.
8. (a) YORG NDB – A approach plate. See notes. AIP ENR 1.5
– 11 PARA 1.15.1 gives a normal speed range of 120 –
180kt but the NDB plate note takes precedence. PARA
1.16.1 refers.
9. (c) AIP GEN 2.2 – 6 D.A. and – 16 M.D.A. definitions. AIP
ENR 1.5 – 33 PARA 5.3.2.
10. (b) The left-hand circuit is the ideal from the pilot’s
perspective of better visibility. Answer (d) is incorrect
because no lighting is available on RWY 22.
1. (a)
2. (d)
3. (c)the three current transformers to
the star point are contained within
the generator.
4. (a) t he contaminants include water.
5. (a)
6. (a)
7. (b)
8. (d)
9. (b)
10. (c)
Phone 02 9791 9099 • Email mail@aopa.com.au
Web www.aopa.com.au
We have an unrivalled 40-year reputation, having trained
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With SA’s widest range of aircraft for training, your
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We are SA’s leading Multi-Engine Instrument Rating
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Training done from our newly refurbished facilities at
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Our costs are always keen and competitive
Quite simply - there is no flight training service in
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Standing personal minimums checklist
(Review every 100 hours, or annually, or on completion of new rating/endorsement)
Endorsement, training & experience summary
Run-up bay
Intermediate holding position
Runway holding position
Runway incursion hotspot
Apron grass area
Apron area
Manoeuvring area
Movement area
An area on the aerodrome intended to accommodate aircraft for the purpose
of loading or unloading passengers, cargo, fuelling, parking, or maintenance.
That part of the aerodrome to be used for take-off, landing and taxiing
of aircraft, excluding aprons.
That part of the aerodrome to be used for take-off, landing and taxiing
of aircraft,Area
consisting of the manoeuvring area and the aprons.
Run-up bay
Operation on the aerodrome
Intermediate holding position
Apron area – no taxi clearance required. Monitor Ground on 119.9 MHz.
Runway holding position
Taxiway – taxi clearance from Ground required before entering this area.
Runway incursion hotspot
Toll facility
Runway – specific clearance required from ATC
before94entering this area.
Maximum crosswind as % of pilot’s operating
handbook figure for type
Minimum runway requirement as % of pilot’s
operating handbook figure for type
Minimum visibility – day VFR
Minimum visibility – night VFR
Minimum ceiling – day VFR
Minimum ceiling – night VFR
Surface wind speed & gusts
Maximum cross wind
Other VFR (eg: mountain flying,
over water beyond gliding distance)
Fuel reserves (day VFR)
Fuel reserves (night VFR)
Right tank
Left tank
3,000 feet
5,000 feet
15 knots 5 knot gust
7 knots
Consult instructor/
1 hour
1½ hours
30 min
Right tank
Left tank
Gauge each tank
Your personal
TR (m)
My aircraft
fuel flow
100 hour VFR pilot
CENSAR 1800 814 931
Left tank
Right tank
30 min
each tank Gauge
TEMPO (60)
* Recommended
PILOT NOTES ________________________________________
1009.1351 (d)
E3 ELEV 39
Taxiway crossing (pedestrian)
ROUnsealed Taxiway
Swing Bay
1108.1571 (c) v2
For these and many more other free* safety
promotion products visit the CASA online
store at www.casa.gov.au/onlinestore
Endorsement/ratings (eg: night VFR, MPPC)
Flight review
Time since last instruction in aircraft #1:
Time since last instruction in aircraft #2:
Time since last instruction in aircraft #3:
Familiarity with avionics/GPS
Total flying time in hours
Number of years flying
Hours in the last year
Hours in this or identical aircraft in last year
Landings in last year
Night hours in last year
Night landings in last year
High density altitude hours in last year
Mountainous terrain hours in last year
Strong crosswind or gusty landings in last year
Personal minimums
For more information and a full price list, contact Air South
on (08) 8234 3244 or visit www.airsouth.com.au
www.casa.gov.au | p.131 757
An area on the aerodrome intended to accommodate aircraft for the purpose
Intermediateof holding
positionpassengers, cargo, fuelling, parking, or maintenance.
loading or unloading
area holding
That part of the aerodrome to be used for take-off, landing and taxiing
of aircraft, excluding aprons.
Movement area
Apron area
Apron area
Apron area – no taxi clearance required. Monitor Ground on 124.3 MHz.
Manoeuvring area
That part of the aerodrome
for take-off,
Taxiwayto– be
taxi used
from Ground
entering this area.
of aircraft, excluding Runway
aprons. – specific clearance required from ATC before entering this area.
1108.1571 J
That part of the aerodrome to be used for take-off, landing and taxiing
of aircraft, consisting of the manoeuvring area and the aprons.
Run-up bay
Intermediate holding position
Runway holding position
Runway incursion hotspot
Operation on the aerodrome
Apron area – no taxi clearance required. Monitor Ground on 121.9 MHz.
Taxiway – taxi clearance from Ground required before entering this area.
Runway – specific clearance required from ATC before entering this area.
An area on the aerodrome intended to accommodate aircraft for the purpose
of loading or unloading passengers, cargo, fuelling, parking, or maintenance.
Manoeuvring area
That part of the aerodrome to be used for take-off, landing and taxiing
of aircraft, excluding aprons.
Movement area
That part of the aerodrome to be used for take-off, landing and taxiing
of aircraft, consisting of the manoeuvring area and the aprons.
1108.1571 C
That part of the aerodrome to be used for take-off, landing and taxiing
of aircraft, consisting of the manoeuvring area and the aprons.
An area on the aerodrome intended to accommodate aircraft for the purpose
on thepassengers,
aerodromecargo, fuelling, parking, or maintenance.
of loading
or unloading
Operation on the aerodrome
* please note that a postage and handling fee of $15 applies to each order
Apron area – no taxi clearance required. Monitor Ground on 119.9 MHz.
Taxiway – taxi clearance from Ground required before entering this area.
Runway – specific clearance required from ATC before entering this area.
1108.1571 B
… essential aviation reading
Inside MAR - APR 2012
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Data recovery – the aftermath of a sport aviation crash
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