Flight Safety Australia Sept-Oct 2012

Flight Safety Australia Sept-Oct 2012
September–October 2012
Aviation communication | mind your language
Fatigue regulations | wake-up call on fatigue rules
26 FEBRUARY - 3 MARCH 2013
Australian Sales Team
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Penny Haines
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Issue 88 | September–October 2012
call on
fatigue rules
Circadian Function
08 Mind your language 02 Air mail
In a crowded sky your words
really matter
20 A Christmas tragedy
Time of Day
Could it have been averted?
22 Wake-up call on
fatigue rules CASA proposes new standards
to manage fatigue
26 QF32 and the black swan
Richard de Crespigny’s reflections
on QF32
31 Shift handovers in
the hangar
Communication is the invisible but
vital tool
40 Ageing aircraft
management plan
comes of age
Taking another closer look
44 Trapped in the sky
Communication failure = tragedy
62 In plane sight –
hazard ID and SMS
Part two
Letters to the editor
03 Flight bytes
Aviation safety news
16 ATC Notes
News from Airservices Australia
18 Accident reports
18 International accidents
19 Australian accidents
31 Airworthiness section
46 Close calls
46 Yesterday’s papers
48 Power line! Much too close
for comfort
50 Think first, fly later
52 ATSB supplement
News from the Australian Transport
Safety Bureau
66 Av Quiz
Flying ops | Maintenance
IFR operations
Upcoming aviation events
71 Quiz answers
72 Coming next issue
72 Product review
CASA’s new SMS resource kit
Aviation safety news
Director of Aviation Safety, CASA | John F McCormick
Manager Safety Promotion | Gail Sambidge-Mitchell
From the editor
Editor, Flight Safety Australia | Margo Marchbank
Writer, Flight Safety Australia | Robert Wilson
After the distribution of the last printed issue of Flight Safety
Australia (July-Aug 2012), we had feedback from various
passionate readers. Some welcomed the decision, some were
angry, and others like Ian Jennings, were philosophical.
Sub-editor, Flight Safety Australia | Joanna Pagan
Designer, Flight Safety Australia | Fiona Scheidel
It is with deep regret that I note the passing of the ‘Crash
Comic’, a publication that I have been holding in my hands
to read for the last 40 years. I understand the reasons for
its demise from my letterbox and now I look forward to its
arrival in my in box. That’s progress!
Phone 131 757 | Email fsa@casa.gov.au
Flight Safety Australia GPO Box 2005 Canberra ACT 2601
Phone 131 757 | Fax 02 6217 1950 | Email fsa@casa.gov.au
Web www.casa.gov.au/fsa
Glenn Batson was saddened to hear that a hard copy of
Flight Safety Australia will no longer be mailed. I believe this
is a bad move and I will not be going online to read the new
format. A sad day for safety in Australia.
If you have an aviation reference number (ARN) and want to
update your contact details, go to http://casa.gov.au/change
For address change enquiries, call CASA on 1300 737 032.
Another reader gave some bouquets for the magazine, as well
as considered comment.
Bi-monthly to aviation licence holders, cabin crew and industry
personnel in Australia and internationally.
I have long enjoyed Flight Safety Australia as the most clearly,
intelligently and accurately written flying magazine available,
and I do literally read it from cover to cover. I find that many
aviation folk, including students, also read it thoroughly
because of the admirable balance of content.
While I am fully supportive of the environmental and probable
cost benefits of phasing out the hardcopy magazine I have a
couple of minor observations:
A magazine is highly portable, unbreakable and does not
need a power supply
While most information sources are favouring online
transmission I am not convinced that such material is
‘taken in’ as effectively in terms of the learning process.
Joerg Hofmann wrote: I am rather dismayed to hear that
Flight Safety Australia magazine will be discontinued—the
printed version, that is. I think this is a retrograde step for
promoting a strong safety culture in aviation. True, there has
been an increasing trend of media going online, but let’s not
forget that people are very selective in what they read online.
We at Flight Safety Australia assure readers that although the
magazine may have changed its delivery method, our focus on
providing clear, accurate and intelligent content has not changed.
Stories and photos are welcome. Please discuss your ideas with
editorial staff before submission. Note that CASA cannot accept
responsibility for unsolicited material. All efforts are made to ensure
that the correct copyright notice accompanies each published
photograph. If you believe any to be in error, please notify us at
Advertising appearing in Flight Safety Australia does not imply
endorsement by the Civil Aviation Safety Authority.
Warning: This educational publication does not replace ERSA, AIP,
airworthiness regulatory documents, manufacturers’ advice, or
NOTAMs. Operational information in Flight Safety Australia should
only be used in conjunction with current operational documents.
Information contained herein is subject to change. The views
expressed in this publication are those of the authors, and
do not necessarily represent the views of the Civil Aviation
Safety Authority.
© Copyright 2012, Civil Aviation Safety Authority Australia.
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).
ISSN 1325-5002.
Cover design: Fiona Scheidel
Flight Safety Australia
Issue 88 September–October 2012
Safer skies for children
AAGSC Safety Award
CASA is exploring the best ways of protecting infants and small
children in aircraft, and will be publishing a discussion paper
on the topic. Advisory material on infant and child safety will
also be updated and improved to provide guidance on child
safety best practices and newly available restraints.
Nominations for the Australasian Aviation Ground Safety
Council Safety Award are now open. You can nominate
an individual or a team who have made an outstanding
contribution to improvements in ground safety. The
Australasian Aviation Ground Safety Council would like
to recognise them so that all can learn from their initiatives.
The award celebrates outstanding contributions to, and
significant improvement in, ramp safety through innovation
and implementation of new methods, practices or procedures.
The method of carrying infants and small children in aircraft
has not changed substantially since the early years of aviation,
although there have been major advances in child safety in
other forms of transport such as motor vehicles.
Evidence from accidents and research says children who are
carried on the lap of an adult passenger are likely to be more
severely injured in an accident than other passengers. Other
research says that seating small children individually on an
aircraft seat may not be appropriate. CASA has been working
with Standards Australia on a revision to standards for motor
vehicle child restraint systems to allow them to be used in
aircraft. New standards would include testing of seats in an
aircraft-like environment, restrictions on dimensions, and
instructions on how to fit seats in aircraft. This would allow
restraints to be marked as acceptable for aircraft use.
Previous entrants have received national and international
recognition. Queensland Airports Ltd, Aviation Ground
Handling and Gold Coast Airport received coverage in
international ground handling magazines, while Virgin
Tech’s entry featured in Flight Safety Australia magazine.
Entries close Friday 28 September 2012—go to
www.aagsc.org for details.
Find out more about the infant and child safety project
CS12/23 on the CASA website under changing the rules >
active projects.
Informing and entertaining pilots for over 20 years.
$48 (4 ISSUES)
Use coupon code: FSAFY
Offer valid for print subscriptions of Australia only.
Aviation safety news
Eyes in the sky
Stormy weather
Good visual function is critical for safe aviation activities.
Many eye abnormalities are easily correctable to restore good
functional vision. Flight Safety Australia covered the topic of
(refractive) eye surgery extensively in the November-December
2010 issue (www.casa.gov.au/fsa).
Aircraft turbulence guidelines may need rewriting after new
research by the Sydney-based Centre of Excellence for Climate
Systems Science chief investigator, Dr Todd Lane, revealed
that thunderstorms could produce unexpected turbulence more
than 100km away from storm cells.
However, following such surgery, as a pilot, you need to:
Lane’s research has highlighted the impact of atmospheric
gravity waves caused by thunderstorms and how air safety
guidelines have not taken them into account.
Report it to your DAME/CASA
Not go flying—for at least a minimum of four weeks,
to three months (most recreational activities are not
recommended for four weeks minimum). This is because:
• There is a risk of damage—the flap is subject to
slippage in the first few days to weeks, even months,
post surgery and this could be caused by even such
minimal trauma as eye rubbing.
• You may experience glare disability and haloes
following refractive surgery. If you are flying at
night, or in poor light, you may therefore experience
an unacceptable loss of visual acuity or image
While eye examinations are only mandatory for Class 1
medical certificate holders at initial issue, then biennially from
age 60, it pays pilots to have regular check-ups, to diagnose
and treat conditions such as glaucoma, cataracts and retinal
abnormalities early.
‘It is likely that many reports of encounters with turbulence
are caused by thunderstorm-generated gravity waves, making
them far more important for turbulence than had previously
been recognised,’ Dr Lane said.
‘Previously it was thought turbulence outside of clouds was
mostly caused by jet streams and changes in wind speed at
differing altitudes, known as wind shear, but this research
reveals thunderstorms play a more critical role’, he said.
Lane said it is now recognised that thunderstorms have
far-reaching effects, modifying airflow, strengthening the jet
stream and enhancing wind shear at a significant distance
from the storm cell itself.
Flights along domestic Australian routes and international
routes across the tropics towards Asia and between Australia
and the US regularly detour around storm cells.
Source: AvMed CASA
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Flight Safety Australia
Issue 88 September–October 2012
However, this research indicates they may still be close enough
to encounter gravity waves and clear-air turbulence.
This unexpected turbulence mid-flight can lead to passenger
injuries, with around 97 per cent of injuries caused by
turbulence during flight occurring because people are not
wearing seatbelts. On average, around 15 people are injured
every year due to turbulence.
Beyond the immediate safety concerns, it has been estimated
that turbulence costs the aviation industry more than $100M a
year globally due to associated rerouting and service checks.
‘Last year the International Civil Aviation Organization (ICAO)
reconvened their EFB group, as there was recognition that
regulators needed to consider the introduction of the tablet
computer’, says Read.
‘We are proposing to adopt ICAO’s four levels of functionality.
Function level 1 is basically a document viewer; function
level 2 adds some software such as weight and balance and
performance calculations; function level 3 can also read data
from the aircraft; and function level 4 is a two-way link with
the aircraft.
Source: http://phys.org/news/2012-06-storm-air-safetyguidelines.html
‘The regulations will be introduced in stages, with pilots and
companies first making use of EFBs at levels 1 and 2.
Boarding soon – electronic flight bags
‘We will require air operator certificate (AOC) holders to
develop procedures and guidance in their operations manuals,
with other users such as private pilots to follow the CAAP.
Comment on NPRM 1211OS is due by mid-late September;
go to the changing the rules section on the CASA website.
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Dangerous Goods
Flight Crew
Cabin Crew
Check-in Staff
Mal Read, project manager, says the regulations are framed
around what the devices are used for, rather than the hardware
or software type.
‘A trial into the use of EFBs is currently underway with
Qantas and Jetstar.
As our
cu k a
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co om ut
ur is ou min
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CASA has previously released a civil aviation advisory
publication (CAAP) on electronic flight bags to an industry
forum made up of major and some smaller operators and
industry groups such as the Aircraft Owner’s and
Pilot’s Association.
‘Our intent is to create regulations that maximise the
advantages offered by new technology, while minimising
the risks.
CASA has recently released a notice of proposed rulemaking
(NPRM 1211OS) on the use of electronic flight bags (EFB).
Aviation safety news
Global aviation needs global standards
Performance based navigation (PBN) is one of the International
Civil Aviation Organization’s (ICAO) highest priorities, with a
major push to implement global PBN standards to realise the
full benefits this technology offers. PBN encompasses a shift
from ground-based navigational aids emitting signals to aircraft
receivers, to a system that relies more on the performance
and capability of equipment on board the aircraft. It brings
numerous safety, economic and environmental benefits.
Increased airspace safety and efficiency come with the
implementation of a common global standard that includes
stabilised approach procedures using vertical guidance.
The accuracy of PBN allows more efficient and flexible use
of airspace, with less reliance on ground-based navigation
aids, bringing optimal route placement, fuel savings and
environmental benefits.
As part of this global shift, and following an extensive
consultation process, CASA is implementing two Civil Aviation
Orders (CAO): CAO 20.91 (which covers PBN standards and
the associated navigation authorisations) and CAO 20.18,
which will mandate the equipment required for PBN and
ADS-B from February 2016. CAO 20.91 came into effect on
18 July 2012, with CAO 20.18 imminent.
The introduction of PBN affects all stakeholders involved in
IFR flight operations. ‘In Australia, if you’ve got a GNSSequipped aircraft approved for IFR operations, then you are
good to go without any changes. That’s why there are
deeming provisions in the CAOs,’ says CASA’s PBN specialist,
Ron Doggett.
‘The deeming provisions say if you’ve got a TSO-certified,
stand-alone navigation system that’s been fitted according
to the regulations and you’re a suitably qualified pilot, you
are deemed to hold the required navigation authorisations.’
Existing navigation authorisations remain valid for two years
under CAO 20.91 unless they lapse or are replaced. After
those two years expire, PBN navigation authorisations will
be required.
However, aircraft with flight management systems (FMS),
such as some newer commuter/regional aircraft, will need
to obtain navigation authorisations from CASA. The PBN
standards also provide for IFR helicopter-specific operations
such as in metropolitan areas and for offshore support.
Further information
Advisory circulars to support CAO 20.91 are due in the
near future.
November-December 2012’s Flight Safety Australia’s
feature will also focus on PBN and airspace reform.
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Flight Safety Australia
Issue 88 September–October 2012
New – and available now! Safety reminders
for your hangar walls
Eight new A3 posters designed to promote the importance
of safety in aviation workshops have just been released.
They depict vital maintenance safety issues, such as tool
control, fatigue management, unapproved parts and using
the correct data, and are available from the CASA online
store www.casa.gov.au/onlinestore
Aviation safety relies on the right parts used in the right way.
Submit a service difficulty report when you discover a malfunction, failure, or defect that might affect
the safety of an aircraft or be a danger to people or property.
Positive identification of unapproved parts is often difficult. Check that you:
have authentic paper work, have the current part number, have the correct parts
installed in the correct location, and know your suppliers.
Report defects as soon as possible to CASA at www.casa.gov.au/airworthiness/sdr
Do you have the knowledge for the task? Are you current? Need further training?
Understanding your responsibilities is important for safe aircraft maintenance.
(Refer CASR Part 42.C.4 and CAR 51)
For further information visit www.casa.gov.au or phone 131757
For further information visit www.casa.gov.au or phone 131757
For further information visit www.casa.gov.au or phone 131757
A test panel of engineers and industry members said that
their somewhat humorous/quirky take on safety messages
would appeal to maintenance professionals and remind them
to think outside the box and avoid complacency.
The posters are free of charge but a $15 postage and
handling fee applies to orders of any size, so you can add
other useful items from the online store.
Misplaced tools are a threat. Always know where your tools are.
Put your tools back where they belong...not in the aircraft.
For further information visit www.casa.gov.au or phone 131757
Is it approved? Is it valid? Is it current? Is it applicable?
Before you begin any work, make sure you are using the correct manufacturer’s data.
The latest information may introduce vital changes to procedures as well as new
tolerances, tensions, pressures etc.
For further information visit www.casa.gov.au or phone 131757
Coming soon – learning and event
management registration
CASA’s new online learning and event management
registration system is set to go live later in the year,
providing industry with a streamlined registration process
for seminars and other events, along with access to
online learning modules. Look out for more information in
the November-December issue of Flight Safety Australia.
No scheduled shifts over twelve hours long.
Shifts longer than 13 hours with overtime
Less than 11 hours between shifts.
The risk of error increases during night shifts. Don’t just accept excessive night-time
hours and a lack of adequate daytime rest.
Fatigue accumulates over successive work periods. Does your working week regularly
exceed 60 Hours?
Fatigue in maintenance - do you know YOUR limits?
Fatigue in maintenance - do you know YOUR limits?
Fatigue in maintenance - do you know YOUR limits?
For further information see AC145-2 (0) Chap 3-H; visit www.casa.gov.au or phone 131757
For further information see AC145-2 (0) Chap 3-H; visit www.casa.gov.au or phone 131757
For further information see AC145-2 (0) Chap 3-H; visit www.casa.gov.au or phone 131757
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Aviation communication
Mind your language
Kümmern Sie sich um Ihre Sprache
Let op uw taal
Occupi del vostro linguaggio
Occupez-vous de votre langage
In a crowded sky, what you say and
how you say it are as important
as how you manage the controls.
Likewise, in an industry where
lives depend on complex machines
functioning perfectly, the instructions
on how to maintain them are vitally
important. Your words matter—make
no mistake.
About this, Wilbur Wright was wrong. ‘I know of
only one bird—the parrot—that talks; and it can’t
fly very high,’ the pioneer of powered flight said
in declining to make a speech. Aircraft may fly
because their wings move through the air—but
they fly safely because of clear communication.
Pass your message: the
spoken word
The International Civil Aviation Organization’s
(ICAO) resolution A37-10 requires ‘Proficiency
in the English language for radiotelephony
communications’, in effect making English the
official language of aviation.
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What qualifications does English have to be the
official language of the sky? It is the first language
of only 375 million of the world’s seven billion
people. It is, however, the world’s most widely
spoken and read second language. Including those
who speak its many dialect, pidgin and creole
varieties, English has up to one billion non-native
speakers and users.
However, as a language, English has some
features that are problematic for high-reliability
technical communication. More than 30 years
ago Charles Grayson and Ralph E. Billings
listed 10 types of error that could occur in spoken
messages between pilots and air traffic controllers:
three of them—ambiguity, transposition and
actor in approx
a causal f
Flight Safety Australia
Issue 88 September–October 2012
be part of a wing or a permitted time to take off or
land; and go ahead, which can mean go forward or
speak, a big difference on a busy aerodrome.
The Flight Safety Foundation identifies 49 cases
where the US Federal Aviation Administration
and ICAO use different words to refer to the
same thing.
This confusion of words and sounds has a
name—mondegreen—a word coined by author
Sylvia Wright for misheard song lyrics. As a child,
she heard the words ‘and laid him on the green’ as
‘and Lady Mondegreen’. Others have heard ‘there’s
a bad moon out tonight,’ as ‘there’s a bathroom
on the right’, or have, against all conventions of
decency, accepted that AC/DC really did sing ‘dirty
deeds, done to sheep’. The actual words were
‘dirty deeds, done dirt cheap’.
phonetic similarity—specifically relate to the nature
of English.
The English language has an alphabet of 26
letters, but 42 distinct vocal sounds, many of
which are represented by unlikely and inconsistent
combinations of letters. English also has a very
wide vocabulary, making it possible to say the
same thing with several different words or phrases,
known as synonyms. It also has a large number
of homonyms, similar sounding words or phrases
that mean different things, such as ‘two’ and to’.
There are an estimated 100,000 homonyms in
English. Possible causes of confusion in aviation
include roll—meaning take-off, or turning around
the longitudinal axis of an aircraft; slot, which can
t el y
75 p
er cen
t of aviation accidents
Aviation mondegreens are not as funny. Steven
Cushing’s Fatal Words (1994) describes several
documented aviation mondegreens. The similarity
between two and to is a particular problem,
Cushing says, which contributed to the crash in
1989 of Flying Tiger Line flight 66, a Boeing 747
Freighter, after the pilots heard ‘descend 2400’ as
‘descend to 400’. The aircraft hit a hill near Kuala
Lumpur, Malaysia.
‘Descend to and maintain two thousand four
hundred feet’ was the Australian version from
Airservices Aeronautical Information Package
(AIP GEN 3.42-82) of the correct phrase that might
have saved flight 66.
In the United Kingdom, the word ‘to’ is banned
by convention from any message regarding flight
levels, and all messages relating to an aircraft’s
climb or descent to a height or altitude employ
the word ‘to’ followed immediately by the word
‘height’ or ‘altitude’. A British controller would
say: ‘G-CD, descend to altitude 2000 feet’ or
‘Speedbird 38, climb flight level 350’.
British controllers also make a practice of saying
flight levels in round hundreds as ‘flight level
e fac‘flight
tor level
in othree
en oorhundred’,
hundred’,for example, instead of ‘flight level veer
three-zero-zero’. The intent is to reduce confusion
between similar sounding flight levels. For
consistency they do not use the word ‘hundred’
in heading messages.
75 p
Aviation communication
‘One of our biggest issues is communication,’
says Russell Eastaway, an ATC training
specialist at Airservices’ Learning Academy in
Melbourne, reinforcing this with a telling statistic:
‘communication is a causal factor in approximately
75 per cent of aviation accidents/incidents’.
Confusion can also creep in as to whether words
are an instruction or a description.
Cushing cites a controller who told a general
aviation pilot ‘traffic at ten o’clock, three miles,
level at 6000 to pass under you’. A short time
later the controller asked the pilot why he was
descending from 7000 feet—the pilot had
interpreted ‘level at 6000’ as an instruction.
To this potential for confusion, add complex and
critics would say, disorganised, grammar. English
has about 1000 grammar rules—and 1500
exceptions. In short, English is the language that
gave the world Shakespeare—but also the Tenerife
accident of 1977.
The ritual of the readback is an attempt to
control this inherent ambiguity. The readback
acts as a trap for misunderstanding before it can
cause damage.
Russell Eastaway explains that the Learning
Academy emphasises ‘active listening, where
ATC trainees focus on listening to every word’,
as well as not combining a number of different
instructions in one transmission, in order to
minimise confusion.’ Compared to the rest of the
world, Australian ATC training and oversight is
‘very regimented’, Eastaway says. ‘All controllers
have regular six-monthly assessments, with
communication one of the test elements. To retain
their ATC endorsements, controllers must score
at least 4 on a scale of 1-7. If controllers scored 3
on communication/phraseology, for example, they
would have to undertake remedial study, and be
reassessed in a month’s time.’
Standard phraseology is another convention to
control error, eliminating potentially confusing
words and phrases. Thus in the international
phonetic alphabet the number nine is pronounced
as niner, in order to differentiate it from the similar
vowel sounds in five (correctly pronounced as fife)
and the German word ‘nein’, meaning no.
But standard vocabulary cannot always stop what
linguists call code switching. This is when native
English speakers switch between technical jargon
and normal, vernacular English. Problems arise
when the same word has different meanings in
technical and vernacular use. And human beings
tend to code switch at just the worst time for
safety—when they’re under stress.
At the suburban Los Angeles John Wayne
Airport in 1981, a flight was cleared to land at
the same time as another flight was cleared
to taxi into position for take-off. The controller
told the approaching flight to go around, but the
pilot asked for permission to continue landing.
In understandable stress, the pilot used the
word ‘hold’ to express his request. In aviation,
‘hold’ means to ‘stop what you are doing’, but
in ordinary, or colloquial, English it can mean to
continue on the same course (hold fast, hold your
line, hold your own etc.). The controller agreed
for the flight to hold, in the aviation sense, and
expected it to go around. Instead it continued with
its landing and collided with the aircraft on the
runway. ‘Hold’ is still heard in aviation contexts,
but this accident suggests it is a word for pilots
and controllers to use with caution.
The Tenerife accident of 1977 involved a subtle
case of code switching. Here the captain of the
KLM flight, although fluent in English, appears
to have reverted to Dutch grammar in his radio
call that preceded the runway collision of two
Boeing 747s that killed 583 people. Captain
Veldhuyzen van Zanten said ‘we are now at take
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is not
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Flight Safety Australia
Issue 88 September–October 2012
off’. In English, this is ambiguous. One meaning
would be ‘we are at the take-off point,’ which
was how the English-speaking Spanish air traffic
controller understood it. But in Dutch, the English
grammatical ‘ing’ ending for verbs (such as ‘taking
off’) becomes ‘at’ plus the infinitive form of the
verb—‘at take-off’. In Dutch you say the equivalent
of ‘at’ instead of ‘ ing’. Athough Captain van Zanten
spoke in English, his grammar was Dutch, and it
said, ‘we are taking off’. It didn’t help that minutes
earlier he had received an en-route clearance that
sounded like a clearance to take off.
Language of the gods:
English as a foreign tongue
Over the next 20 years, aviation English is likely to
follow a similar path to the language generally—
towards having more non-native speakers than
native speakers. The fastest-growing region in
global aviation is the Asia Pacific region, which
takes in the markets of China and Southeast Asia.
In 2010, the International Air Transport Association
(IATA) estimated that about a third of all
passengers travelled on routes to, from, or within,
the Asia Pacific. For North America and Europe,
the equivalent number was 31 per cent. By 2015,
IATA anticipates that Asia-Pacific traffic will grow
to 37 per cent, while Europe and North America
will fall to 29 per cent of world aviation traffic.
He quotes a NASA study: ‘Twenty-five per cent of
the reports cited language problems as a primary
cause of the foreign airspace operational incidents
reported to ASRS.’
However, former Emirates head of human
factors, Surendra Ratwatte, argues that English
proficiency is, to use an idiom, a two-way street.
Native English speakers also need to be careful,
disciplined and precise in how they use the
‘English is the official language of aviation and its
practice should be mandated; however, language
training is not just for the non-native speaker of
English,’ Ratwatte writes. ‘Anglo pilots, who have
been arbitrarily granted the linguistic advantage,
should be taught how to communicate simply,
slowly, and precisely with non-Anglo personnel
as required,’ he and Ashleigh Merritt wrote in a
1997 paper.
Dominique Estival and Brett Molesworth studied
English proficiency and communication in general
aviation, using the abbreviation EL2 pilots to
describe those who spoke English as a secondary
language. They concluded that: ‘the most
challenging communication problem for pilots
is not with ATC, but with other pilots, and that,
irrespective of qualification or native language,
pilots find it most difficult to understand other
Atsushi Tajima’s 2004 study on aviation safety
summarises a popular view on the safety
implications of non-native English speakers
as pilots.
Estival and Molesworth concluded that pilots
found communicating with ATC to be the least
challenging of their communication tasks. ‘This
result indicates that communication problems
within general aviation cannot be solely attributed
to language proficiency levels of EL2 pilots. Rather,
the problem appears to be more widely spread
and the results suggest that all pilots experience,
and contribute to, communication problems within
general aviation.’
‘When pilots report problems regarding crosscultural communication, they identify “language/
accent”, “dual-language switching [in non-Englishspeaking countries, speaking in English to foreign
pilots, but simultaneously speaking in the local
language to local pilots]” and “[different] reception
across languages” as among the most frequently
reported problems,’ Tajima writes.
Communication is also an issue within the
cockpit. Here research has produced surprising
and heartening conclusions. In 1997, Merritt
and Ratwatte compared the safety performance
of mono- versus multicultural cockpits. They
presented diverging conclusions. Merritt found that
language barriers and cultural differences inhibited
open communication and team fellowship.
Australia is already playing a part in this
transformation, with a substantial industry arising
to train airline pilots from Asian and Pacific
countries. For most of these young pilots, English
is their second, or third language.
Aviation communication
However, Ratwatte found that multicultural crews,
especially those comprising crew members with
English as a second language, had to verbalise
their messages concisely and perform ‘by
the book’. He said this led to strict rule-based
behaviour, with standard operating procedures
(SOPs) being used more often than in more
relaxed flight decks. Ratwatte argues that greater
reliance on crew resource management principles,
such as more precise communication and more
crosschecking, means mixed-cultural cockpits
may actually be safer.
Tajima is scathing about the idea that language
problems in aviation can be cured only by more
training or censure of non-native speaking pilots.
‘Merely and hegemonically blaming their language
inabilities or limitations for preventable accidents
will not fundamentally solve the problem’,
he writes.
‘It is important to notice that the ultimate goal
is “not to improve their English proficiency
itself,” but “to avoid fatal accidents due to
miscommunication”. Their efforts in acquiring
English proficiency may have certain limitations,
or will reach a “ceiling”, as it were. Although the
KLM captain of the Tenerife accident had made
intensive use of aviation English for decades, he
was still not totally free from interference from his
native language. Therefore, we should sincerely
and rigorously strive to create an error-resistant
and mistake-free language environment.’
The theme of the role of language in ‘avoiding fatal
accidents due to miscommunication’ is one taken
up by passionate opponent of dead, managerial
English, Don Watson, author of books such as
Weasel Words and Bendable Learnings.
Watson outlines the sinister impact of abstract
managerial language in a powerful essay on
the 7 February 2009, Black Saturday fires in
Victoria. Describing it as ‘the day words fell
short’, seven months after the fires, he reflected
on the evidence that fire managers were giving
to the royal commission about what they called
‘One CFA manager described the business of
telling the public as “messaging”; “communicating
the likely impact”; “to communicate the degree of
the circumstance”; providing “precise complex fire
behaviour information”; “to communicate more
effectively in a timely manner not just that it is a
bad day, but other factors as well.” He spoke of
his task as “value-adding” and “populating the
document.” He and other managers talked a good
deal about “learnings,” “big learnings” and even
“huge learnings”.
They neglected to tell people in concrete language
that any fire on February 7 was likely to be one
they could not fight, and might not survive. If
instead of “fire activity with potential to impact”
we had dangerous, unpredictable, deadly fires, the
CFA’s “messagings’’ might have persuaded more
people to get out of the way. If instead of “wind
events” the experts and the authorities had said
the wind will blow a tremendous gale of searing air
through forests so dry they will explode into fires
that no one can stop …’
Watson concluded: ‘Telling people requires
language whose meaning is plain and
unmistakable. Managerial language is never
this.’ In a technical field such as aviation, where
safety is paramount, concrete language is
especially critical.
not to improve
elf ..
their Eng
lish proficien
ue t o m
bu t
to av
oid fatal accid
Flight Safety Australia
Issue 88 September–October 2012
Leaving a mark:
the written word
Any language where the unassuming
word fly signifies an annoying insect,
a means of travel, and a critical part
of a gentleman’s apparel is clearly
asking to be mangled.
Bill Bryson Mother Tongue: The English Language, 1990
Aviation enthusiasts with the leisure time to peruse
the excellent online resource that is FlightGlobal’s
digital archive may notice a charming feature in
editions from the magazine’s first 20 years. As
the semi-official voice of British aviation Flight
published notices to airmen (later abbreviated to
notams) on behalf of the British air ministry.
Here is an example from February 1930:
‘In preparation for air survey work in the vicinity
of Baghdad a number of white circular ground
marks have been made in various localities within
an area extending 40 miles N. and 20 miles S. of
Baghdad, and approximately 20 miles on each side
of the River Tigris ... Pilots of aircraft visiting or
passing over Iraq are warned of the existence of
these marks, which might be mistaken for landing
ground markings.’
Here is part of a modern NOTAM
06280355 TIL 06280402
06290351 TIL 06290358
06300347 TIL 06300354
9999 // BKN054 BKN063 17/09 Q1021 RMK
TAF TAF YSBK 272214Z 2800/2812 VRB03KT
FM280200 06005KT 9999 SCT040 RMK T 13
15 15 12 Q 1025 1022 1020 1020
FROM 07 031000 TO 07 041200
DAILY 1000/1200
The contrast between the quaint but lucid notices
in Flight and the ATCK of ABRVTD information in
CPTLS is jarring. Notams, which began as plain
language bulletins, have evolved into the ultimate
in jargon.
The use of teletype machines to propagate notams
to remote airfields in the 1930s left a legacy of
abbreviation and upper-case lettering at odds
with all conventions of readability. This was done
because teletype machines used only upper case
letters and charges were metered by the letter.
The result—long after teletype machines have
been consigned to history in most parts of
the world—is that vital aviation information
is transmitted in a hostile and deliberately
obscure format.
Defenders of the system argue that its codification
produces an exact message and that all pilots
should be able to read and decode notams as a
mark of professionalism.
However, the highly coded notam format is unique
in transport. Contrast a modern notam with the
language of an equally modern notice to mariners,
dated July 2012.
che Leistung
Aviation communication
‘Mariners are advised that a survey of the
Mooloolah River and its coastal bar on 2 July
2012 shows a least depth of approximately 2.5
metres at LAT near the centre line of the entrance
channel. There are lesser depths to approximately
2.0 metres at LAT near the channel’s eastern and
western extremities.’
Notams fail in at least three ways:
Robert F. Potter and Michael D. Nendick of the
University of Newcastle studied notams in Australia
and reached some strongly critical conclusions.
They concluded: ‘Notam information is often
required to be published by regulatory dictates.
Some information is either not directly understood
by aircrew, not able to be used by aircrew in
some operations because of the technical nature
of the effects, or not of any apparent operational
A specific criticism by Potter and Nendick was
that notams are not only issued with immediate
implementation requirements, but also with
implementation dates which may be some time
in the future. The reason is to give advance
warning of changes, but Potter and Nendick
argued that this requires aircrew to read but
effectively ignore notams that do not apply on the
day of intended operation. ‘Where this involves a
number of notams, a significant amount of time is
consumed searching through notams which have
no relevance to operations within the current time
frame,’ they say.
The all-capital format of notams is the worst
example of a deadening failure in aviation
CAPITALISATION. Studies such as Miles Tinker’s,
Legibility of Print, established that all-capital print
greatly slows speed of reading, in comparison with
lower-case type. Most readers judge all uppercase text to be less legible. Tinker found that the
faster reading of the lower-case print was due to
its characteristic word forms. These permit reading
by word units, while all capitals tend to be read
letter by letter.
Codified notams may be difficult for humans to
understand, even with training, but machines can
read them easily. The Eurocontrol Digital Notam
(xNOTAM) Project, run in cooperation with the US
FAA, is endeavouring to provide notam information
in a format suitable for automatic processing,
to enable automated systems that support ATC
and air navigation. A notam advising a closed
runway could be received and read by a computer
on an aircraft flight deck and this information
could be presented to pilots in the form of a cross
or red line over the runway on a navigation display,
or even on a heads-up display.
For a closer look at the safety-critical role
of communication in aviation maintenance,
see the airworthiness section of this issue,
pages 31-33.
Excessive abbreviation, coupled with an evergrowing list of abbreviations, produces a situation
where parts of notams can have several meanings.
There are 1500 acronyms and abbreviations on
CASA’s list, many with the potential for confusion.
For example, BC means ‘back course’ in a notam,
or ‘patches’ in a METAR weather report; likewise,
BLO can mean ‘below’ or ‘blowing’.
‘Notams are not written in clear and simple
language and they are replete with unfamiliar and
sometimes ambiguous contractions,’ a 2004 study
by the Flight Safety Foundation concluded.
s are
ar and simple langu
not written in cle
Flight Safety Australia
Issue 88 September–October 2012
Further information
Grayson R.L., Billings C.E.‘Information
transfer between air traffic control and aircraft:
communication problems in flight operations’.
In: Information Transfer Problems in the Aviation
System. C.E. Billings; E.S. Cheaney; eds.
NASA Technical Paper 1875, National Aeronautics
and Space Administration, 1981.
‘Pilot air traffic control communications.
It’s not (only) what you say, it’s how you say it’.
In Flight Safety Digest July 1995 http://flightsafety.
The Clarity and Accessibility of NOTAM Information
for the Aviation Industry Technical Report
Prepared for the Bureau of Air Safety Investigation
(BASI) Robert F. Potter and Michael D. Nendick
Department of Aviation and Technology,
University of Newcastle http://www.atsb.gov.au/
Airservices Australia fact sheet:
Communication with air traffic control
Helicopter (hover taxi, air taxi)/to move
One or many aircraft
Name of letter N/aircraft identification
Name of letter T/air taxi or helicopter
Name of letter Z/time at Greenwich meridian
Type of approach to an airport/command to
radio the controller who handles approaches
Location at the terminal building/
point in the sky
Pivot in the air about longitudinal axis/
forward movement
A part of forward edge of some wings/
time interval for a takeoff
Localisation/radio frequencies
Top of an aircraft carrier/cockpit of
an airplane
Urge speaking/forward motion
Contact approach
Flight deck
Go ahead
Stand by
‘Mayday, Mayday—We are sinking’
Vulcanair P68C, P68R,
Observer & A-Viator turboprop
– Training
– Business
– Charter
For more information on a demonstration flight in your region please contact
Charles Gunter on 0417 108 602 or charles.gunter@aviaaircraft.com.au
– Mining
– Observation
– Aerial work
Operating in Class D Airspace
Airservices frequently receives questions from pilots about operating in Class D airspace
- metropolitan and regional. To help pilots with their questions, we have recently released
a Safety Net explaining some of the common points of confusion.
This Safety Net covers:
the level of separation provided to IFR and VFR
the abbreviated clearance process
the requirement to comply with ATC instructions
why TCAS advisories are sometimes received
when maintaining separation from other
aircraft, and
the requirements to make a Departure Report.
ATC clearances
All aircraft require a clearance to operate in, or transit
through, Class D airspace. Pilots must establish and
maintain two-way communications with the tower
and receive clearance prior to entering the airspace.
You are required to read back and comply with the
clearance provided by ATC.
In addition to your initial clearance (either abbreviated
or full) there are also a range of operations that require a
specific ATC clearance, including take-off and landing,
or entering, crossing or taxiing along any runway.
ATC service level
When operating in Class D airspace, you will be
provided with an ATC service. This varies depending
on if you are operating IFR or VFR.
IFR flights are separated from other IFR and Special
VFR flights and receive traffic information (not
separation) in respect of VFR flights. VFR flights
receive traffic information in respect of all other flights.
In the event that you are given responsibility
for separation with other aircraft, this will be
communicated to you. In this situation, you must also
consider how TCAS operates and manoeuvre the
aircraft in such a way as to minimise the likelihood of
an unwarranted TCAS Resolution Advisory.
For more information on operating in Class D airspace the Safety Net is available on the ‘Pilot and
Airside Safety’ pages of our website at: www.airservicesaustralia.com/publications/safety-publications/
Clearer skies
ahead with ADS-B
Airservices is continuing the roll-out of Automatic Dependant Surveillance
Broadcast (ADS-B) technology – a satellite-based technology enabling aircraft
to be accurately tracked by air traffic controllers and other pilots without the
need for conventional radar.
rom 4 September 2012, ADS-B services
will be provided to all aircraft that are
ADS-B Out capable with individual
aircraft approvals no longer required. Approval
to operate using ADS-B, issued by the state of
registration, will also no longer be required.
Aircraft operators must ensure they meet CASA
ADS-B regulations when operating in Australian
airspace. They will also be responsible to
ensure that ADS-B transmissions comply
with the Civil Aviation Orders and that flight
crew are adequately trained to operate the
ADS-B equipment, including knowledge of the
appropriate phraseology and correct entry of
Flight ID, and correct lodgement of flight plans
including RMK/ADSB in the remarks field when
ADS-B equipped.
Civil Aviation Order (CAO) 20.18 para 9B.6
requires ADS-B transmissions to be disabled
before flight if the avionics is not compliant
with the CASA standards and requirements.
Airservices still retains the ability to suspend
ADS-B services for any aircraft transmitting
incorrect ADS-B data.
Operators who become aware their aircraft have
non-compliant ADS-B related avionics fitted
should contact Airservices as soon as possible.
Airservices is already seeing significant take-up
of ADS-B services by domestic and international
airlines ahead of the December 2013 mandate.
The continued roll-out of ADS-B in Australia
will continue to deliver enhanced safety
benefits for aircraft operating into and out of
Australian airspace.
Further information on ADS-B can be found at:
Accident reports
International accidents | Australian accidents
International accidents/incidents 10 June – 17 July 2012
10 June Let L-410UVP
Borodyanka, Ukraine
Written off
10 June DHC-8-311
Int. Airport
near Serov, Sverdlovsk,
Written off
Sandy Lake Airport,
ON, Canada
Atlanta-DeKalb Airport,
Written off
20 June Boeing 767-381ER Tokyo-Narita Airport, Japan 0
21 June Fokker F-27
1km north of Jakarta-Halim 7 + 4
Airport, Indonesia
23 June Cessna 208B
near La Leona, Tocaima,
Hotan Airport, China
Written off
near Edgemont, SD, U.S.A. 4
Written off
Skydiving plane (first flight 1981), carrying 18 skydivers
and two crew members, crashed into a field as it returned to
the airfield because of an approaching rainstorm. The plane
appears to have been caught in a downdraft about 2km short
of the runway.
Passenger plane (first flight 1990) and its hangar destroyed in
a nighttime fire.
Biplane (first flight 1986) disappeared after being taken on an
illegal flight by a group of drunken revelers, allegedly including
the chief of the local police, three police inspectors, an airport
security guard and others.
Cargo plane (first flight 1970) destroyed when it caught fire on
the ground after arriving on a routine fuel drop off.
Executive jet (first flight 1993) ran off the end of the runway
and through a fence after landing. Both pilots and the two
passengers suffered minor to moderate injuries and required
hospital treatment.
Passenger plane (first flight 2002) sustained ‘severe wrinkling
of the forward fuselage’ when it made a hard landing in strong
gusty cross winds and bounced on its main and nose landing
gear. Wind shear had been reported at the airport at the time.
Indonesian Air Force transport plane on a training flight
destroyed when it crashed on approach, coming down into a
housing complex near the airport. All the crew, and four people
on the ground, were killed in the ensuing fire.
Military aircraft (first flight 2007) crashed en route, killing all
four people on board.
Passenger jet returned to Hotan after an apparent hijacking
attempt. According to media reports the ‘hijackers’ carried
explosives and had attempted to break into the cockpit with
a crutch. Two of them later died from injuries sustained
while being overpowered by passengers and crew. The crew,
passengers and two security guards have received generous
cash and/or apartment and car rewards from the airline and the
Civil Aviation Administration of China.
Modular Airborne Fire Fighting System (MAFFS)-equipped
transport aircraft (first flight 1994) supporting firefighting
efforts in South Dakota crashed during a mission, apparently
killing four of the six people on board.
Military jet (first flight 1974) damaged when the LH main gear
collapsed on landing.
Helicopter crashed in a remote area of PNG after a mayday call
about five minutes after it left an oil well site in Gulf Province
en route to refuel in Hou Creek and then travel to Mount Hagen.
The crash site and the bodies of the three crew members were
found after an extensive week-long search.
Seaplane (first flight 1975) experienced a LH float collapse
after striking the dock at the resort while on taxi, and became
partially submerged. The three crew and 14 passengers were
able to escape uninjured.
Transport plane destroyed when it crashed shortly after takeoff, killing all on board. Aircraft operated by the Mauritanian Air
Force on behalf of the Kinross Gold Corporation.
11 June Antonov 2R
12 June HS-748-264
18 June Beechcraft 400A
29 June Embraer ERJ190LR
1 July
Lockheed C-130H
4 July
Rockwell Sabreliner El Palomar Airport,
Bell 206
near Bawata,
Papua New Guinea
DHC-6 Twin Otter
Conrad Resort, Rangali,
12-July Harbin Yunshuji
Nouakchott Airport,
Written off
13-July Gulfstream G-IV
Le Castellet Airport, France 3
Written off
Corporate jet (first flight 1987) destroyed when it overshot the
runway on landing and broke in two, with the front part ending
up in a pond and the rear in a clump of trees, where it caught
fire. A photo of the crash scene showed that the jet’s thrust
reversers were deployed.
17 July CRJ-200ER
St George Airport, UT,
Passenger jet (first flight 2001) damaged when it hit the
terminal building and ended up in a car park after being stolen
and started at night by a commercial pilot wanted by police in
connection with the death of his girlfriend. The pilot then shot
and killed himself inside the plane.
6 July
9 July
Flight Safety Australia
Issue 88 September–October 2012
Australian accidents/incidents 4 June – 11 July 2012
4 June
Cessna 182Q
9 June
Robinson R44 II
Coonabarabran Aerodrome, Fatal
264° M 38km, NSW
Horn Island Aerodrome, N Nil
M 83km, Qld
10 June Robinson R44
Alice Springs Aerodrome,
S M 93km (Maryvale), NT
Maryborough Aerodrome,
107° M 21km, Vic
Tennant Creek Aerodrome,
336° M 43km, NT
Redcliffe Aerodrome, Qld
19 June Eurocopter
Cunnamulla Aerodrome,
070° M 53km, Qld
Ceduna Aerodrome, 267°
M 56km, SA
23 June Beech 58
Bathurst Aerodrome, NSW Nil
12 June Robinson R44
17 June Robinson
R22 Beta
18 June Schweizer
19 June Cessna 182P
The aircraft was reported missing and was subsequently found to
have crashed and caught fire. Investigation continuing.
Substantial During the cruise, the alternator fail light illuminated. Subsequently,
the pilot noticed unusual engine noises and abnormal engine
indications and therefore conducted a precautionary ditching at sea.
Investigation continuing.
Destroyed Helicopter reported to have crashed. Investigation continuing.
Substantial After take-off, the helicopter struck a single power line and then
crashed. Investigation continuing.
Destroyed During low-level flight, the low rotor RPM horn sounded and the
helicopter then crashed.
Substantial During a simulated forced landing, the helicopter landed heavily and
rolled onto its side. The helicopter was substantially damaged and
both crew members suffered minor injuries. Investigation continuing.
Substantial Aircraft reported to have crashed soon after take-off, seriously
injuring the pilot. Investigation continuing.
Destroyed During the cruise, the pilot and passenger detected fuel fumes in the
cockpit and conducted a precautionary landing. After landing, the
helicopter caught fire and was destroyed. Investigation continuing.
Substantial During departure from Bathurst, the landing gear failed to fully retract.
The aircraft subsequently landed at Bankstown with the landing gear
partially extended, resulting in substantial damage. Engineers found
that the sector gear in the landing gear gearbox had failed.
Substantial During the cruise, at FL 250, the right window detached from
the aircraft. The crew donned their oxygen masks, conducted an
emergency descent and diverted to Adelaide. Aircraft sustained
substantial damage.
Substantial During approach, the engine failed due to fuel exhaustion and the
pilot conducted a forced landing on a nearby road. The aircraft
landed hard and the pilot lost directional control. Aircraft substantially
damaged but pilot uninjured.
Substantial Helicopter crashed during cattle mustering. Pilot sustained serious
injuries. Investigation continuing.
Substantial During mustering operations, the engine lost power and the
helicopter crashed. The pilot suffered minor injuries and the
helicopter was substantially damaged.
2 July
Lancair IV-P
2 July
Piper PA-25-235 Ayr (ALA), N M 2km, Qld
6 July
R22 Beta
R22 Beta
Miranda Downs (ALA),
037° M 23km, Qld
Victoria River Downs
(ALA), E M 370km
(Tanumbririni Station), NT
R22 Beta
Tennant Creek Aerodrome, Nil
NW M 37km, NT
During mustering operations the helicopter struck a powerline,
crashed, and was substantially damaged.
near Broome Aerodrome,
Aircraft crashed and its pilot was fatally injured.
Investigation continuing.
9 July
9 July
11 July Piper PA-34-200
Adelaide Aerodrome, 250° Nil
M 272km, SA
Australian accidents
Compiled from 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.
International accidents
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.
Pilot reporting
A Christmas tragedy
When families gather for their Christmas celebrations they
hardly imagine that an aircraft is going to crash and burn less
than a kilometre from their home but, just occasionally, the
unthinkable happens.
Robert Alan How owned and flew a
Cessna 172M and had a landing strip
on his property at The Gurdies, to the
south-east of Melbourne.
On Christmas morning 2008, he went
for a solo flight in his plane. He flew
from his private airstrip to Tyabb airport
to refuel, and then headed back towards
home. About three kilometres from
his property, he flew very low over a
neighbour’s house, where Christmas
festivities were underway. Hearing the
loud sound of the engine, David Gill, the
neighbour, looked out of his window
and saw the undercarriage of the plane,
which he estimated was only about fifty
feet off the roof of his house.
Gill was on the phone, but about five
seconds after Gill saw the plane, the
phone went dead. His teenage daughter
told him that the plane had ‘landed’
in a nearby paddock, so Gill and his
father hopped on their motorbikes and
rode over to investigate. Unfortunately,
the plane had clipped a power line
about eighty-six feet above the ground,
crashed, and, within seconds, had
burst into flames. Robert How was
already dead.
Gill told the inquest into How’s death that
the pilot had often done a ‘flyover’ of
their property at previous Christmases.
His daughter confirmed this and added
that she had sometimes seen the same
plane ‘flying over the property and doing
The wreckage of the plane was
examined by licensed aircraft
maintenance engineer, Barry Foster.
He found no mechanical failure that
might have caused or contributed
to the accident. The subsequent
Australian Transport Safety Bureau
(ATSB) investigation found that How
had no operational reasons, such as
adverse weather, or take-off or landing
manoeuvres, to be flying below the
required 500 feet at the time of the
accident. There was also no evidence
of any flight control failure before the
wire strike.
The power lines did not need to be
marked because they were under 90
metres (295 feet) from the ground.
How’s GP said that during all her, and
previous, medical assessments of him,
‘there was no sign of any cognitive
disturbance, thought disorder, altered
affect or response to internal stimuli’.
Mr How held a private pilot’s (aeroplane)
licence, issued on 3 September 2003,
and endorsed for VFR flights. He also
had a valid class 2 medical certificate.
He had an estimated 600 hours total
flight time, but did not have any low
flying qualifications or ratings.
The ATSB report reinforced the
inherently hazardous nature of low flying
and also concluded that ‘although the
pilot probably knew about the power
line, it is apparent that he did not see it
in enough time to avoid the wire strike.
Power lines are inherently difficult to see,
especially when unmarked as they were
in this case. Compounding the problem
can be factors such as sun glare and
windscreen visibility. However, given
the position of the sun at the time of the
accident and the pilot’s southerly track,
it was unlikely that sun glare was a
factor. Windscreen visibility was unable
to be established’.
History of low flying complaints
January 2006: Ms Kim, who lived on
a property about 100m from How’s
airstrip, made a complaint of ‘reckless
flying’, saying that he had flown so
low that he was almost level with the
windows in her house.
February 2007: A further complaint
was made by Ms Kim about Mr How’s
reckless flying. She said that a plane
took off from the airstrip, turned sharply
back towards her property and was
flying only about 40-50m over her head.
She described the plane as banking
so sharply that the wings were vertical
to the ground. It then flew back directly
over her house, almost touching the
Flight Safety Australia
Issue 88 September–October 2012
roof. ‘It was extremely noisy, frightening
and very dangerous’.
December 2007: Leigh Charlton
described a plane that was flying so low
he could clearly see its letters, and said
that it could not have been taking off or
landing as it was at right angles to the
landing strip. He added that his wife had
told him she no longer liked living at their
home because she feared that Mr How
would crash into their house.
January 2008: Ms Kim details another
four incidents of unnecessary and
dangerous low flying, saying that she
only wants Mr How to ‘take off properly
and then there would be no bother’.
Mr Gary Morrison, the owner of Tooradin
Airport, told the inquest that How had
landed and parked his plane there from
time to time and used its re-fuelling
facility. However, after a couple of years
of near misses and other incidents, he
had finally banned How from Tooradin
Airport for his lack of judgment, safety
and airmanship. The catalyst for this
was an incident when How overshot
the runway, ditched his plane with its
propeller stuck in the mud and then
refused to have his plane properly
checked before taking off again.
After being banned from Tooradin
Airport, How joined the Peninsula Aero
Club, which operated out of Tyabb
Airport. Alexander Robinson, the CFI
at the club, said that they kept a
complaints book and acknowledged that
incidents had been recorded in it about
How’s low flying. He described How
as a very good flyer but admitted that
he would ‘push boundaries’, especially
when it came to landing.
He said that Mr How would ‘brag about
how he could land in a short distance.
People were just not willing to go
with him’.
The Gurdies or elsewhere because he
has misjudged one of his flying tricks
and crashed into a house, or caused a
bush fire’.
After a number of such occurrences
How was asked to undertake a ‘check
flight’ with the chief flying instructor to
demonstrate that he had a reasonable
knowledge of the visual flight rules and
the club’s ‘Fly Neighbourly’ policy. He
participated in the required tasks and
demonstrated his understanding of what
was required of him, but a few months
later was again reported for taking his
approach to the airstrip too short.
In these cases reports from members of
the public may need to be supplemented
by information from industry members
with professional knowledge of the
issues involved.
One of the coroner’s conclusions was
that, ‘Mr How, whilst an apparently
capable and experienced pilot of light
aircraft, had a poor attitude to some
aspects of air safety. This poor attitude
was well known by the two clubs he
had belonged to and resulted in him
being banned from one and disciplined
by the other’. There was, however,
some uncertainty about whether any
report about How’s low flying had been
made to CASA by the Peninsula Aero
Club, because they ‘had no way to
substantiate that and therefore could
not report it, other than it is hearsay, but
there was an awful lot of hearsay’.
If experienced CFIs and other aviation
professionals feel that they have tried
but failed to exert enough influence to
change a fellow pilot’s irresponsible
behaviour it is important to submit a
report to CASA, so that follow-up action
can be taken.
The coroner raised the questions:
should there be mandatory reporting
obligations on flying clubs to report
breaches of safety or unsafe conduct
by pilots? Should incidents only be
notifiable if someone is injured or killed,
or the aircraft is significantly damaged?
We welcome our readers’ feedback …
Questions raised
Robert How did not kill anyone apart
from himself, but the outcome could
have been very different. In one of
Ms Kim’s complaints she wrote,
‘I hope I don’t have to wait until there
is a newspaper report of a tragedy in
If someone is putting safety at risk – report it!
CASA confidential hotline 1800 074 737
Fatigue regulations
The rules covering fatigue are changing. Civil Aviation Order
(CAO) 48, which regulates flight and duty times, has been in force
from around the early 1950s, and it is tired. Along with other global
regulators, CASA is creating new standards to manage fatigue, in
keeping with International Civil Aviation Organization requirements.
The proposed new CAO 48 is anticipated in late 2012, with a
transition period for compliance by December 2013.
In the half-century or so since these original fatigue rules were introduced the
demands of a 24-hour society, and fatigue research within the aviation industry
generally, have led to an increasing number of exemptions to CAO 48. These
exemptions have complicated the rules, which no longer meet the needs of
contemporary aviation safety.
CASA has used the standard industry exemptions as the foundation for the
new CAO 48, in line with ICAO’s fatigue management standards, but
believes there is a need to go beyond simple prescription to manage fatigue
safely. The new CAO 48 therefore will have three tiers, ranging from
simple prescription to the more complex and sophisticated fatigue risk
management system (FRMS):
1. The basic prescriptive level (basic
2. Fatigue management—using prescriptive
rules, but improving safety through a
greater emphasis on operator-managed risk
control and requirements for training and
promotion of awareness regarding fatigue
Fatigue risk management system—the
most sophisticated level.
call on
fatigue rules
Circadian Function
Time of Day
The first tier, the basic duty periods and flight time limits, may well suit
smaller ‘his and hers’ operators with few staff and simple operations.
However, mid- and larger-sized operators, whose businesses are more
complex, with changing 24-hour operational demands, are likely to
work under more flexible rules. These introduce higher risk
management requirements, including hazard ID, and continuous
monitoring and improvement of fatigue management, as well as the
need to provide flight crew with fatigue training and to promote
awareness of fatigue.
CASA anticipates that the majority of operators will fall into this
group, with only a small percentage applying to operate under a
fatigue risk management system. Operators wishing to operate
under an FRMS will need to demonstrate that their systems are
mature, data driven, integrated with an existing SMS where
possible; with comprehensive policies, documentation, risk
management, safety assurance to monitor the system’s
Flight Safety Australia
Issue 88 September–October 2012
effectiveness, and safety promotion. They will also need
to demonstrate they have dedicated sufficient resources to
implementing and maintaining their FRMS. People who have
an intimate working knowledge and experience of the complex
operational environment to which it will apply should be
the ones who develop, implement and maintain the FRMS.
An FRMS is not just a manual, although documentation is
obviously one of the important parts of an FRMS.
The proposed new rules address a number of issues:
The new CAO 48 not only defines the obligations for operators,
but importantly, also those for individual flight crew members.
Improved scientific understanding of fatigue and
related issues.
Managing fatigue is a shared responsibility: both
operators and individuals must play their part.
The increasing demands of global aviation, and the pace
of contemporary travel. Flying today’s A380s or B787s
places very different demands on pilots, compared to flying
Constellations or Comets. The old rules related more to
the beginning of the jet era, not to one of ultra long-haul
aviation, where flight crew can cross up to eight time zones
in 24 hours.
• The past ten years have seen a rapid growth in
knowledge about fatigue. Various studies have looked
at the human body clock, and how this affects fatigue
and performance. Humans are basically diurnal
creatures – in other words we are awake during the day
and sleep at night, as distinct from nocturnal creatures
such as owls. Many of our body’s physiological
functions: variations in body temperature, production of
enzymes to digest our food, production of hormones,
and wakefulness and sleepiness, operate on a roughly
24-hour cycle. These are known as circadian rhythms
(circadian means ‘about a day’).
• The growth in shift work affects our circadian rhythm
because it means we work at times when our bodies
are programmed to be asleep. One especially critical
time for shift workers is from 0200-0500, also known
as the window of circadian low (WOCL). At this time
our body temperature is at its lowest, and our mental
alertness can be at its poorest. (There is another
peak in sleepiness with implications for fatigue—in
the early afternoon—sometimes called the afternoon
nap window [around 1500-1700 for most people].
Restricted sleep at night, or disturbed sleep, make it
harder to stay awake during the next afternoon nap
• Shift work not only has the potential to disrupt the body
clock, but also often prevents employees from getting
enough sleep, and, importantly, can affect the quality of
that sleep.
• Fatigue risk can result from not enough sleep, combined
with the quality of that sleep. Most of us need on
average between seven and eight hours of uninterrupted
sleep a day to perform at our best. Then you have to
consider ‘the time awake’ as a contributor to fatigue.
How long you have been awake, how long you have
been at work, and the time of day are all factors
contributing to fatigue.
Managing fatigue—CAO 48 timetable
December 2012
New CAO 48 rules made – flight
crew members and operators
December 2013
Standard industry exemptions no
longer available after December 2013
Operators will be expected to commence
transition to the new rule set over this
year. Operators may apply for an FRMS
December 2013
Transition to the new flight crew
member fatigue rules complete
Cabin crew fatigue management
rules anticipated
July 2014
Cabin crew fatigue management
rules due to come into effect
Individuals, including private pilots, must not fly when they
are fatigued, or likely to become fatigued. Pilots also have a
responsibility to use their off-duty time responsibly, in order to
gain adequate rest.
Six fatigue myth busters
There is no magic anti-fatigue bullet
Fatigue is not a sign of weakness
Fatigue is not something you can overcome with coffee
and willpower
A can-do attitude—‘we’re paid to do the job—we can
handle it’—can be dangerous
You cannot train yourself to need less sleep, nor can you
‘store’ sleep
Just because you have experience with fatigue, does not
mean you are immune to its effects.
Recognising the complexity of fatigue as an aviation safety
issue – that there is no ‘one-size-fits-all’ solution, hence the
tiered approach of CAO 48.
The increase in the number of flight crew commuting longer
distances to work, and the resulting impact on fatigue.
Fatigue regulations
Aviation accidents in which fatigue was implicated
21 December 1994
Air Algerie/
Warwickshire UK
Five people killed: flight crew and passengers. The flight crew were fatigued—
they had had 10 hours of flight duty, with five flight sectors which included six
approaches to land.
6 August 1997
Korean Air/Guam
Boeing 747-300 crashed on approach to Guam’s international airport, killing
223 passengers and crew at the crash site. Captain’s fatigue was cited in the
report as a contributing factor.
18 August 1998
Kalitta DC-8-61F/
Guantanamo Bay
The Guantanamo Bay accident was the first in which pilot fatigue was cited
as the primary cause. The pilot stalled a perfectly serviceable aircraft into
the ground on approach. His inability to monitor the aircraft’s safe flight was
accepted as being the direct result of fatigue. The flight crew had been on
duty for 18 hours, and flying for nine hours, and were suffering from circadian
rhythm disturbance and lack of sleep.
1 June 1999
American Airlines/
Little Rock USA
Douglas MD-82 overran runway on landing and crashed, killing the captain and
10 passengers. Knowing that they were approaching their 14-hour duty limits,
the pilots might have exhibited ‘get-there-itis’.
25 June 2007
Cathay Pacific 747F/
ground collision at
Stockholm (Arlanda)
Swedish investigator said crews had been awake for 18-20 hours; the time
was 0330 local; and fatigue was a factor. Hong Kong CAA dissented, saying
the crew had been given sufficient rest opportunity, so it was not fatigue.
12 February 2009
Colgan Air/Buffalo
Fifty people killed in the crash of a Bombardier Dash 8-Q400. Fatigue was cited
as a factor—the young co-pilot frequently commuted across the USA to report
for duty.
22 May 2010
Air India Express/
All six crew members and 152 passengers killed when the Boeing 737-800
crashed at Mangalore. The report found that the chief cause of the accident
was the captain’s failure to discontinue the ‘unstabilised approach’ and his
persistence in continuing with the landing, despite three calls from the first
officer to ‘go around’ and a number of EGPWS alerts. The report also identified
that in spite of the availability of adequate rest before the flight, the captain slept
for a prolonged one hour and forty minutes during flight, which could have
led to sleep inertia. The relatively short time between his awakening and the
approach possibly led to impaired judgement, accentuated because he was in
the window of circadian low.
14 January 2011
Air Canada/
Boeing 767-333/
North Atlantic
Approximately halfway across the Atlantic, at night, the aircraft experienced a
46-second pitch excursion. This resulted in an altitude deviation of minus 400ft
to plus 400ft from the assigned altitude of 35,000ft above sea level. Fourteen
passengers and two flight attendants were injured. The first officer had reported
not feeling altogether well. The father of young children, his home sleep was
frequently interrupted, and his 75-minute controlled rest (nap) on the aircraft
meant it was highly likely he was suffering from sleep inertia.
Circadian Function
Time of Day
Flight Safety Australia
Issue 88 September–October 2012
The terms of fatigue
Process of adapting to a new time zone after the body clock (circadian) disruption that is part of
crossing numerous time zones.
Tools used to evaluate group work schedules (generally based on group average data) to help identify
how some aspects of fatigue exposure are distributed. They can be used as one of a number of tools
in managing fatigue, but should never be used to make ‘go, no-go’ decisions for crew members.
Circadian rhythms
Our body clock—our body’s physiological functions: variations in body temperature, production of
enzymes to digest our food, production of hormones, and wakefulness and sleepiness, operate on a
roughly 24-hour cycle. These are known as circadian rhythms (circadian means ‘about a day’)
Jet lag
Physical and psychological discomfort caused by disruption to the body’s circadian rhythms by
travelling across time zones. Eastbound travel shortens the day or night, so ‘west is best’ because it
produces less jet lag.
Sleep inertia
The period of confusion when you wake, or are awakened, from sleep, which generally lasts from
5–20 minutes. Performance and alertness can be impaired during this time.
Sleep cycles
Sleep varies during the night, cycling through different stages, each with distinctive brain wave
patterns. Each cycle of between 90–120 minutes comprises five stages: 1–falling asleep; 2–light
sleep; 3–4 deep sleep; and 5–REM (rapid eye movement). Stages 3–5 contribute to physical
restoration, and the REM stage is also important for mental health and learning.
Sleep apnoea
A breathing-related sleep disorder, which can reduce your alertness at work, driving, or at play.
It is the best known of over 50 sleep-related disorders, which also include dyssomnias such as
narcolepsy and insomnia; hypersomnia, sleep walking and night terrors.
Time zone
Any of the regions of the globe that vary in local time from one another by one hour.
Window of circadian
low (WOCL)
The time from 0200-0500, when our body temperature is at its lowest, and our mental alertness
is most reduced.
Further information
Go to the ‘operator’ section of CASA’s website (www.casa.gov.au) for a wide selection
of frequently asked questions on fatigue management and the new CAO48
Visit: www.redcliffeaeroclub.com.au for a course outline
or contact us at: mecir@redcliffeaeroclub.com.au
Human factors
QF32 and The black swan
Qantas pilot Richard de Crespigny’s account of the QF32 engine failure offers
some useful insights that apply to all aircraft and pilots. They are about the effects
of massive stress, both on complex systems and human emotions.
Flight Safety Australia
Issue 88 September–October 2012
The two most celebrated airline incident survival stories of
recent years have been bird strikes—sort of. US Air flight
1549 hit a flock of geese over New York in January 2009,
and on November 4 the following year Qantas flight 32
hit a metaphorical bird on climb-out from Singapore—a
‘black swan’.
The facts at the time of writing were incomplete, pending
the final Australian Transport Safety Bureau report, but the
narrative is well known, and disturbing. QF32 suffered an
intermediate stage turbine disc failure—the first in the 40-year
and 200-million-hour history of the Rolls-Royce RB211 family
of turbofan engines.
A black swan event is an improbable event that causes
massive consequences. Like the black swans of Western
Australia—which were unseen by European eyes for centuries,
so all swans were presumed to be white—it exists, but can
only be guessed at.
Shrapnel from the disintegrating engine cut more than 600
wires and left more than 100 impacts in the wing, about 200
impacts on the fuselage and 14 holes in the fuel tanks. The
No.1 and No. 2 AC bus systems failed, the flight controls
reverted to alternate law and two other engines, in addition
to the destroyed one, went into what the ATSB preliminary
investigation called ‘degraded mode’. Fuel was streaming
from the wing. One of the projectiles that passed straight
through the wing was later found to have missed the top of the
fuselage by 2cm.
The author of The Black Swan, Nassim Nicholas Taleb, argues
that it is pointless trying to predict such extreme events.
All that can be hoped for is that societies and systems are
robust enough and have adequate redundancy to withstand
them. The crew of QF32 and the design of the Airbus A380
proved this point eloquently.
The captain of QF32, Richard de Crespigny, has written a book
on the event. Predictably, its launch publicity on TV and radio
played up the ‘steely-eyed aviator’ stereotype, but in speaking
to Flight Safety Australia de Crespigny emphasised several
very different messages. For a start, he says any Qantas crew
would have been just as successful.
Lesson 1. The nuances of CRM
Crew resource management is a concept that de Crespigny
strongly believes in. It’s a conviction that goes back to his air
force days when, after a career in multi-crew aircraft (Caribou
and Iroquois), he realised he had become a different sort of
pilot to the fighter pilots whose ranks he had once aspired to
join. But he is also aware of its limits. Because de Crespigny
was undergoing a line check, there were two other pilots on
the flight deck of QF32: a check captain, Harry Wubben, and a
senior check captain, David Evans, supervising Wubben. With
first officer, Matt Hicks, and second officer, Mark Johnson,
there were five pilots on the flight deck.
De Crespigny pays tribute to his colleagues and says the
successful landing was a team effort. But his point is that
even a team needs a leader. ‘The flight deck is not a
committee’, he says.
The pilot in command has ultimate responsibility for the
aircraft. Their seat is where the proverbial buck stops.
But at the same time control is often best exercised
through delegation.
In the book QF32 de Crespigny writes of his standing order
to the pilots in the second-row seats, ‘If we are all up front
looking down, you look up. If we are all looking up, you
look down.’
The ever-shifting balance between authority, delegation and
consultation meant de Crespigny took some cockpit decisions
himself, and consulted the entire extended crew when there
was time.
Human factors
Lesson 2. The cliché is true:
aviate, navigate, communicate
The crew of QF32 was faced with an unprecedented number
of checklists from the A380’s electronic centralised aircraft
monitor (ECAM). De Crespigny estimates there were more
than a hundred and twenty.
‘We were just getting checklist after checklist telling us what
was going wrong. It took us an hour to know what all the
threats were—then we had to mitigate them.’
Despite this, the crew adhered to one of aviation’s
most hallowed (and wise) clichés: ‘aviate, navigate,
communicate’, meaning that the first priority should
always be to keep control of the aircraft.
‘Every 10 minutes we reassessed the fuel and we reassessed
whether we should continue doing checklists, or ignore the
checklists and just (somehow) get the aircraft down on the
ground. We all discussed it’, says de Crespigny.
With threat and error management you have to fix the
problem—or mitigate for its loss. It’s a see-saw: if the aircraft
wing had been on fire I would have put it straight on the
ground or into the water. But we didn’t have a wing fire so we
had more time – but how much more time? ‘
The threat of landing an aircraft in an unknown state ... I think
if we had thrown the aircraft down straight away people might
have died.’
An important principle was to act after consideration, rather
than blindly obeying checklists.’ No checklist was actioned
immediately,’ de Crespigny says. ‘We discussed everything.
We were trying to assess the threat and either fix it, or work
out how we would mitigate it.’
A habit from de Crespigny’s military career asserted itself
as they made their initial approach. He insisted on a control
check. ‘It’s bred into the air force psyche.’ He was also
thinking of El Al flight 1862, a Boeing 747 freighter that
crashed into a block of flats in Amsterdam in 1992, killing the
crew and 47 people on the ground. “They slowed down to
configure and because they were asymmetric, went into an
unrecoverable roll. You have to check the ability of the aircraft
to fly and remain in control at the speed you want to land.’
‘We did a dress rehearsal of the landing at 4000 feet. If we
had been losing control we would have sped up and brought
the flaps up one step. What that meant was that a few
minutes later, when we got speed and stall warnings they
were certainly unexpected—but deep down I knew the aircraft
would fly.
De Crespigny is an enthusiast for all Airbus and Boeing and
fly-by wire aircraft generally, but he says automation can
make it more difficult for pilots to honour the command to
always aviate.
‘Flying is getting so much harder because there is so much
more automation and so many more systems. There are four
million parts in an A380. Manufacturers may say automation
makes flying easy, but I maintain that if pilots are to recover an
aircraft from an unimaginable position they still need to have
knowledge of that aeroplane, much the same as pilots did in
the 70s and 80s.’
Lesson 3. It’s not over after you
touch down
De Crespigny has an endearing nerdish delight in analysing
complex systems. (The Singapore incident interrupted his
magnum opus, a technical book on new generation fly-by-wire
airliners). The aftermath of QF32 required him to turn that gaze
on himself.
Weeks after the event he found himself weeping, for the first
time since his mother died decades earlier, while recounting
parts of the event to ATSB investigators. There was another
bout of tears and a six-hour car trip where he hardly spoke to
his wife, Coral. Instead he went over and over the flight in his
mind. De Crespigny was confronting post-traumatic stress.
‘Pilots who have these incidents ... we’ve never been told what
to expect, nobody around us knows how to handle us and
we’re totally blind as to how our emotions are affecting our
lives and our work,’ he says.
‘Even for pilots who think they’re OK, the stress they
thought they were handling can reemerge.’
‘I insisted that it go in the book. I, and all male pilots are
alpha males; we think we’re indestructible. When something
happens we think “let’s toughen up and get through it”.’
De Crespigny instinctively knew it was more than a question
of toughening up.
Flight Safety Australia
Issue 88 September–October 2012
Do a deal with Coral that you’ll stay in the loop for another
three or four weeks, as long as you need to write down all
the details of the flight for the investigators. After three weeks
you’ll run this process I’m going to teach you and you’ll get
out of the loop and start forgetting.’
I was scheduled to take delivery of a brand new A380 three
weeks after QF32. I called up my manager and said, “I am not
in a condition to assess whether I am safe to fly. You have to
take me off this trip.” It turns out I wasn’t in a fit state at all. I
was so preoccupied with the aftermath of QF32.’
He visited aviation psychologist Ron Zuessman who, with a
bluntness appropriate to his speciality, said: ‘I know pilots:
what’s your problem?’
Zuessman explained how de Crespigny’s tears were a delayed
expression of the stress he felt during the emergency.
‘He said, “revisit it, keep doing it – it will go away – if you
don’t revisit it then it will stay there in your mind for ever, and
every time it re-emerges, it will be just as painful as it was the
first time”.’
‘I went away, thought about it and realised the crying was
just natural’.
Zuessman then started working on what de Crespigny calls
‘the loop’—his endless mental replaying of the flight. ‘He said:
“You’re probably talking to investigators, or writing a book—
once I clear you from the loop you’ll start forgetting things.
Call: +61 2 8006 0618
The method was simple, but took advantage of recent research
on brain function: ‘Just as I’m about to serve in a game of
tennis I think QF32’, or when I’m mowing the grass I suddenly
think QF32, de Crespigny says. ‘Anything that needs intense
concentration, I think of QF32. It’s a way of making new
synapse connections and breaking the older, post-traumatic
stress synapse connections in my brain.’
‘In the weeks before I returned to flying I was looking up
whenever an aircraft went over: I was ready for normal flying
duties. I’ve been flying now for the past sixteen months. I’m
sane, content and not afraid of anything because I took time to
handle the PTS. Most importantly I’m not afraid of the aircraft.
My message in putting this long description of post-traumatic
stress in the book was to let others know that these issues are
real and that they can be fixed.’
De Crespigny’s account of QF32 is published by
Pan Macmillan Australia ISBN 1742611174
A key moment, says de Crespigny, was when the
pilots used Apollo 13 inverted logic that prompted
them to abandon attempts to work out what had
failed in the aircraft’s complex fuel system and
instead look at what was still working. The plane
had only three usable fuel tanks out of 11 and this
was a crucial calculation.
Email: solutions@tflite.com
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Copyright Gulfstream
Flight Safety Australia
Issue 88 September–October 2012
Communication in the hangar
One of the most important items in your toolkit has no little recess in which to store it between jobs.
This vital tool is invisible, but without it you can’t work safely. It is communication. There are at
least three areas where accurate communication is essential for the safe maintenance of aircraft.
Redundant and rich—the handover
Shift handover is when one group of workers passes their task
on to another group. It is vital that both the details (everything
being done) and the context of the task (why it is being done)
are passed on to the new crew. On oil rigs and in hospitals the
lessons of poor handovers have been learned the hard way.
In the 1988 Piper Alpha disaster, an offshore oil platform in the
North Sea exploded and burned, killing 167 men. It was high
summer, the maintenance season on an oil rig, and there had
been a engineering shift change at 6pm, four hours before the
explosion. But in that change a detail went missing. The day
shift had removed a pressure safety valve on a condensate gas
pump and replaced it with a blind flange—a loosely bolted steel
disc. The day engineer found his night counterpart busy and left
a notice about the pump on the night engineer’s desk, where it
got lost. Later that night, the other condensate pump failed and
the night crew switched on the dismantled pump. The disaster
began within seconds.
In 2006, an Aboriginal elder, Peter Limbunya, died alone and
forgotten at an outback airstrip in the Northern Territory after
being discharged from hospital in Katherine, where he had
been treated for pneumonia. His discharge paperwork had been
faxed to the community health centre in Kalkaringi on a Friday,
advising of his arrival by air the following Monday. However,
the fax went unseen, and the health centre was unaware of
his return. The coroner found the health centre’s systems to
be haphazard. ‘Faxes were taken off the machine by whoever
sighted them and pinned on a notice board,‘ her report says.
Nor did the hospital have any checking system to confirm
that the discharge paperwork had been received; instead its
staff assumed that the fax would be acted on and someone
would be there to collect the patient from the remote airfield.
As it happened, there was no one to meet him. Mr Limbunya
tried to walk home, but was found dead from pneumonia
and dehydration three days later. He had managed to cover
400 metres.
In 1991, Continental Express Flight 2574 crashed in a field in
Texas, killing all 14 people on board. The National Transportation
Safety Board investigation found bolts had been removed from
the Embraer Brasilia’s tail plane during maintenance the night
before the accident. There had been a shift change, and the
bolts on the high-mounted T-tail had not been replaced. The
plane crashed on its second flight of the day, when the leading
edge of the tail plane came off, causing a sudden pitch down
that quickly led to in-flight break-up.
All three cases are examples where what might be called the
cardinal rule of shift handover had been broken.
Pull-out section
That rule is: make sure the new guys understand
what’s happening. The best way to do that is to
make the handover face to face, with confirmation.
However, this is seldom done in aviation. Writing for the
Australian Transport Safety Bureau, consultant Alan Hobbs
concluded: Authorities on shift handover recommend faceto-face handovers by the people doing the work, instead of
verbal briefings filtered through a shift lead, as is currently
the case in many maintenance facilities. Face-to-face
handovers are standard operating procedure in many highrisk industries such as nuclear power, offshore oil, and air
traffic control, yet are relatively rare in aircraft maintenance.
Shift handover is a major operational issue for NASA’s robotic
missions to explore other planets. On a mission of months or
years, shift handovers happen thousands of times. The agency
has studied the issue and concluded: ‘Face-to-face handover is
a best practice that is agreed upon in all guidelines and reviews
of the literature and is aimed for in most domains studied. The
reason is that handover errors are due to differences in the
mental models of the outgoing worker and the incoming worker.
Two-way communication enables the incoming worker to ask
questions and rephrase the material to be handed over, so as to
expose these differences.’
NASA found the human touch to be essential, even for robotbased exploration. ‘Face-to-face handovers enable gestures,
eye contact, tones of voice, degrees of confidence, and other
redundant and rich aspects of personal communication to be
utilized in conveying possible different mental models.’
Boeing Alert Service Bulletin 737-53A109 said: ‘Repair fatigue
cracks using a repair similar to that shown in 737 Structural
Repair Manual Subject 53-30-3, Figure 16, and replace all
remaining upper row flush joint-fasteners in that panel joint
with oversized protruding head solid fasteners per Part IVRepair Data.’
In other words: engineers were not only to follow the structural
repair manual, but also to go beyond its recommendations. Not
all did. Aloha put protruding head solid fasteners only in the
repair area.
What the FAA meant, the agency later said, was that the
fasteners were to be installed throughout the skin panel joint
where cracking was found.
The US National Transportation Safety Board concluded: ‘In the
case of this AD [airworthiness directive], it is believed that the
repair instructions could have been presented more explicitly.
This was, in fact, done in subsequent ADs pertaining to the
same subject.’
The few studies that have looked at communication in aircraft
maintenance suggest that it is a safety concern. In 2002,
the British Civil Aviation Authority looked at maintenance
communication and maintenance-related accidents. Of 102
maintenance-related events, 74 involved inadequate data or
communications. Twelve of these events were fatal accidents,
which killed 143 people and injured 92.
A rivet here, a rivet there … maintenance
Vague words in a maintenance instruction were one of the things
that blew the top of the fuselage off an Aloha Airlines Flight 243
Boeing 737 near Maui, Hawaii in April 1988. An extraordinary
performance from the flight crew landed the aircraft safely, but
a flight attendant was killed by the initial outburst.
A Federal Aviation Administration airworthiness directive issued
in 1987 said: ‘Repair all cracks and tearstrap delaminations
found as a result of the above inspections prior to further flight
in accordance with Boeing Alert Service Bulletin 737-53A109,
Revision 3, dated August 20, or later FAA-approved revisions.
As part of an agency-wide campaign on plain language, the FAA
has begun to take the clarity of maintenance bulletins seriously.
It is a good example to follow. Here is an airworthiness directive
from July 2012 that verges on being blunt, but is also simple
and clear:
We are adopting a new airworthiness directive (AD) for all
The Boeing Company Model 777 airplanes. This AD was
prompted by four reports of retaining cross bolt hardware
not fully engaged into the fuse pins of the forward trunnion
lower housing of the main landing gear (MLG), which
could result in an incorrect MLG emergency landing breakaway sequence.
Flight Safety Australia
Issue 88 September–October 2012
Analyse this: logbook entries
1. Have a structured, handover procedure that includes a
pre-formatted sheet to improve consistency.
See a sample below.* This will ensure that all the
critical information is included or considered during
a face-to-face handover. While this sheet is never
intended to replace the aircraft’s technical logbook,
it does provide a valuable reference to ensure
information passed on verbally during the handover
is not forgotten.
Anyone who has been involved in aviation for more than a few
months invariably encounters the maintenance log joke. It’s an
oldie but a goodie, with entries such as: ‘Pilot: autoland very
rough. Engineer: autoland not fitted on this aircraft’.
But the joke shines a light on a serious issue—communication
between pilots and engineers.
Surveys have found that this communication is often
disorganised. A survey of Australian regional airlines found
maintenance personnel reported that flight crew write-ups of
deficiencies were often of little help in identifying a problem.
The same survey found pilots sometimes recorded deficiencies
on loose pieces of paper, or made verbal reports to engineers,
instead of formally documenting maintenance problems.
Hobbs quotes a study where pilots and maintenance engineers
at two U.S air carriers were asked about their use of the aircraft
logbook. ‘The results indicated a distinct split between the two
groups’, Hobbs said. ‘Engineers reported that they frequently
wanted more information from pilots’ logbook entries, yet pilots
were generally satisfied with the level of detail in maintenance
write-ups. A common complaint from engineers was that pilots
make logbook entries in which a component is simply described
as INOP (inoperative), with no further details.’
So, in defining the problem, what simple techniques can be
used within any size of organisation to improve both the quality
and quantity of communication?
* Handover
2. Develop supervisors’ briefing and de-briefing skills
as part of your human factors training course.
Remember: effective communication is a skill and
like any skill must be practised to improve. Ideally, if
you can identify ‘good’ communicators within your
organisation, use them as mentors to raise the quality
throughout your organisation.
3. Get pilots and engineers together with sample logbook
entries (good and bad) to discuss the impact of poor
write-ups and show how they can help each other with
clearer language and agreed terminology.
Above all, educate the entire organisation so everyone knows
that the crucial part of communication is not what is said, it
is what people hear and understand. The person attempting
to convey information is responsible for making sure that the
recipient of that information accurately understands it.
Pull-out section
17 May – 13 July 2012
Boeing 7378FE Weather radar suspect faulty.
SDR 510015070
Investigation found no faults.
Note: Similar occurrence figures not included
in this edition
Boeing 7378FE Wheel bolt failed.
SDR 510014858
No. 3 main wheel assembly tie bolt failed
approximately halfway along the threaded area.
One similar defect. Wheel: P/No: 277A6000204.
TSN: 17,031 hours/9784 cycles.
TSO: 1932 hours/1018 cycles.
Airbus A320232 Galley station equipment odour.
SDR 510014943
Hot plastic smell in aft galley. Investigation found no
definitive cause for the odour.
Airbus A330303 Escape slide failed test.
SDR 510014988
Door 2 LH escape slide partially deployed but hung
up on girt bar for a few seconds before finally
deploying. Time to full deployment − 16.8 seconds.
Maximum time allowed is 16 seconds.
P/No: 7A1539125
Airbus A330303 Fuselage keel beam cracked.
SDR 510014908
LH centre wing box keel beam fastener holes cracked
at frame 40. Cracking evident in fuselage skin to
lower doubler interface. Investigation continuing.
Four similar defects
Airbus A380842 Air conditioning system
smoke/fumes. SDR 510014819
Fumes in cabin after take-off. Fumes ceased after
approximately 15 minutes of flight. Investigation could
find no definitive cause.
Airbus A380842 Flight control system power
supply faulty. SDR 510014955
Control system back-up power supply (FIN 2CJ2)
faulty. Found during inspection iaw EA SA08544.
Investigation continuing. P/No: 41100103001
Airbus A380842 Passenger station seat locking
device out of calibration. SDR 510014968
First-class passenger seats (4off) found to have
incorrect functioning 16G locks.
Airbus A380842 Pitot/static system MFP faulty.
SDR 510015027
Captain’s pitot static system multi-function probe
(MFP) faulty. Initial investigation found angle of
attack portion missing. Investigation continuing.
P/No: 0859BB26.
BAE 146100 Engine vibration sensor faulty.
SDR 510015018
No. 4 engine vibration pick-up sensor
(accelerometer) faulty.
BAE 146100Fire Detection system terminal
block failed test. SDR 510014929
Fire detection system 10-way ceramic terminal
blocks (3off) failed resistance test. Found during
inspection iaw ISB 24-143. Terminal blocks located in
engine pylons. Five similar defects.
P/No: S3409872.
BAE 146RJ100 Flight compartment windshield
shattered. SDR 510015061
Captain’s LH B windshield outer pane shattered.
Investigation continuing.
P/No: NP1701021. TSN: 72 months.
BAE 146RJ100 Passenger/crew doors cabin
door unlocked. SDR 510014999
Cabin door warning. Investigation found door
handle mechanism stiff requiring lubrication.
Upper door hinge pivot tight. Loose terminals on
TB strip 251-00-00.
Beech 1900D Flight control wiring short circuit.
SDR 510014835 (photo following)
Flap wiring system short-circuited to ground.
Water in wiring following heavy rain caused short
circuit. TSN: 9473 hours/9555 landings.
Beech 1900D Fuselage skin cracked.
SDR 510014900
Lower fuselage skin cracked. Corrosion found
between stringers and skin.
Beech 1900D Passenger oxygen system
nut cracked. SDR 510014899
Oxygen fill line nut cracked. Copper pipe seam
also leaking.
Boeing 737376 Crew station locknut missing.
SDR 510015013
Captain’s seat track lock broken. Nut missing
from bolt.
Boeing 737376 Wing, plates/skin nut cracked
and leaking. SDR 510015006
RH wing fuel tank access panel 7th from inboard
dome nut cracked and leaking.
Boeing 737476 Crew oxygen mask failed.
SDR 510014893
Captain’s oxygen mask difficult to breath through
due to restricted flow in ‘emergency’. Second
observer’s mask had erratic flow. Investigation
continuing. P/No: MC1025104.
TSN: 49,135 hours. TSO: 1271 hours.
Boeing 737476 Wheel bolt sheared.
SDR 510015098
No. 2 main wheel tie bolt sheared. P/No:
6558256262. TSN: 27,041 hours. TSO: 327 hours.
Boeing 7377FE Air distribution system
filter dirty. SDR 510014936
Strong smell from rear of aircraft.
Investigation found a dirty recirculation filter.
P/No: CD01068F2.
Boeing 73782R Detection system control
panel unserviceable. SDR 510014891
Engine and APU fire control panel unserviceable.
P/No: 693707300. TSN: 31,993 hours/19,570 cycles.
Boeing 767336 Engine cowling system panel
separated. SDR 510014923
RH engine outlet guide vane infill panel separated
in flight.
Boeing 767336 Cargo equipment wiring loom
burnt. SDR 510014956
Power Drive Unit (PDU) wiring loom burnt/short
circuited. Burn damage to surrounding insulation
blankets. Investigation continuing.
Boeing 7773ZGER Galley oven smoke/fumes.
SDR 510014937
Rubbery/smokey smell from ovens F107 and
F108. Investigation found the ovens serviceable,
but the packaging of the meals in them was
unsuitable. P/No: 820216000001.
Boeing 7773ZGER Leading edge slat bird strike.
SDR 510014839
No. 10 leading edge slat had bird strike damage in
area of wing anti-ice access panel 2.
P/No: 114W4150Y112. TSN: 6842 hours/523 cycles.
Bombardier CL604 Trailing edge flap control
system failed. SDR 510014837
Numerous reports of flap system failing over the
previous six months. Various components in the flap
system replaced during extensive troubleshooting.
No more recurrences since replacement of the
flexible drive shafts.
Bombardier DHC8402 Wheel bearing failed.
SDR 510014969 (photo below)
RH nose wheel noticed to be slightly inclined
inwards. Investigation found that that the outboard
wheel bearing had suffered a catastrophic failure,
resulting in significant damage to the axle.
Suspect may have been caused by incorrect torque
of the axle nut. Investigation continuing.
TSN: 3458 hours/3853 cycles.
Boeing 737838 Attitude gyro and indicating
system battery charger failed. SDR 510015016
Integrated standby flight display (ISFD) battery
charger failed. Investigation continuing.
P/No: 312BS1011. TSN: 16,677 hours. TSO: 69 hours.
Boeing 737838 Wheel failed. SDR 510015030
No. 2 main wheel seized on axle. Initial investigation
found the inner hub shattered and axle
sleeve damaged. Investigation continuing.
P/No: 277A6000204. TSN: 13,729 hours/221 cycles.
Boeing 7378FE Landing gear retract/extension
system suspect faulty. SDR 510014953
Uncommanded nose landing gear extension when
the landing gear control lever was selected to ‘off’
position. Investigation could find no definitive cause
for the defect.
Boeing 7378FE Pressure control system
PRSOV leaking. SDR 510014982
Trim air pressure regulating and shut-off valve
(PRSOV) leaking. PRSOV had been locked out due to
ruptured duct downstream. P/No: 32149721 – Duct
P/No: 213A150145. TSN: 6695 hours/4014 cycles.
CVAC 340 Flight compartment window cracked.
SDR 510014918
LH main window cracked. Investigation found
evidence of a bird strike on the top of the fuselage,
with impact close to the edge of the window.
P/No: 34031103019.
Embraer EMB120 Flight compartment windshield
overheated. SDR 510014935
Pilot’s forward windshield overheated with electrical
burning smell. Initial investigation found heat
damage/discolouration on the terminal block earth
leads. Investigation continuing.
TSN: 3602 hours/2644 cycles/51 months.
TSO: 3602 hours/2644 cycles/51 months.
Embraer EMB120 Fuselage door hinge bracket
damaged. SDR 510014917
Passenger/crew entry door forward actuator inboard
attachment bracket top and bottom intercostals at
stringer 19 damaged. Attachment bracket rivets pulled
through outer skin.
Flight Safety Australia
Issue 88 September–October 2012
Embraer EMB120 Ice and rain protection wiring
terminal overheated. SDR 510014934
De-ice system current sensor wiring terminals
discoloured due to overheating. SB 120-30-30
had previously been carried out. P/No: 36160.
Embraer EMB120 Landing gear failed – extend.
SDR 510015025
Nose landing gear indicated unsafe following landing
gear extension. Landing gear cycled, with nose gear
eventually indicating down and locked. Investigation
could find no definitive cause for the defect.
Embraer EMB120 Trailing edge flap actuator
suspect faulty. SDR 510015002
RH outboard flap actuator suspect faulty. During
lowering flaps for access, the RH outboard flap
only extended to 15 degrees when all other flap
segments fully extended to 45 degrees. Flap failed
to extend correctly three more times. Flaps left
for approximately 20 minutes, and the flap then
operated correctly.
Embraer EMB120 Trailing edge flap control
system annunciator faulty. SDR 510014905
Flap annunciator unit faulty. Investigation continuing.
Embraer ERJ170100 Hydraulic pump failed.
SDR 510015029
No. 3 electric hydraulic pump failed. Investigation
continuing. P/No: 5116603.
TSN: 5673 hours/4711 cycles/37 months.
Embraer ERJ170100 Trailing edge flap actuator
locked. SDR 510014832
Flap 2 caution light illuminated during approach.
Initial investigation found the RH inboard flap
actuator torque limiter pin tripped. Investigation
also found manual rotation of the input splines
to be difficult and rough, suggesting a problem
with the flap actuator gearbox.
P/No: C1548152.
TSN: 7582 hours/5146 cycles/82 months.
Embraer ERJ190100 Hydraulic system
O-ring failed. SDR 510015084
RH inboard brake lower bleed fitting O-ring
seal failed, causing loss of hydraulic fluid.
P/No: ABP0046.
Embraer ERJ190100 Pitot/static system sensor
unserviceable. SDR 510014920
Integrated pitot/static/AOA sensor unserviceable.
P/No: 2015G2H2H8A. TSN: 2 hours/2 cycles.
Embraer ERJ190100 Pressure regulator/outflow
valve restricted.SDR 510015034
Cabin pressurisation system outflow valve
operation interfered with by insulation blanket
due to five missing blanket-to-frame retaining clips.
Blanket residue found in valve and belly fairing.
Fokker F27MK50 Landing gear retract/extension
system lockplate damaged. SDR 510015010
LH main landing gear upper member outboard pivot
pin lock plates broken and bent. Suspect caused by
restricted rotation in the airframe bracket bushes.
Fokker F28MK0100 Landing gear retract/
extension system terminal loose connection.
SDR 510015082
Landing gear selector anti-retraction solenoid
terminal loose. Investigation found two flat washers
P/No: MS35338-40 and lock-spring washer
P/No: AN960KD3L not installed at the anti-retraction
solenoid terminal connection. Solenoid fitted by a
previous operator.
Fokker F28MK0100 Wheel/ bolt sheared.
SDR 510014993
LH No. 2 main wheel tie-bolt sheared.
Tie-bolt found on runway. P/No: MS21250.
Fokker F28MK0100 Wheel cracked.
SDR 510015064
Nose landing gear wheel inboard hub cracked
in bead seat. Crack length approximately 44.5mm
(1.75in). Found during eddy current inspection.
P/No: 50081331.
Fokker F28MK0100 Wing, control surface attach
fitting bolt sheared. SDR 510014829
No. 2 lift dumper lever mounting bracket attachment
bolt head sheared. Lift dumper rod assembly locknut
loose and safety wire broken.
Fokker F28MK1000 Flight compartment
windshield shattered. SDR 510014945
Co-pilot’s windshield outer pane cracked and then
shattered. P/No: D20543406.
Gulfstream GV Passenger compartment window
cracked. SDR 510014897
Cabin window outer pane cracked along edge.
Caused by inadequate clearance between window
and fuselage skin.
P/No: 1159CE5000117. TSN: 5912 hours/2282
cycles/2282 landings/144 months.
Beech 58 Mixture control cable failed.
SDR 510014996
RH engine lost power and fuel flow needle dropped
to zero. RH engine feathered. Engine able to be
restarted on the ground. Investigation found mixture
control inner cable snapped at swaged end (FCU).
P/No: 5038901223.
Beech 58 Power lever cable broken.
SDR 510014866
LH engine throttle cable broken at swaged
end fitting. Cable had only 779 hours TSN.
P/No: 5038901223.
Beech C90 Elevator tab control system cable
failed. SDR 510014881
Elevator trim cable failed at pulley in floor located
forward of door. P/No: NASJ0266577D.
Cessna 172E Control column corroded.
SDR 510014997 (photo below)
Significant internal corrosion of control yoke found
during inspection iaw Cessna SEB01-3. (SDRer AWB
27-4) P/No: 05117821. TSN: 5314 hours/576 months.
Saab SF340B Elevator control system servo
unserviceable. SDR 510014901
Elevator control system went to nose-down without
pilot input. Pulling back on LH control column had
no effect until control suddenly released. RH control
column had normal input. Investigation found servo
had a seized bearing which allowed the clutch shaft
to continue spinning, wearing the inner bearing and
causing end play. The servo mount was also found
to have an incorrect torque setting.
P/No: 622-2027-002.
Saab SF340B UHF communication system
controller odour. SDR 510014957
Intermittent burning smell in cockpit. Investigation
found a faulty Comm 1 controller. Controller had
been fitted just prior to flight. Investigation found
the smell on the replacement controller was a
residual smell left over from the previous repair.
P/No: 6226520009.
TSN: 23,136 hours. TSO: 23,136 hours.
Cessna 172R Aileron control system
nut cracked. SDR 510015093 (photo below)
LH and RH aileron bellcrank nuts cracked.
P/No: MS21042L4.
Below 5700kg
Beech 200 Aileron tab control system out of
adjust. SDR 510014840
Excessive RH aileron trim required for straight and
level flight. Investigation continuing.
TSN: 22,524 hours/17,685 cycles.
Beech 200 Hydraulic pump electric motor
short-circuit. SDR 510015078
Hydraulic pack electric motor internal short-circuit.
P/No: 481. TSN: 156 months. TSO: 156 months.
Beech 58 Landing gear gearbox failed.
SDR 510014972 (photo below)
Landing gear failed to retract. LH and RH main
landing gear and nose landing gear stuck in transit
position. Emergency gear extension lever reported
not engaging. Emergency landing carried out with
landing gear not extended. Damage caused to aircraft
structure, engines and propellers. Investigation found
a failed gearbox had caused the landing gear motor
to burn out. P/No: 958100175.
Cessna 172R Aircraft fuel line rubbing.
SDR 510014827
Fuel system return line worn due to rubbing on nose
landing gear steering RH pushrod. Investigation
also found the fuel return check valve hinge position
at base could allow valve to stay open if the spring
weakened. Found during inspection iaw AD 2012-0202. Aircraft has only 25 hours TSN. P/No: 05160311.
Cessna 172R Aircraft fuel line worn and
damaged. SDR 510015058
Numerous fuel supply lines and wiring connectors
worn and damaged.
Cessna 172R Flight control system cable worn.
SDR 510015055
Rudder cables, elevator trim cables and aileron
cables worn beyond limits. Elevator and aileron
rigging and travel incorrect.
Cessna 172R Fuselage skin distorted.
SDR 510015059
RH skin lap joint between side and belly skins located
at FSTA 8.12 below the lift strut attachment point
buckled and distorted. Lift strut supporting frame
flange had two drilled holes, with rivets removed/not
fitted. P/Nos: various.
Pull-out section
Kavanagh B350 balloon envelope melted.
SDR 510014994
Hot air balloon envelope load tape P/No: KP2327,
K-27 fabric P/No: KP1320, and flying wire P/No:
KP2701 melted. TSN: 347 hours/51 months.
Cessna 172RG Fuselage tunnel cracked.
SDR 510014916
LH nose landing gear/control yoke support tunnel
P/No: 2413001-5 cracked from rudder torque tube
bearing attachment hole. Investigation also found
the RH tunnel P/No: 243001-8 cracked in the same
location. P/No: 24130015L2430018R.
TSN: 10,326 hours.
Cessna 172R Horizontal stabilizer nut plate
missing. SDR 510014976 (photo below)
Elevator down stop bolt anchor nut plate missing.
Sheared rivet tails still in the mounting. Stop bolt had
been fastened to the vertical stabiliser casting with
AN970-3 washers and loose nuts. Aircraft had only
28 hours TSN. P/No: MS210783.
Cessna 310R Aircraft fuel distribution system
hose fitting broken. SDR 510014870
Fuel smell in cockpit. Investigation found a broken
LH fuel bleed hose fitting under the co-pilot’s dash.
P/No: 3112D.
Cessna 310R Vertical stabiliser rib corroded.
SDR 510014922 (photo below)
Fin root rib and skin attachment rivets corroded.
Initial investigation found an AN3 bolt instead of
a rivet attaching skin. When paint removed, more
rivet heads separated.
P/No: 08313031. TSN: 6842 hours.
Cessna 182P Main landing gear leg corroded.
SDR 510015088 (photo below)
RH main landing gear leg corroded in area of step
bracket attachment. Area of corrosion approximately
31.75mm by 6.3mm (1.25in by 0.25in) in area and
2.54mm (0.1in) in depth. Investigation found the glue
attaching the step bracket was partially delaminated
allowing moisture ingress between the bracket and
leg that contributed to the corrosion.
P/No: 07416302. TSN: 10,779 hours.
Cessna 208B Trailing edge flap bracket broken.
SDR 510014926
Flap actuator support bracket twisted and torn.
P/No: 26111447. TSN: 4881 hours.
Cessna 210L Landing gear door actuator bolt
broken. SDR 510015019
LH and RH main landing gear actuator attachment
bolts (three per actuator) broken or loose. Only one
bolt per actuator was tight. P/No: NAS464P4A29.
Cessna 210N Control column screw separated.
SDR 510014963
Pilot’s control column internal glide screw fell out
and glide separated. Found during inspection iaw
SEB-27-01. TSN: 5284 hours.
Cessna 210N Nose/tail landing gear attach
trunnion cracked. SDR 510014888
Nose landing gear lower trunnion cracked.
P/No: 124340216.
Cessna 210N Wing spar corroded.
SDR 510014836 (photo following)
Wing main spar carry-through forging corroded on
lower lugs. Investigation found corrosion caused by
contact with the rear cabin vent Sceet ducts. Duct
clips left undone, allowing ducts to sag and rest on
lower lugs. AD Cessna 210/61-2 carried out in 2009.
P/No: 21100013. TSN: 3256 hours/384 months.
Cessna 402B Rudder damaged. SDR 510015049
Rudder hard to trim for straight and level flight.
Investigation found lower rudder pivot attachment
point bracket angle damaged. Trim tab actuator
rod bent approximately 35 degrees to 40 degrees,
causing jamming of the screw jack. Suspect caused
by wind gusts when aircraft was parked.
Cessna 402C Hydraulic line split.
SDR 510014818
Main pressure supply line to hydraulic manifold
split at first bend upstream of manifold.
Split approximately 10mm (0.39in) long, causing
loss of hydraulic fluid. P/No: 520010766.
Cessna R182 Landing gear actuator piston worn
and damaged. SDR 510015077
Nose landing gear actuator piston shaft gland seal
P/No: MS28775-112 leaking and piston shaft worn
beyond limits. P/No: 12802412.
TSN: 9216 hours/396 months.
Cessna T337G Trailing edge flap cable
unserviceable. SDR 510015062
LH and RH inboard flap cables beginning to fray.
Found during inspection iaw AWB 27-003.
P/No: 14601007.
Lancair Legacy Main landing gear strut failed.
SDR 510014987
Main landing gear strut hydraulic actuator
attachment fitting weld cracked and partially failed.
Suspect caused by insufficient penetration of weld.
TSN: 76 landings. TSO: 76 landings.
Pilatus PC12 Crew station equipment system
cable broken. SDR 510014989
Pilot’s seat adjustment cable broken.
Suspect caused by items stowed on top of cable.
P/No: 9593012221.
Pilatus PC12 Elevator tab actuator
suspect faulty. SDR 510014864
Pitch trim actuator suspect faulty.
Investigation continuing.
Piper PA31350 DC alternator failed.
SDR 510015001
LH and RH alternators failed. Investigation found
wiring loose on the back of the LH alternator,
and the RH alternator not producing any power.
P/No: ALU8521R. TSO: 1746 hours.
Piper PA31350 Elevator control spring failed.
SDR 510015036
Elevator down spring failed at point where radial
winding bends at 90 degrees to form the hook.
Suspect forming mark in area of failure. Another
forming mark found on the other end of the spring.
P/No: 7105603. TSN: 103 hours/2 months.
Piper PA31350 Engine oil distribution (airframe)
system hose failed. SDR 510014967
RH engine oil pressure hose chafed on fuel line
in area outboard of the wing root, causing loss
of engine oil.
P/No: 2267372. TSN: 17,745 hours/22,001 landings.
Piper PA32300 Stabiliser control cable
separated. SDR 510014970
Abnormal elevator control during taxi. Investigation
found forward RH elevator cable separated at terminal
at approximately FS 230.0. Failure resembled other
failures, as described in AWB 27-001 issue 3 figure 2.
P/No: 62701037. TSN: 4404 hours/420 months.
Piper PA32300 Vertical stabiliser bracket
corroded. SDR 510014862
Fin upper bracket corroded.
P/No: 63502000. TSN: 8632 hours.
Piper PA34200 Rudder control cable frayed.
SDR 510014856 (photo below)
LH and RH forward rudder control cables excessively
worn, with broken strands in area where they
pass beneath the forward-most cable pulley bank.
P/No: 6270181.
Diamond DA42 Fuel transfer valve connector
faulty. SDR 510014821
RH auxiliary fuel tank wiring connector faulty.
Investigation found a poor wiring connection with
the pins not mating correctly. Plug disturbed at
previous 100-hourly inspection.
Gulfstream 500U Trailing edge flap cable
unserviceable. SDR 510014880 (photo below)
LH inboard flap cable almost broken with two
strands intact. Damage in area of flap bellcrank.
P/No: 50000439.
Reims F406 Rudder control system out of
adjust. SDR 510014975
Take-off aborted due to excessive amounts of
rudder and trim required to keep aircraft straight.
Investigation found rudder and trim cables had
slightly low tensions.
Flight Safety Australia
Issue 88 September–October 2012
Lycoming IO540AE1A5 cylinder inlet valve
broken. SDR 510014887 (photo below)
No. 5 cylinder inlet valve failed in collet area and
entered cylinder.
P/No: SL13622. TSN: 121 hours/14 months
Swearingen SA227AC Hydraulic pipe
unserviceable. SDR 510015033
Hydraulic pipe broken, causing loss of hydraulic
fluid. Pipe in RH flap actuator retraction circuit.
P/No: 5510008E110Y.
TSN: 30,466 hours/38,812 cycles.
Swearingen SA227AC Landing gear retract/
extension system safety override seized.
SDR 510014919
Landing gear handle safety override jammed
in pedestal.
Swearingen SA227AC Wing structure corroded.
SDR 510015020 (photo below)
Lower wing badly corroded. TSN: 29,893
hours/45,760 cycles/45,760 landings.
Swearingen SA227DC Landing gear
actuator bearing damaged. SDR 510015009
(photo below)
Nose landing gear actuator bellcrank forward
roller bearing outer race missing.
P/No: YCRS12OR. Alternate P/No: CYR34S.
TSN: 18,293 hours/13,685 cycles.
Fuel pump bearing worn. SDR 510014894
Engine fuel pump bearings worn beyond maximum
limits. Pump had nil time since overhaul.
P/No: RB9084.
Locknuts faulty. SDR 510014915
Starter-generator main cable attachment locknuts
P/Nos: MS21042-5 and MS21042-6 did not appear to
have any locking properties and could be wound down
the studs using only finger pressure. Nuts were new.
Investigation continuing. P/No: MS210425.
Lycoming IO540AE1A5 cylinder nozzle
separated. SDR 510014825
Engine piston cooling nozzle separated, causing
damage to two pistons. Some camshaft damage
also found but not attributed to the nozzle separation.
P/No: 73772. TSO: 1385 hours.
Lycoming LTIO540J2BD rocker failed.
SDR 510014867
RH engine No. 1 cylinder rocker cover holed due to
failure of rocker. Investigation found rocker tight on
shaft, dislodging shaft from rocker boss and flattening
retaining plate integrated into rocker hat. Investigation
also found two small cylinder tie-down studs sheared
off and lower through bolt sheared off at nut.
P/No: LTIO540J2BD. TSO: 944 hours/60 months.
Continental GTSIO520M crankcase cracked.
SDR 510015011
RH engine RH crankcase half cracked between No.1
and No. 3 cylinders.
Continental IO360K piston incorrect part.
SDR 510014946
During inspection of new cylinder/piston kit, it was
noticed that the new piston was a high-compression
piston, while the old one was a low-compression
type. Investigation found the pistons fitted to the
other five cylinders were also low-compression,
but they all should have been high-compression.
P/No: 655478A5. TSO: 734 hours/107 months.
Continental IO520C piston ring seized.
SDR 510014927
Engine shutdown due to low oil pressure. Investigation
found piston rings tight in ring grooves due to carbon
build-up following cylinder replacement.
Tecnam P2006 Stabilator control rod worn
and damaged. SDR 510015050
Stabilator control rod worn and damaged.
Aircraft only had four hours TSN. P/No: 2695402.
Vulcan P68C Cabin smoke/fumes.
SDR 510014979
Fumes in rear cabin with CO2 detector indicating
‘Caution’. Fumes seemed worse when flaps deployed.
Investigation could find no cause for the fumes but
minor gaps found in both firewalls. Aircraft does not
use an exhaust shroud
for cabin heating. TSN: 1924 hours.
Vulcan P68C Elevator trim system slipped.
SDR 510014849
Stabiliser trim system slipping when operated
electrically, causing insufficient nose-down trim.
Three similar defects. TSN: 1865 hours.
Altimeter illegal modification. SDR 510014872
Altimeter found to be faulty during calibration,
so internal inspection carried out. Scale found to
have been changed from in inches Hg to Mb by
attaching a printed paper scale over the original
scale. Manufacturer contacted and confirmed illegal
modification had been carried out.
P/No: 10173511807.
Autopilot servo bearing worn. SDR 510014938
(photo following)
Autopilot servo clutch bearing seized, allowing
shaft to spin and wear inner bearing race.
P/No: 3091997010.
Continental IO520M crankshaft cracked.
SDR 510014855
Crankshaft cracked in two places on alternator
gear flange. Found during magnetic particle
NDT inspection following engine removal and strip
for overhaul. P/No: 649895.
Continental IO550N Engine fuel system
clamp broken. SDR 510015023
Engine fuel injection line clamps (2off) broken.
Found during inspection iaw AD/Con/60 Amendment
4. P/No: 6524361. TSN: 956 hours/110 months.
De Havilland Gipsy Major 1 Carburettor float
unserviceable. SDR 510014981
Carburettor float contaminated by fuel due to
softening of the float coating. Flooded carburettor
leaking from gasket and manifold. Aircraft operates
P/No: CHA31267. TSO: 350 hours/480 months.
Jabiru JABIRU2200B connecting rod failed.
SDR 510014914
No. 3 cylinder connecting rod failed in area of
little-end bearing. Broken connecting rod damaged
crankcase and starter motor. TSO: 15 hours/1 month.
Lycoming IO360L2A Fuel control servo
contaminated. SDR 510014952
Numerous fuel servos contaminated with fuel dye
residue in area behind air diaphragms and venturis.
P/No: 25765362.
Lycoming IO540AE1A5 Magneto distributor
worn. SDR 510015091
LH magneto distributor block worn excessively.
P/No: 10357426. TSN: 1235 hours/108 months.
TSO: 348 hours/8 months.
Lycoming O235L2C cylinder cracked.
SDR 510014851
No. 2 cylinder base cracked separated from cylinder
barrel. P/No: 05K23037. TSN: 3150 hours/60 months.
Lycoming O320 Manifold gasket damaged.
SDR 510014848
Engine inlet manifold gaskets excessively hard and
brittle, allowing air leakage.
P/No: 71973. TSN: 490 hours/12 months.
Engine fuel pump bearing worn. SDR 510014894
Engine fuel pump bearings worn beyond maximum
limits. Pump had nil time since overhaul. Numerous
reports. P/No: RB9084.
Crankcase cracked. SDR 510014980
Crankcase cracked from through stud above
No. 4 cylinder. Investigation continuing.
P/No: LW11026. TSO: 1678 hours.
Hartzell PHCJ3YF2 Propeller hub corroded.
SDR 510014859
Propeller hub corroded under paint in area of two
blade sockets. Investigation suspects that corrosion
had been there for some time, as area had been
sand blasted and repainted. Investigation also
found the paint used was not an approved type.
P/No: E71693. TSO: 1977 hours.
McCauley 1C235LFA Propeller incorrect fit.
SDR 510014817 (photo below)
Propeller incorrectly installed 60 degrees out of
position. The incorrect positioning caused two
mounting nuts to be pushed out of the crankshaft
flange, with two indents made in the propeller
spacer P/No: C-7726, making it unserviceable.
Aircraft had just been imported from overseas.
TSN: 25 hours/12 months.
Pull-out section
Agusta A109E Engine exhaust pipe cracked.
SDR 510014910
No. 1 engine exhaust tube cracked from rear edge.
Crack eventually split into two cracks of 8mm
(0.31in) and 15mm (0.59 in) lengths.
P/No: 109060150201. TSN: 1662 hours.
TSO: 1662 hours.
Agusta A109E Main rotor blade delaminated.
SDR 510014853 (photo following)
Main rotor blade delaminated at tip cap. Area of
delamination approximately 100mm by 100mm
(4in by 4in) from Stn 5420 to tip cap.
Suspect caused by water ingress. P/No: 7090103109.
TSN: 2041 hours.
Bell 412 Emergency exit window separated.
SDR 510014977
LH cabin window (emergency exit) separated from
aircraft. Suspect tall patient’s foot came into contact
with the window during an aeromedical operation.
Investigation also found seal installation stretched,
contributing to the incident. P/No: 412670101.
Bell 412 Rotorcraft tail boom longeron cracked.
SDR 510014826
Tail boom LH upper longeron cracked.
Eurocopter BK117C2 Helicopter vibration
absorber unserviceable. SDR 510015043
(photo below)
Vibration absorber cracked and resting on
fuselage floor below cabin. P/No: B183M1005104.
TSN: 1218 hours.
Eurocopter AS350BA Tail rotor drive shaft
support cracked. SDR 510014974
Tail rotor driveshaft support and bearing bracket
found to be cracked. P/No: 350A23105344.
Robinson R44 Horizontal stabiliser top skin
cracked. SDR 510015094
P/No: C0441. TSN: 1,335 hours/74 months.
TSO: 1335 hours/74 months.
Robinson R44 Horizontal stabiliser top skin
cracked. SDR 510015095
P/No: C0441. TSN: 730 hours/22 months.
TSO: 730 hours/22 months.
Robinson R44 Main rotor transmission mount
fuselage frame cracked. SDR 510014966
(photo below)
Main rotor gearbox RH rear upper frame cracked.
Crack length approximately 19.05mm (0.75in),
running along the lower edge of the weld bead.
P/No: C0201. TSN: 1798 hours.
Turbine Engine
Allison 250C20B combustion section heat
shield broken. SDR 510014971
Engine needing longer, warmer starts; normal
operating temperature had increased by about
40 degrees C. Investigation revealed that the No. 8
bearing heat shield had completely broken off and
fallen into the burner can, affecting flame control
and air distribution. TSO: 1252 hours.
Allison 250C40B Turbine engine compressor
support damaged. SDR 510015039
No.1 engine compressor rear support assembly
damaged. Metal contamination of chip detector.
Investigation continuing. P/No: 6896025.
Garrett TPE33110 combustion section plenum
cracked. SDR 510015083
RH engine casing (plenum) split for 180 degrees
around circumference. Investigation found split was
along a machining mark where plenum modified
to accommodate a de-swirl vane. Investigation
continuing. P/No: 31037006.
TSN: 7985 Hours/8018 Cycles. TSO: 4886 hours.
Eurocopter AS332L Hydraulic filter leaking.
SDR 510014822
Hydraulic oil leaking from drain. Investigation found
leaking autopilot pencil filter. Investigation continuing.
P/No: 704A34621013.
Eurocopter AS332L Landing gear failed –
extend. SDR 510014877
Landing gear failed to extend in both normal and
emergency electrical extension modes, but finally
pumped down manually. Investigation continuing.
Eurocopter AS350BA Tail rotor blade FOD.
SDR 510015099
Tail rotor blades damaged due to FOD.
Helicopter about to land on pad when the rubber
matting covering the pad was blown into the tail
rotor by the downwash. Investigation also found
tail rotor gearbox and driveshaft damage.
P/No: 355A12004008. TSN: 2482 hours.
Garrett TPE33112UH Turbine engine oil pump
failed. SDR 510014902
Engine rear turbine bearing oil scavenge pump failed.
P/No: unknown.
GE CF3410E turbine engine odour.
SDR 510014865
Strong odour in aircraft with engines running.
Investigation could find no definitive cause,
but an engine wash had been carried out overnight.
GE CF680C2 Turbine disc eroded.
SDR 510014933
Stage 1 high-pressure turbine disc eroded
beyond limits in armpit radius. P/No: 1531M84G12.
TSN: 42,005 hours. TSO: 42,005 hours.
GE CFM563C Turbine engine oil tube cracked
and leaking. SDR 510014869
No. 2 engine leaking oil. Engine removed.
Further investigation found a cracked aft sump,
No. 5 bearing squeeze film tube cracked and leaking,
one HPT blade tip missing and extensive downstream
damage to other turbine blades.
Suspect oil tube cracked due to vibration caused by
damaged turbine blades. P/No: 3351043090.
GE CFM567B Thrust reverser suspect faulty.
SDR 510014834
No. 2 engine thrust reverser warning light illuminated
in cruise. Investigation found no faults with the thrust
reverser; aircraft returned to service.
Lycoming ALF502R5 Engine bearing seal
leaking. SDR 510015022
No. 4 engine oil quantity dropped to zero, with
associated loss of oil pressure. Ground run confirmed
loss of oil. Suspect internal bearing pack leaking.
Investigation continuing.
Lycoming ALF502R5 Turbine engine stator
band fractured. SDR 510014892
No. 4 engine No. 1 stator assembly stator band
detached from end bolt fastener. Investigation
continuing. P/No: 204314803.
Lycoming LTS101750B1 FCU failed.
SDR 510015047
No. 2 engine uncommanded acceleration.
Following removal of the fuel control unit (FCU)
it was found to be seized due to drive bearing failure.
P/No: 430128308. TSO: 2050 hours.
PWA PT6A41 Turbine engine reduction gearbox
failed. SDR 510014995
Momentary engine chip detector light illumination,
followed by torque fluctuations. Propeller stopped
rotating before engine could be fully shut down.
Investigation found metal contamination of the
reduction gearbox. TSN: 9123 hours/9795 cycles.
TSO: 6208 hours/6743 cycles.
PWA PW123B Fuel injector nozzle leaking.
SDR 510014857
LH engine No.13 fuel nozzle leaking. Investigation
found a faulty No.14 nozzle allowed the centre fuel
transfer tube to bottom out. This extra travel
allowed fuel to flow past the O-ring on No.13 nozzle
due to insufficient sealing.
P/No: 304578801. TSO: 26 hours/19 cycles.
PWA PW206C Engine exhaust pipe cracked.
SDR 510014910
No.1 engine exhaust tube cracked from rear
edge. Crack eventually split into two cracks of
8mm (0.31in) and 15mm (0.59 in) in length.
P/No: 109060150201. TSN: 1662 hours.
TSO: 1662 hours.
PWC PW207D1 Engine fuel filter contaminated.
SDR 510014960
No.1 and No. 2 engine fuel injector manifold filters
contaminated with a ‘rubber-like’ compound.
Investigation continuing. Two similar defects.
TSN: 54 hours.
Rolls Royce RB211 thrust lever suspect faulty.
SDR 510014884
LH and RH engine thrust levers split during climb.
Rolls Royce TAY65015 Engine accessory drive
gear failed. SDR 510014947
Following LH engine starter turbine failure, a new
starter turbine was fitted which then had another
failure, with the turbine spline shearing. Initial
investigation suspects failure of the starter drive gear
in the high-speed gearbox. Investigation continuing.
TSN: 4073 hours/3919 cycles.
TSO: 1136 hours/966 cycles.
Rolls Royce Trent 97284 Turbine faulty.
SDR 510014838
High vibration levels from No. 1 engine LP turbine.
Inspection of the engine found metal in the tailpipe.
Engine removed for further investigation.
P/No: TRENT97084.
Flight Safety Australia
Issue 88 September–October 2012
18 – 31 May 2012
Bell Helicopter Textron 412 series helicopters
2012-0086-f Equipment and furnishings –
hoist hook – inspection
Eurocopter EC 135 series helicopters
2012-0085-E Main rotor system – main rotor hub –
Eurocopter EC 225 series helicopters
2012-0087-E Main rotor drive – main gearbox bevel
gear vertical shaft – inspection/limitation
Below 5700kg
Aerostar (Piper/Ted Smith) 600 and 700
series aeroplanes
AD/TSA-600/36 Amendment 4 – engine exhaust
systems and installation of fire detection system
for turbocharged aircraft
Beechcraft 55, 58 and 95-55 (Baron)
series aeroplanes
2012-10-02 Fuel vapour return and/or fuel vent lines
Cessna 206 series aeroplanes
2012-10-52 Hartzell Engine Technologies (HET)
turbochargers – insufficient oil flow to bearings
Cessna 207 series aeroplanes
2012-10-52 Hartzell Engine Technologies (HET)
turbochargers – insufficient oil flow to bearings
Cessna 210 series aeroplanes
2012-10-52 Hartzell Engine Technologies (HET)
turbochargers – insufficient oil flow to bearings
2012-10-04 Wing main spar lower cap – inspection
Piper PA-31 series aeroplanes
2012-10-09 Aircraft data plate – inspection
Above 5700kg
Airbus Industrie A319, A320 and A321
series aeroplanes
2010-0046R1 Flight controls – elevator servocontrol rod eye-end – inspection
Airbus Industrie A330 series aeroplanes
2012-0090 Air conditioning – bulk cargo isolation
valve bonding lead and route 1M – modification
Airbus Industrie A380 series aeroplanes
2012-0089 Wings – die-forged front spar –
Boeing 747 series aeroplanes
AD/B747/140 Fuselage – lap joint upper nose
section BS 400 to 520 – cancelled
2012-10-03 Fuselage skin – lap splice between
BS 400 to BS 520 at stringers S-6L and
S-6R – inspection
1 – 14 June 2012
Boeing 777 series aeroplanes
2012-09-14 Forward cargo door – latch
pin – inspection
2012-10-10 Horizontal stabiliser pivot pin –
replacement/repetitive inspection
Bell Helicopter Textron Canada (BHTC)
206 and Agusta Bell 206 series helicopters
CF-2012-19 Control box assembly
manufacturing defect
Bombardier (Canadair) CL-600 (Challenger)
series aeroplanes
AD/CL-600/76 Pitch feel simulator input
lever – cancelled
CF-2012-18 Defective horizontal stabiliser
trim actuators
Eurocopter EC 225 series helicopters
2012-0104 Main rotor drive − main gear box
bevel gear vertical shaft − inspection/limitation
Eurocopter SA 360 and SA 365 (Dauphin)
series helicopters
2012-0098-E Rotorcraft flight manual −
emergency procedures − rush revision
Bombardier (Boeing Canada/De Havilland)
DHC-8 series aeroplanes
CF-2011-29R1 Hydraulic accumulators –
screw cap/end cap failure
CF-2012-17 Aft entry and service doors –
translating door handle jamming
Below 5700kg
Fokker F28 series aeroplanes
2011-0233-CN Fuel – wing and integral centrewing tanks – inspection/modification
De Havilland DHC-1 (Chipmunk)
series aeroplanes
AD/DHC-1/12 Amendment 7 − wing spar booms
and centre section − fatigue life limitation
Fokker F100 (F28 Mk 100) series aeroplanes
2011-0233-CN Fuel – wing and integral centrewing tanks – inspection/modification
Great Lakes Aircraft Company, LLC Model
2T-1A-1 and 2T-1A-2 aeroplanes
2012-11-08 Horizontal stabiliser spars − inspection
Gulfstream (Grumman) G1159 and G-IV
series aeroplanes
2012-11-06 Wing-to-fuselage attachment
fittings – inspection/repair
Pilatus PC-12 series aeroplanes
2012-0099 Time limits/maintenance
checks − airworthiness limitation section −
Piston engines
Robin Aviation series aeroplanes
DCA/R2000/41 Air filter – inspection/replacement
Lycoming piston engines
AD/LYC/117 Amendment 2 – Lycoming
crankshaft replacement
Above 5700kg
Rotax piston engines
2012-0093-E Engine – fuel and control –
fuel pump – replacement
Airbus Industrie A319, A320 and A321
series aeroplanes
2012-0100 Nacelles/pylons − aft pylon
moveable fairing rib 5 − inspection/repair
Teledyne Continental Motors piston engines
2012-10-13 Replacing CMI starter adapters
due to fractures in shaft gears
Airbus Industrie A330 series aeroplanes
2012-0094 Engine − forward engine
mounts bolts − torque check/replacement
Turbine engines
Airbus Industrie A380 series aeroplanes
2012-0096 Airborne auxiliary power −
suspension system assembly − replacement
International Aero Engines AG V2500 series
2012-09-09 High-pressure compressor (HPC)
stage 3-8 drum cracking
Boeing 737 series aeroplanes
AD/B737/270 Amendment 1 − aft pressure
bulkhead web 2
Rolls Royce turbine engines - RB211 series
AD/RB211/46 State of design airworthiness
directives - 1
AD/RB211/47 State of design airworthiness
directives - 2
Boeing 767 series aeroplanes
AD/B767/163 Amendment 1 − door emergency
escape system − cancelled
Rolls Royce turbine engines - RB211
TRENT 900 series
2012-0057 (Correction) Engine – intermediate
pressure shaft coupling – inspection/replacement
Boeing 777 series aeroplanes
2012-11-03 Main landing gear trunnion
lower housing fuse pin cross bolts and fuse
pins − inspection
continued on page 42
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/
Pull-out section
Ageing aircraft management
plan comes of age
CASA has recently released a discussion paper on how we manage ageing aircraft.
The discussion paper provides information about ageing aircraft issues and, importantly,
outlines several possible options for managing our ageing aircraft fleet in future.
Regular readers of Flight Safety Australia will have seen
our series of articles on ageing aircraft, but as a refresher—
did you know that:
the average age of Australia’s piston-engine aircraft
fleet is around 40 years?
this represents some 7000 aircraft in Australian
skies that are 40 years or older?
most of these aircraft were designed and built with
a notional life of 20 years?
Given these statistics, it is no wonder that the Federal
Government has asked CASA to increase its focus on
ageing aircraft.
Then there is the added complexity that each and every aircraft
ages, in its own unique way, from the day it is made. The rate
at which each aircraft ages depends on a range of factors,
such as how that aircraft is operated, maintained and stored
over its life. As a result, no two aircraft on the Australian
register age in the same way. Addressing the ageing process
properly requires an individual, aircraft-by-aircraft approach,
rather than sweeping fleet-wide initiatives. That type
of one-size-fits-all approach merely deals with the most badly
deteriorated aircraft, at the expense of those that have been
well maintained, operated and stored throughout their lives.
The recently released discussion paper provides a background
to CASA’s findings about ageing aircraft in Australia. It also
introduces several CASA initiatives to help registered operators
(that is owners) more fully understand general ageing aircraft
concepts, and how they affect their own particular aircraft.
The discussion paper provides a hyperlink to the recently
developed CASA e-learning course for registered operators.
Do this course online before you respond to the discussion
paper, so you, as an owner, will be across all the issues. After
completing the course, which is available to all industry
members and takes roughly an hour and a half, you will
have a comprehensive overview of lifeing concepts, fatigue,
corrosion and systems degradation. The e-learning also
gives an overview of why CASA is considering options for the
continued safe operation of these aircraft.
The paper not only includes a link to the new e-learning, but
also a link to the recently developed prototype matrix tool.
This tool is a world-first, locally developed, web-based CASA
educational initiative for aircraft owners. It allows an owner
(or potential owner) to enter objective engineering data for
their specific aircraft and receive an indication as to how likely
it is that their aircraft could be susceptible to ageing issues.
The data includes factors such as how long ago certain
components or systems have been overhauled or replaced,
how the aircraft is operated, how and where the aircraft is
stored, and so on. The cumulative impact of all these variables
is displayed on a colour-coded continuum (from red to green)
indicating how likely the individual aircraft is to need additional
attention because of ageing issues.
The prototype matrix tool can only ever be general in nature
and therefore is intended purely as an educational feedback
tool for owners and industry generally. And of course, there
is no substitute for a licensed aircraft maintenance engineer
(LAME) physically inspecting an aircraft to determine its
exact ageing status. Educating owners as to why they should
t e
consider having a LAME inspect their aircraft, and the
urgency for such an inspection, are the themes of CASA’s
‘Take a Closer Look’ campaign.
You will find the discussion paper, including links to the
e-learning for registered operators and prototype matrix tool,
on the CASA web site. We invite all interested parties to
respond to the discussion paper and help formulate CASA’s
future policy for the safe management of Australia’s ageing
aircraft fleet.
Further information
To trial the prototype matrix tool or view the discussion paper,
go to www.casa.gov.au/ageingaircraft
Flight Safety Australia
Issue 88 September–October 2012
Pull-out section
continued from page 39
Boeing 767 series aeroplanes
2012-11-11 Door emergency escape system
Bombardier (Boeing Canada/De Havilland)
DHC-8 series aeroplanes
CF-2010-28R1 Elevator power control unit −
shaft (tailstock) swaged bearing wear
Piston engines
Boeing 767 series aeroplanes
2012-12-14 Lower main sill inner chord of
the hatch opening of the over-wing emergency
exit − inspection
Bombardier (Boeing Canada/De Havilland)
DHC-8 series aeroplanes
CF-2012-21 Main landing gear up-lock wear
British Aerospace BAe 146 series aeroplanes
AD/BAe 146/125 Centre fuselage top aft longeron
at rib ‘0’ − cancelled
2012-0106 Fuselage − inspection of longeron
at rib ‘0’ − inspection/repair
Wheels and tyres
2012-05-01 Goodyear tyres − inspection/
Fokker F50 (F27 Mk 50) series aeroplanes
2012-0109 Time limits/maintenance checks −
maintenance requirements − implementation
15 – 28 June 2012
Piston engines
Rotax piston engines
2012-0097R1 Engine fuel and control −
fuel pump pressure side hose − replacement
Bell Helicopter Textron 412 series helicopters
2012-11-13 Aft crosstube − life limit
Enstrom F-28 series helicopters
2012-11-05 Cyclic trim system relay failure
Eurocopter AS 332 (Super Puma)
series helicopters
2012-0111 Door − cabin sliding and plugging
doors − limitation/modification/inspection
Eurocopter EC 225 series helicopters
2012-0107 Main rotor drive − main gear box
bevel gear vertical shaft − inspection/limitation
2012-0111 Door − cabin sliding and plugging
doors − limitation/modification/inspection
Eurocopter SA 360 and SA 365 (Dauphin)
series helicopters
2012-0108-E Fuselage − frame No. 9 −
Below 5700kg
TECNAM P92, P96, and P2002
series aeroplanes
2012-0113 Landing gear − main landing gear
(MLG) locknuts − replacement
Above 5700kg
Airbus Industrie A319, A320 and A321
series aeroplanes
2012-0100R1 Nacelles/pylons − aft pylon
moveable fairing rib − repair
Airbus Industrie A330 series aeroplanes
2010-0109R1 Flight controls − flight control
primary computer (FCPC) − dispatch restriction
and operational test
Airbus Industrie A380 series aeroplanes
2012-0105 Equipment/furnishings − galley
seat rail fitting – replacement
Boeing 717 series aeroplanes
2012-12-09 Centre section ribs − horizontal
stabiliser − inspection
Boeing 737 series aeroplanes
AD/B737/250 Amendment 3 − forward entry door
forward and aft side intercostals − cancelled
AD/B737/343 Cracks in fuselage skin − cancelled
2012-12-04 Cracking − fuselage skin at the chemmill steps − inspection
2012-12-05 Fatigue cracking - intercostals on
the fore and aft sides of the forward entry door
cutout - inspection
Boeing 777 series aeroplanes
2012-12-08 Fuse pin − MLG retract actuator −
2012-12-19 Ceiling support structure − installation
Thielert piston engines
2012-0112 Engine oil − gearbox oil filling
plug − inspection
Turbine engines
Turbomeca turbine engines − Arriel series
2009-0236R1 Engine − gas generator 2nd-stage
turbine − inspection/replacement
29 June – 12 July 2012
Bell Helicopter Textron Canada (BHTC) 206
and Agusta Bell 206 series helicopters
CF-1995-17R2 Crosstube assemblies − inspection
Eurocopter AS 332 (Super Puma)
series helicopters
2009-0271R1 Equipment and furnishings −
hydraulic hoist cable − limitation/modification
2012-0115-E Main rotor drive − main gearbox
bevel gear vertical shaft − inspection/limitation
Eurocopter AS 350 (Ecureuil) series helicopters
2011-0116 Fuselage − tail boom/ fenestron junction
frame − inspection
Eurocopter EC 225 series helicopters
2012-0115-E Main rotor drive – main gearbox
bevel gear vertical shaft − inspection/limitation
Eurocopter SA 360 and SA 365 (Dauphin)
series helicopters
AD/DAUPHIN/95 Main gearbox casing −
corrosion − cancelled
2011-0127 Main rotor drive − main gearbox
casing − inspection/repair
2TCD-7745-1-2011 Instrument control panel
BARO adjustment knobs
Schweizer (Hughes) 269 series helicopters
2011-12-16 Tailboom after cluster fitting strut locknut
Below 5700kg
Aerospatiale (Socata) TBM 700
series aeroplanes
2011-0130 Navigation − standby compass
lighting − modification
Fairchild (Swearingen) SA226 and SA227
series aeroplanes
AD/SWSA226/38 Amendment 1 − elevator return
spring location − modification – cancelled
Above 5700kg
Airbus Industrie A319, A320 and A321
series aeroplanes
AD/A320/71 Slide/slide raft release
cable − cancelled
AD/A320/105 Amendment 1 − emergency
escape slide frangible link − cancelled
AD/A320/182 Magnetic fuel level indicator −
AD/A320/189 Forward passenger doors −
escape slide raft − cancelled
AD/A320/208 MLG door keel beam hinge and
actuator fitting − cancelled
AD/A320/220 Emergency escape slide −
cancelled AD/A320/221 Escape slide doors numbers
2 and 3 R and LHS − cancelled
2012-0100R2 Nacelles/pylons − aft pylon moveable
fairing rib 5 − inspection/repair
2012-0118 Fuselage − centre fuselage/main
landing gear (MLG) door keel beam hinge and
actuator fittings − inspection
2012-0119 Fuel system − magnetic fuel level
indicators − inspection/replacement/repair
2012-0122-CN Cancelled: equipment/furnishings
− escape slides and rafts − inspection/
Airbus Industrie A380 series aeroplanes
2012-0114 Wings − wing rib foot − inspection/
Boeing 737 series aeroplanes
2011-12-13 (Correction) − testing of the stabiliser
take-off warning switches
2012-13-07 Outboard trailing edge flap
carriage spindles
Boeing 747 series aeroplanes
ad/b747/15 Amendment 2 − trailing edge
flap track fuse bolt − inspection and replacement
2012-13-08 Tension tie channels − STA 740
and STA 760 − inspection
Bombardier (Canadair) CL-600 (Challenger)
series aeroplanes
CF-2011-18 Integrated drive generator wire
chafing in aft equipment bay
British Aerospace BAe 146 series aeroplanes
AD/BAe 146/135 Wing-to-fuselage and main landing
gear door fairing panel grommets − cancelled
2012-0125 Fuselage − wing-to-fuselage and main
landing gear (MLG) door fairing panel grommets −
2012-0126 Fire protection − engine and auxiliary
power unit automatic fire extinguishers −
Fokker F50 (F27 Mk 50) series aeroplanes
AD/F50/97 Fuel tank safety − fuel airworthiness
limitations – cancelled
Piston engines
Thielert piston engines
2012-0116 Engine fuel and control −
full-authority digital engine control (FADEC)
software – modification
Turbine engines
Allison turbine engines − 250 series
2012-14-06 Turbine blades 3rd and 4th
stages − inspection
CFM International turbine engines −
CFM56 series
2012-0123 Engine fuel and control - hydromechanical units - operational limitation
Turbomeca turbine engines− Arriel series
2011-0128-E Engine fuel and control −
hydro-mechanical metering unit (HMU) −
2012-0117 Engine − gas generator rotating
assembly and rear bearing − check/replacement
2012-0124 Engine − module M03
(gas generator) − turbine blade − modification
Flight Safety Australia
Issue 88 September–October 2012
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Aviation communication
Trapped in the sky
Data Point 6
Flight Safety Australia
Issue 88 September–October 2012
Macarthur Job looks at a tragic aviation
case where words failed
Six little words could have saved everyone on board.
Pan-Pan, Pan-Pan, Pan-Pan. Had the crew of Avianca
flight 52 uttered these, the international code for an
urgent but not yet life-threatening situation, when they
realised they were critically low on fuel, all the mistakes
in flight planning and misunderstandings in air traffic
control that had conspired to trap them in the sky would
still have been serious – but not fatal.
The weather over the north-eastern
United States was anything but
favourable on the afternoon a
Boeing 707 was flying from Bogota,
Colombia, to New York and it was
held three times for extended
periods. Communication on the flight
deck and with ATC was ineffective,
and during the second attempted ILS
approach, all four engines flamed
out for lack of fuel.
Flight path
Data Point 5
DP 1
Data Point 4
DP 3
DP 2
The flight
The Colombian Boeing 707-321B was
operating Avianca Flight 052 from Bogota
to John F. Kennedy Airport, on
25 January 1990. Taking off from Bogota
at 1.10pm local time, the aircraft landed
at Medellin just after 2pm and was
refuelled. Departing again at 3.08pm,
its flight was over the Bahamas towards
the east coast of the USA. Routed via
Norfolk, Virginia, New Jersey, and on to
JFK, it cruised at flight level 370.
Just after 7pm, ATC required it to hold
over Norfolk because of weather and
conflicting traffic. This continued for
19 minutes. Again, at 7.43pm, nearing
Atlantic City, the aircraft was held for a
continued on page 58
Yesterday’s papers
Yesterday’s papers
Name withheld by request
An embarrassing incursion
into controlled airspace
taught a normally thorough
private pilot the importance
of having the latest charts
and listening to his instincts
When something doesn’t feel right,
do you ignore it and press on, or do
you use all the resources at your
fingertips? In this case, this pilot
thought he was doing all the right
things, but he was on the wrong
frequency and alarm bells were
ringing. When things don’t feel right
what other resources are available?
The trip
I planned a VFR trip from Bankstown
to Mangalore with my wife, daughter
and her fiancé, intending to stop
over for a few days and then fly
across to Merimbula, then back up
the coast. I am usually meticulous in
my flight planning and I spent some
hours at home using the charts I
had (VTC, ERC Low, ERSA etc.),
as well as entering coordinates into
my handheld GPS. I was fully aware
that some of my charts were out of
date and made a mental note to buy
some new ones at Bankstown before
the flight. We all know that changes
do occur on charts, but the ones I
was using were not too far out of
date, and things don’t really change
that much—or do they? I therefore
planned on my ‘lapsed’ charts and
folded them for future use.
On the day of departure I checked
the weather and quickly scanned
the area notams. at Bankstown I
ducked into the pilot shop, purchased
an ERSA and the latest Canberra/
Albury VTC and threw them into my
flight bag. In the aircraft, I pulled out
the folded charts I had planned with
and left the latest charts in the flight
bag, which was placed deep in the
baggage compartment. Probably my
subconscious telling me I had the
correct charts on board (good), but
when nothing much changes anyway,
it’s OK to use the old charts I had
initially planned on.
I intended to fly though Canberra
and Albury airspace. The clearance
through Canberra was fine, but on
the outskirts of Albury I called Albury
tower on the 124.2 frequency listed
on my ‘old’ charts. I got no reply
and after a few more calls I changed
radios, just in case one radio was not
transmitting. I also checked the NDB,
but the ATIS was not on the NDB.
There was no tower response on
124.2. I then assumed that perhaps
no one was in the tower (it was late
in the afternoon and only a couple of
days into the new year) and perhaps
it had reverted to an after-hours CTAF.
I therefore made the appropriate CTAF
calls and traversed the edge of Albury
airspace, keeping a good lookout.
No problems!
After a few days in Mangalore, the
weather deteriorated badly over the
coast so we decided to go back to
Bankstown direct. All the charts
were in the plane and with my family
impatiently waiting to get going, I
quickly did some reciprocal planning
on the charts I had come down on.
Obviously, in my mind they were still
good enough.
Flight Safety Australia
Issue 88 September–October 2012
On approaching Albury airspace
I started making calls out from a
reporting point. Again, no response
from the tower. This time the alarm
bells were jangling. It just did not
feel right that I could not get a
response. After a quick check of
my ‘lapsed’ charts and ERSA, calls
on both radios (just in case) and
because I had been here before, I
thought that maybe the tower was
inoperative for some reason and
I had missed it when reading the
notams. Nonetheless, I felt uneasy
and decided to skirt most of Albury
airspace, but still cross the edge.
I made the appropriate CTAF calls,
listening out on the Albury and
Melbourne Centre frequencies,
watching out of the window and
keeping an eye on the aircraft TCAS.
About 25 miles to the north east of
Albury I got a call from Melbourne
Centre asking me to call Albury
Tower on 123.25. Oops—that’s why
I could not contact them on 124.2.
Albury Tower were obviously
concerned that there had been
an incursion and advised me that
there had been a frequency change.
However, the tower did say they were
still monitoring the old frequency, but
I can only say that considering the
number of calls I made, the radio was
either turned down or there was a
problem with it.
Nonetheless, I was on the wrong
frequency in controlled airspace. I
had the right charts in the plane (in
the baggage compartment, not on
my lap) and I had other resources
available to check—but I did not use
them. I felt like an idiot. How could
this have happened to me, as I am
normally so meticulous in how I plan
and operate? Where was my mind?
Subsequent action
On my return to Bankstown, I tracked
down the tower controller in Albury
and we had a good discussion.
He was very professional and
relaxed and we both put it down as
one of those things you don’t need
to do twice. He seemed appreciative
that I was concerned enough to
talk directly to him after the event,
but I had made a major error
that could have had disastrous
consequences so an incident report
had to be submitted.
On reflection, when things started
not to feel right, did I utilise the
resources I had at my fingertips? NO.
In fact, this makes me even more
disappointed with myself. I had a
fully functioning GPS in the plane
with the latest card updates. I also
had a handheld GPS. I did not even
think about asking one of the rear
passengers to delve into the baggage
compartment for the latest charts.
One call to Melbourne Centre would
have given me the right frequency.
Why didn’t I check the ATIS on the
VOR? I must have been in dreamland
on that trip.
Things learnt from
this incident
1. Never plan a trip on old charts
lying around at home.
2. Never fly anywhere without
all the current charts and
current ERSA.
3. Have them at your fingertips
for ease of use.
4. If you see something that
appears not to be right, ask
for assistance. ATC is there
to assist and one quick call
could have solved the matter
5. If in doubt, do not assume.
If you can’t raise local ATC
– don’t go there. Spend 10
minutes flying around the
airspace. Making wrong
assumptions can be deadly.
6. Check the ATIS – regardless
of where it is on the frequency
7. Know your plane and your
equipment. While many of us
are unlikely to know all the
knobs and dials on our GPS,
make it your goal to be familiar
with the main functions that
can assist you. That GPS is
loaded with a huge amount
of supporting information, so
get into the habit of knowing
how to access it quickly for
everyday use.
8. Never assume that nothing
changes. That’s the very
time when things suddenly
do change.
Power line! Much too close for comfort
Power line! Much too
close for comfort
by Ross Knudsen
All too often we read or hear accounts of helicopters experiencing near-misses or collisions with
power lines. If the crew survives to tell their tale, their explanations of these events are many
and varied. We all know there are numerous factors including weather, mechanical problems,
pilot/crew error, fatigue etc. However, I always thought my training and vigilance in this high-risk
environment would never let a near-miss or collision occur on any of my flights
I had been deployed with my pilot to assist with firebombing
duties as an air attack supervisor (AAS) on an active
fire in the Gypsy Creek area of the Bunyip State Forest
east of Melbourne. I was an accredited AAS with ten
years experience in both rotary and fixed-wing aircraft.
Our working platform at this fire was a Bell 206 Long
Ranger. Training included briefs on hazards and power
lines and safety was always a priority—for good reason.
The helicopter was mechanically sound, the pilot and I
were fit, healthy and hydrated and the weather conditions
on the day were hot and sunny, with a moderate wind
and good visibility.
The early autumn weather continued to be dry and the
regular weather changes resulted in little if no rain. The fresh
northerly wind that drove the fire for most of the day abated
to calm conditions by early evening. The smoke from the
fire settled into the valleys of the ranges and fire behaviour
became quite sedate. Firebombing operations ceased by
last light and we were instructed to land at Noojee and rest
there for the night before continuing operations the following
day. Not only had the day included firebombing, but also the
plotting of the fire perimeter and reconnaissance required by
the Incident Control Centre (ICC).
The following morning our first task involved intelligence
gathering about the fire’s behaviour and condition, mapping
the new fire perimeter and reporting that information back
to the ICC. Overnight, the fire had spotted over a bulldozed
firebreak along a ridge and was burning slowly downslope
into steep inaccessible terrain on the southern flank of the
fire. We concentrated our efforts in this area as it was the
only active fire perimeter. We used Helitack (a helicopterdelivered fire resources for initial attack on a wildfire) to
assist in suppressing the active fire edge. This technique is
often very concentrated and intense.
Private property bordered the state forest directly below
this ridge and consisted of open, undulating terrain, with
small vegetated areas. Cattle grazed on the grassland and
a farmhouse was located up on a ridge close to the fire
perimeter. During our operations, we had flown over and
close to this house on numerous occasions.
Running east–west and downhill of the house was a singlestrand power line. Being silver in colour, it was quite easy to
see. The supporting timber poles were also clearly visible,
as they stood alone on the open ridges. Another span ran
from one pole up the ridge to the house. The pilot and I
recognised the existence of the poles and power lines and
maintained a safe distance at all times.
Pull-up! I could not believe how
close the rotors came to the
power line and possible wirestrike
Flight Safety Australia
Issue 88 September–October 2012
Late in the morning on the second day of operations, I had
a call of nature. I asked the pilot to find a suitable spot to
land so I could get out and relieve myself. An obvious level
location to land the helicopter was on the creek flats a few
hundred metres downhill from the house. Visibility was good
and there was no turbulence in the lee of the range. We
descended following the ridge, passed over the silver power
line to the flats and came to a hover about 10 metres above
the ground. The pilot then taxied to the left and towards
rising terrain between two ridges at 10 knots ground speed.
The silver power line was clearly visible up and away
from us.
The pilot and I saw the power line at the same time and a
shiver pulsed through my body. Where did that come from?
The power line was now under the rotor disk and just above
the cabin. Pull-up! I could not believe how close the rotors
came to the power line and possible wirestrike. Only the skill
of the pilot averted disaster by pulling up and manoeuvring
away from danger. ‘That was much too close’. Apart from
the pilot’s skill, the only other thing that saved us was the
slow forward speed of the helicopter.
The pilot quickly found a suitable spot to land and I jumped
out. We looked at each other, realising just how close to
calamity we had come.
The power line we almost collided with was not the one we
had identified earlier. This was a separate span, blackinsulated, quite narrow and running parallel to the silver
strand, but further down the hill. It was almost invisible
and had sadly slipped through our ‘vigilance and situational
awareness net’.
Once airborne, we followed the black power line to see
where it went. One thing that made it difficult to identify was
that its supporting poles were located in stands of trees
growing on the ridges, with the long span drooping low into
the valley it traversed. We hadn’t anticipated or expected
another power line running in close proximity and parallel to
the other one. It was a potential trap for anyone!
This was a really close call and a disturbing incident that
could have resulted in severe consequences. It highlights
the importance of vigilance and the need for constant visual
alertness when operating at low levels in unfamiliar terrain,
particularly in helicopters. These are basic principles of
operating safely!
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.
Think first, fly later
Think first, fly later
Name and address withheld
I was in Western Australia for navigation training to complete my private pilot’s licence. The flight
school was in a small-town airport and I was due to conduct my third solo navigation flight, which
would take me near controlled airspace around Jandakot.
The trip there was fine. The weather was actually clear and as I came in over the boatyard I could see
the city in the distance. I made my inbound call and was cleared to the airport, to join the circuit to
runway 24R. OK, I had the ATIS, VTC, my CASA Visual Flight Guide, my ERSA notes and clearance.
I maintained 1500ft and headed towards downwind. There was a bit of wind and a few bumps, but
nothing out of the ordinary.
I was looking forward to approaching downwind and abeam the runway threshold, as I could go
through my checks, relax and concentrate on the approach. I must have just passed the Kwinana
Freeway when I heard the tower call ‘VH-XXX, EXPEDITE DESCENT!’ That was me!
I looked to my right, and the Twin Comanche I had seen a few seconds ago passing the runway
threshold on take-off was now about 100ft below me, heading towards me and climbing really fast.
We were so close that I could see the look of horror on both pilots’ faces in the twin. As I shoved
the yoke forward I felt the negative Gs lift me out of the seat. I saw and heard the twin go behind and
above me. I’m not going to say how near it was, but it was closer than anyone with a healthy respect
for mid-air collision avoidance would ever want.
The first thing I did was question what I had done wrong. Why were we so close to each other?
‘VH-XXX expediting.’ It sounded more like a question than a reply.
I started the downwind checks, gathered myself a little, and set up for the approach. I was turning
base when I had my checks finished and clearance to land.
I made the landing without any more hiccups, just with an overwhelming feeling of wanting the
flight over. I pulled in to get fuelled up again. The whole time I was thinking about what had
happened on the trip in. All sorts of things went through my head. I started telling myself I had
begun descending too late, or hadn’t been paying close enough attention. I decided that the sooner
I got out of there and completed my trip the better. Wrong.
I fuelled up, had a quick look at the charts and flight plan and made my way out to taxi. I checked
the Armadale outbound procedure again. Looking back on it, I didn’t feel comfortable with exactly
what I had to do, but thought if I got up there and took it one step at a time I should be OK. Just had
to remember what my instructor had drilled into me.
I was cleared to runway 24L for my southern departure. I did my checks, took off and grabbed the
Visual Pilot Guide for Jandakot to get my bearings. It put me on the downwind leg, departing, and
with the nose pointed at the prison I lost sight of it quickly. Darn. OK, I can learn from that. I was
on top of the train lines and made a turn to my right for track to Armadale.
We were so close that I could see the look
of horror on both pilots’ faces in the twin.
Flight Safety Australia
Issue 88 September–October 2012
I was now ready to make it over the hills and had just one more decision to make. I could see the
television antennas on the top of the hills and remembered my instructor’s voice telling me, ‘Just keep
the antennas on your right.’ Hang on, or had she said, ‘just keep to the right of the antennas’?
She had said it so many times! Why couldn’t I remember?! I realised I had been so busy mulling
over the inbound flight, and what had gone wrong, that I had done the worst thing possible. I had not
planned properly for the next leg. I had absolutely no idea which side of the antennas I should be on!
Fifty/fifty is a reasonable gamble, but I realised, all too late, that gambling was what I was doing.
It was too late to change direction as the towers were coming closer every second. I decided to bite
the bullet and track to keep the antennas on my right. I tuned into Perth Radar. Perhaps I could just
keep out of Perth Class C airspace. It started out OK. A Qantas plane was cleared to 6000ft. Good,
good. ‘Aircraft north of Jandakot, identify.’ My heart sank. I pressed the transmit button and meekly
stated my call sign and position. After identifying I was confirmed as the culprit and told exactly where
I was—in controlled airspace. As I put my finger on the VTC it all made perfect sense.
Air traffic control squawked and vectored me without any further incident and truth be told, they were
incredibly considerate considering the position I had put myself, and potentially others, into.
I think that my troubles started by not fully assessing my near-miss after landing. I should have
called someone and gone through what had occurred before I took off on the next leg of my flight.
I hadn’t resolved the mystery of what had happened, so I lost confidence in my own abilities and
took that insecurity up on the next leg with me. There could have been much more serious
consequences. I decided to use this as a case study on myself, to learn more about what my
development areas needed to be and to work on them. I learnt a lot, and am now going through
my commercial licence training.
In hindsight, my approach was by the book, and it was the pilots of the twin who were in the wrong.
I don’t know what happened to them, but hopefully they learnt from it too. There is no excuse though,
for not being 100 per cent sure of what and where you are going to be flying on your next leg.
There is no excuse though, for not being
100 per cent sure of what and where you
are going to be flying on your next leg.
Our plan for the
We recently released our annual plan that
highlights the ATSB’s goals, targets and
deliverables for 2012–13. The plan is important
because it spells out what we’ll do to make
transport safer in Australia.
A significant part of the plan focuses on
our safety awareness priorities for the
aviation industry. These priorities reflect the
broad safety concerns that come out of our
investigation findings and from the occurrence
data reported to us by industry.
You’ll hear more about our safety priorities
over the coming months. But it’s worth briefly
sharing with you what the ATSB sees as the
main risk areas that need heightened attention
from the Australian aviation community. They
• Avoidable accidents—GA pilots continue
to die in accidents that are mostly
avoidable. These accidents involve lowlevel flying, wirestrikes, flying visually into
bad weather, mismanagement of partial
power loss, and poor fuel management.
• Handling of approach to land—A
worrying number of pilots are not
adequately handling uncommon
manoeuvres during their approach to land.
• Data input errors—Human error involving
incorrect data entry continues to cause
concern. In some cases, operators’ flight
management procedures are not catching
these errors.
• Safety in the vicinity of non-towered
aerodromes—Non-towered aerodromes
continue to pose a risk to aircraft due
to poor communication between
pilots, ineffective use of see-and-avoid
techniques and a failure to follow CTAF
and other procedures.
24 Hours
1800 020 616
We’ll be regularly talking with industry about
these concerns. We’ll also dedicate a page
on the ATSB website to give our safety
awareness priorities greater visibility.
Martin Dolan
Chief Commissioner
Somatogravic illusion
warning for pilots
In the wake of a fatal accident at Bathurst Island
Aerodrome, the ATSB is alerting pilots to the
somatogravic illusion – a powerful physiological illusion
which can have dire consequences.
On 5 February 2011, the pilot of a Cessna 310R, was
returning to Darwin from Bathurst Island. The pilot
departed Bathurst Island Aerodrome at around 2140
CST and collided with terrain approximately one
kilometre from the end of the runway. The pilot, the
sole occupant of the aircraft, died in the accident and
the aircraft was destroyed.
The ATSB investigators did not find any technical
problems with the aircraft. However, the location of
the wreckage, combined with the dark conditions,
and the light load, suggested the pilot may have been
affected by a powerful human physiological illusion –
the somatogravic illusion.
The somatogravic illusion can develop under
conditions of limited visibility, as the brain is unable to
differentiate between the sensations associated with
tilt and those associated with acceleration. Lacking
outside visual references, pilots experience the
sensation that they are climbing much more steeply
than they actually are.
The illusion is generally felt at takeoff. The natural
impulse is to lower the aircraft’s nose in response to
the sensation that it is climbing too steeply. However,
this reaction increases the acceleration, compounding
the illusion. If the illusion is not recognised and
overcome, the pilot can continue to compensate for
a steep climb that does not actually exist, with the
aircraft ultimately descending into terrain.
Strategies for coping with the effect include
recognising conditions under which it may occur,
strict vigilance in the use of the attitude indicator
(artificial horizon) as the primary source of aircraft
pitch angle information, and correct instrument
scanning techniques to verify the attitude and
performance of the aircraft.
More information can be found in the ATSB Aviation
Research and Analysis Report, Dark night take-off
accidents in Australia. 
Bulletin highlights safety lessons
The ATSB regularly releases a bulletin
of short investigation reports. These
reports provide useful safety messages
and lessons.
important that pilots utilise both alerted
and un-alerted see-and-avoid principles.
Below are five of the occurrences from
the most recent bulletin, issue 10.
A runway undershoot at Warnervale
Aerodrome demonstrated the
importance of establishing wind
direction and strength using all available
references, including those on the
ground, while on approach. On
25 December 2011, due to the
combination of too shallow an approach
and a sudden loss of headwind, a Cirrus
SR22 landed short of the bitumen
AO-2012-002: Runway undershoot
AO-2012-008: Loss of separation
On 8 January 2012, a Boeing B737-8FE
and Boeing B737-838 were subject
to a loss of separation assurance. The
air traffic control’s Short Term Conflict
Alert was activated and the controller
issued instructions that ensured vertical
separation was maintained. The air traffic
controller involved in the occurrence
reported feeling mentally fatigued,
following a very busy shift of continual
high and complex workload, including
multiple weather diversions and holding.
This incident highlights the need for
awareness of the effects of high
workload and sustained task complexity
on performance. Taking regular breaks
and monitoring performance is also an
important safety lesson.
AO-2011-162: Breakdown of
On 9 December 2011, a breakdown
of separation occurred between a
S.O.C.A.T.A. Groupe Aerospatiale
TBM 700 (VH-VSV) and a De Havilland
Canada DHC-8. VH-VSV penetrated
controlled airspace without a clearance,
and the two aircraft came within 1.2
nautical miles at the same altitude. One
of the key factors that led to this was a
miscommunication between the pilot
and the Bankstown air traffic controller.
This incident demonstrated various key
points that pilots need to consider when
operating at unfamiliar aerodromes.
Among them, that the use of correct
phraseology is vital. Also, it is the
responsibility of both the pilot and the
controller to ensure that any omissions
and discrepancies are clarified.
AO-2012-043: Runway incursion
At Taree Aerodrome, on 23 March
2012, as a Van’s RV-10 took off, another
aircraft, a SAAB 340B, entered the
runway. The pilot of the RV-10 decided
that since his aircraft was already
airborne, the safest option was to
continue the takeoff. He passed directly
overhead the other aircraft at about
300 ft.
The key safety message from the
subsequent investigation was that when
operating outside controlled airspace, it
is the pilot’s responsibility to maintain
separation with other aircraft, both in
the air and on the ground. For this, it is
This serious incident also highlights
the unexpected nature of wind gusts
and the need to identify an appropriate
touchdown point on the runway that
provides an adequate safety margin.
AO-2012-016: Partial power loss
On 25 January 2012, a Schweitzer
helicopter 300C suffered a partial power
loss while returning to home base after
a day’s aerial spraying activities. The
helicopter impacted the tree canopy
before coming to rest on the ground
between several large trees. The
cause of the partial power loss was
not determined, in part because the
helicopter was seriously damaged by the
fire. However, this accident highlighted
the value of pilots wearing helicopter
safety helmets. The pilot reported impact
damage to both sides of his helmet, and
remarked that the helmet had saved his
life. 
Aviation Short Investigation Bulletins are
available at: www.atsb.gov.au
Prepare to live
The ATSB’s Avoidable Accidents booklet series tells the
stories of pilots whose simple mistakes have resulted in
serious, and sometimes deadly, consequences.
Covering fuel management, low-level flying, partial power
loss, flying in poor weather and wirestrikes, each publication
can help pilots avoid these types of accidents.
Avoidable Accident Series
Order your free copies now from atsbinfo@atsb.gov.au
or phone 1800 020 616
Help keep
aviation safe
report all aviation accidents
and incidents to the ATSB
1800 011 034
Twitter @ATSBinfo
To confidentially report safety concerns
call REPCON 1800
020 505
Aviation groups collaborate to improve safety
The ATSB, CASA, and the Aerial
Agricultural Association of Australia have
worked together to address a potentially
significant hazard to turbine Dromader
The issue was identified during the
ATSB investigation into a fatal accident
west of Dirranbandi in Queensland.
On 19 July 2011, the PZL-Mielec
M18A Turbine Dromader aircraft, was
conducting spraying at a cotton station.
At 1138, the aircraft took off for its third
spraying flight of the day. At about 1400
a ground staff member could not contact
the pilot by radio. He raised the alarm.
A search was initiated and the wreckage
of the aircraft was located in a ploughed
field on the station. The pilot died in the
accident and the aircraft was destroyed
by impact forces.
ATSB investigators found that the aircraft
had departed from controlled flight
during a turn at low altitude, and the pilot
was unable to recover before impact
with the ground. The investigators could
not conclusively determine the reasons
why this had happened. However, they
did identify a significant safety issue
surrounding the potential for excessive
shifting of the aircraft’s centre of gravity
as the contents of the aircraft’s chemical/
spray tanks were dumped or dispensed.
As a result, CASA and the owner/
developer of the approval for operations
at weights of up to 6,600 kg, which had
effect during the flight, took action to
improve operator and pilot understanding
of the issue. CASA has distributed letters
to operators, cautioning them of the
potential danger. In addition, the owner/
developer indicated that the design
would be reviewed to address any
excessive centre of gravity variations.
Although the hazard was not found to
be a factor in the accident, the ATSB
emphasises the importance of pilots
maintaining their aircraft’s weight and
balance within limits throughout a
flight. They should also understand the
implications of changing weight and
balance. 
Wreckage of the Dromader in the cotton field
30 years of safer aviation
This year marks the 30th anniversary
of operationally independent aviation
safety investigations in Australia.
While a lot has changed in that time,
the fundamental model of transport
safety investigations has largely
remained the same.
On 7 June 1982, the Bureau of
Air Safety Investigation (BASI)
was created as an operationally
independent agency, marking the
start of a new era in aviation safety.
Now operating as the ATSB,
Australia’s national transport safety
investigator plays an essential
role—along with regulators and
operators—in improving the
transport safety system in Australia.
BASI was born out of the specialist
Air Safety Investigation Branch
that was part of the Department of
Civil Aviation in the 1950s. The Air
Safety Investigation Branch was
an operationally independent unit,
and helped to evolve aviation safety
‘In BASI, you can really see the
foundations of the ATSB,’ said
Richard Batt, editor of Past Present
Future, a history of the Australian
Transport Safety Bureau and its
predecessors. ‘So many important
steps were made—steps that
would inform not just how the
ATSB works today, but how aviation
investigations are conducted
worldwide.’ Among these was
BASI’s early adoption and research
into human and organisational
factors, which helped to set the
benchmark for investigations.
On 1 July 1999, BASI combined with
other national transport safety units
to form the Australian Transport
Safety Bureau.
Thirty years after the creation of
BASI, its successor has become
a world-leader in aviation, marine
and rail safety investigations,
continuing the tradition of operational
independence, objectivity, and
technical expertise.
Past Present, Future is available on
the ATSB website. 
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.
Non-standard radio
Report narrative:
The reporter expressed safety concerns
about non-standard radio communication
procedure adopted by local pilots leading
to radio congestion at an aerodrome.
The reporter states that local pilots read
back their squawk code, flight rules
and destination when requesting a taxi
clearance. However, this is not required
under the Aeronautical Information
Publication (AIP) as it has already been
read back to ACD on the ACD discrete
The reporter states that this nonstandard procedure has become
problematic due to the increased traffic
at [aerodrome] and due to the congestion
on the SMC frequency at peak periods.
The reporter suggests that Airservices
Australia ensures local operators are
aware of and follow the standard radio
procedures when requesting a taxi
Response/s received:
Airservices appreciates the opportunity
to respond to the reported concerns
regarding the radio procedures at
The following extracts from the
Aeronautical Information Publication (AlP)
and the Manual of Air Traffic Services
• the information ATC provide in an
airways clearance;
• the standard phraseology used by a
pilot requesting a taxi clearance;
• a pilot’s requirement to read back all
ATC clearances; and
• ATCs requirement to obtain a
Airways clearance delivery
As per AlP ENR 1.1, Paragraph 3.21, an
airways clearance normally contains the
following items:
a. aircraft identification;
b. destination, area of operation,
position or clearance limit;
c. route of flight;
d. assigned level, except when this
element is included in the SID
e. for IFR flights, departure type;
f. SSR code;
g. frequency requirements
h. SSR codes, data link logon codes;
i. level instructions, direction of turn,
heading and speed instructions.
Read back requirements
As per AlP GEN 3.4, paragraph 4.4, pilots
must transmit a correct read-back of ATC
clearances, instructions and information
which are transmitted by voice. For other
than Item a, only key elements of the
following clearances, instructions, or
information must be read back ensuring
sufficient detail is included to indicate
a. an ATC route clearance in its entirety,
and any amendments;
b. en route holding instructions;
c. any route and holding point specified
in a taxi clearance;
d. any clearances, conditional
clearances or instructions to hold
short of, enter, land on, line-up on,
wait, take-off from, cross, taxi or
backtrack on, any runway;
e. any approach clearance;
f. assigned runway, altimeter settings
directed to specific aircraft, radio
and radio navigation aid frequency
Note: An ‘expectation’ of the runway
to be used is not to be read back.
g. SSR codes, data link logon codes;
h. level instructions, direction of turn,
heading and speed instructions.
Likewise, the Manual of Air Traffic
Services states that Air Traffic Control
should obtain a read back containing the
above information in sufficient detail that
clearly indicates a pilot’s understanding
of and compliance with ATC clearances,
including conditional clearances,
instructions and information transmitted
by voice.
Taxi procedure
The reporter states that local pilots read
back their squawk code, flight rules
and destination when requesting a taxi
clearance. Airservices notes that this
is in accordance with AlP GEN 3.4-48
which states that the following standard
phraseology should be used by pilots
when requesting taxi clearance for
departure at a controlled aerodrome:
‘[flight number] [aircraft type], [wake
turbulence category if “Super or Heavy”]
[POB (number)] [DUAL (or SOLO)]
RECEIVED (ATIS identification) [SQUAWK
(SSR code)] [aircraft location] (flight rules,
if IFR] [TO (aerodrome of destination)]
REQUEST TAXI [intentions]’
REPCON supplied CASA with the deidentified report and a version of the
Airservces Australia’s response. The
following is a version of the response
that CASA provided:
CASA notes the response from Airservices
Australia that the read back requirements
are in accordance with instructions
contained in the Aeronautical Information
Publication. 
How can I report to REPCON?
Aviation communication
continued from page 45
second time for 29 minutes. Northbound
again, it was cleared to lower altitudes,
and at 14,000 feet, it joined a
holding pattern at the CAMRN airway
intersection, 39 nautical miles south of
JFK at 8.18pm. Again it was held for 29
minutes, during which it was descended
to 11,000 feet. At 8.44pm, New York
Control asked, ‘How long can you hold –
and what is your alternate?’
This transmission was
evidently unclear, and the
controller asked, ‘Say again
your alternate? The first
officer answered, ‘It was
Boston but we can’t do it now
... we run out of fuel.’
First officer: ’We’ll be able to hold about
five minutes – that’s all we can do.’
The controller’s assistant immediately
telephoned New York Approach Control
to say, ‘Avianca 052 can only do five
more minutes in the hold – think you’ll
be able to take him?’ Approach Control
responded, ‘Slow him to 180 knots and
I’ll take him.’
(The 27-year-old first officer was
making all the radio transmissions.
Using a headset, he was receiving ATC’s
instructions in English, but repeating
them in Spanish for the captain and
flight engineer).
Again the controller asked, ‘What is your
alternate?’ and the first officer responded,
‘Ah, we said Boston, but ah – it is full of
traffic, I think.’
New York Control then relayed, ‘Avianca
052, cleared to Kennedy Airport via
heading 040, maintain 11,000 [feet],
speed 180.’
The first officer contacted New York
Approach, and was told to expect an ILS
for 22 Left. The Boeing was then given
descents and heading changes to place
it in sequence with other aircraft. Seven
minutes later, the controller transmitted,
‘AVA 052 turn right, heading 220, I’m
going to have to spin you sir.’ (i.e. make
an orbit). ‘Windshear ... increase of 10
knots at 1500 feet, and then an increase
of 10 knots at 500 feet.’
At 9.11pm, the final approach controller
transmitted, ’... maintain 2000 until
established on the localiser. Cleared ILS
22 Left....contact Kennedy Tower 119.1’
The Tower told them they were ‘No 3 to
land, following a Boeing 727’.
At 9.22pm, with the aircraft about three
miles from the threshold of Runway 22L,
the first officer warned, ‘Glideslope –
1000 feet above field.’ Seconds later, he
said, ‘This is the windshear.’
Within 20 seconds, there were 11 ‘pull
up’ alerts from the ground proximity
warning system and four ‘glideslope’
deviation alerts. At 200 feet and 1.3
miles from the threshold, the captain
abandoned the approach. The first officer
advised the tower of a missed approach.
Approach control directed them to,
‘Climb and maintain 3000.’
Soon after, the approach controller said:
‘I’m going to bring you about 15 miles
north-east and then turn you back for
the approach. Is that fine with you and
your fuel?’
The first officer deferentially replied: ‘I
guess so – thank you very much.’
He told his captain: ‘El man se calento’‘the guy is angry.’ (NTSB transcript)
Five minutes later, the first officer asked:
‘Can you give us a final now ...?’
Approach said: ‘Affirmative sir – turn left,
heading 040 – climb and maintain 3000.’
For the first time in the flight the first
officer rejected a direction: ‘Ah negative
sir – we just running out of fuel!
Approach responded immediately: ‘OK
– turn left heading 360 please. You’re No
2 for the approach – I just have to give
you enough room so you make it without
having to come out again’.
But less than two minutes later the flight
engineer announced: ‘Flame out – flame
out on engine No 4 – flame out on engine
No 3.’
‘Show me the runway!’ called the
Flight Safety Australia
Issue 88 September–October 2012
The first officer told Approach: ‘We
just lost two engines – we need priority
Approach replied: ‘Turn to a heading of
250 – you’re 15 miles from the outer
marker and cleared for the ILS approach
to Runway 22 Left -- maintain 2000 until
established on the localiser.’
About a minute later, Approach spoke
again: ‘You have enough fuel to make it to
the airport?’
* * *
NE-2, 28 JUN 2012 to 26 JUL 2012
There was no fire.
NE-2, 28 JUN 2012 to 26 JUL 2012
There was no response. Avianca 052 had
already flown into a hillside in a wooded
residential area on Long Island’s northern
shore. It sheared off several trees and
demolished part of a house.
Of the 158 occupants of the aircraft,
73 were killed, including the three flight
crew and five of the six flight attendants;
81 were seriously injured, including
the surviving flight attendant and eight
infants. Only four passengers escaped
with minor injuries.
The aircraft
The aircraft struck the ground on an
up-sloping hill, breaking the fuselage into
three sections. The nose section was
badly damaged, leaving a trail of seats
and interior fittings. The wings were
severely damaged, with the port wing
fractured into three major pieces. There
was no rotational damage to any of the
four engines, indicating that they had run
down before impact, and only unusable
residual fuel was left in the tanks.
The long-range Boeing 707-321B,
previously operated by Pan American
World Airways, was manufactured in
1967. It had flown nearly 62,000 hours,
but maintenance records showed it had
been properly maintained and inspected.
The flight-planned ‘required fuel’ load
of 32,850kg included fuel to JFK,
reserve fuel, fuel to its alternate, and
holding fuel, and an additional 2750kg
had been loaded.
Aviation communication
Flight recorders
The flight data recorder was found to be
inoperable, but the cockpit voice recorder
held 40 minutes of excellent-quality
recording. Communications among the
crew were mostly in Spanish.
There were inadequacies in dispatching
the aircraft, deficiencies in the crew’s
performance, both en route and during
the attempted approach, and in ATC’s
handling of the aircraft. The analysis
therefore focused on the planning of the
flight, and both the crew’s and the air
traffic controllers’ performances.
Flight planning
The Boeing had sufficient fuel to fly
the scheduled route, conduct a missed
approach, and continue to the Boston
alternate. Yet when the flight plan was
lodged, Boston was forecast to be
below IFR minimums, and the weather
there deteriorated while the aircraft
was en route.
Weather data provided to the crew at
Medellin was about 10 hours old. This,
as well as weather data current at the
time of departure, showed the flight’s
planned alternate would be below the
landing minima by the time the Boeing
reached the New York area. There was
no record that the crew updated weather
and traffic information en route. The
investigation could not determine why
the crew and the dispatcher did not
communicate with each other. They could
have done so on the Boeing’s HF radio,
or via dispatch services in Miami.
It was found that Boston was listed as
an alternate only because it was part
of a computer-generated flight plan for
all flights to JFK, regardless of forecast
weather because, being a reasonable
distance from JFK, it was ‘conservative’
for fuel planning. This indicated
inadequate dispatching by the airline.
The Boeing’s crew should also have been
aware of the weather situation at Boston.
On beginning their descent from FL370,
the crew should have estimated the
distance and time remaining to ensure
there was sufficient fuel for their
destination, approach, diversion to
alternate, as well as the reserve fuel
required. The fuel quantity that the
captain would want as he began the
first approach should also have been
There were also deficiencies in the flight
plan. The stipulated reserve fuel did not
allow for the possibility of extensive en
route and landing delays because of
weather and traffic, and factored in only
28 minutes of reserve fuel, equating
to 10 per cent of the planned en route
flight time. If the captain had requested
a new flight plan, the crew might have
anticipated extensive delays in the JFK
area and been more attentive to their
fuel state.
Referred to as the ‘minimum approachlanding fuel,’ this should be a part of a
crew’s calculations as a flight begins its
descent. There was no indication that
the crew established such a figure.
Had the dispatch system been
functioning, the dispatcher could have
assisted with these calculations.
Most international airlines – including
Avianca – require crews and their
dispatchers to keep each other informed
of conditions that could alter the conduct
of the flight. The dispatcher shares
the responsibility for flight planning,
fuel loading, weight and balance
calculations, and weather information.
This requirement is to provide a ‘second
opinion’ in the operation of the flight.
... the captain again told the
first officer to, ‘advise him we
have an emergency’ ... ‘Did
you tell him?’ ... ‘Advise him
we don’t have fuel’ ...
Because there was no record of contacts
between the aircraft and FAA Flight
Services during the flight, it was not
possible to determine why the crew did
not use these services. Their failure was
serious because of the three holdings
the aircraft encountered before its fuel
state became critical. During the first
two holding periods, the crew expressed
no concerns to ATC and did not enquire
about the situation at JFK.
By the time the crew finally realised their
situation and requested priority, the fuel
required to reach their alternate had
already been exhausted. And by the time
the Boeing was cleared from the CAMRN
intersection to begin its approach, its fuel
state had become critical. They should
have declared an emergency then.
It was apparent that while holding at
CAMRN, the crew became concerned
about the fuel. However, at 8.54pm,
when they were given a 360-degree turn
for sequencing with other traffic, the crew
should have realised they were being
treated routinely and been prompted to
report their critical fuel level. They could
have declared an emergency, or at least
requested direct routing to final approach.
Flight Safety Australia
Issue 88 September–October 2012
The crew’s failure to notify ATC of
their fuel situation, and a breakdown in
communication between the crew and
ATC, and among the crew members
themselves, were the key factors leading
to this accident. Much of the crew’s
failure resulted from limitations in their
ability to speak English, and their failure
to use standard ATC terminology.
Shortly afterwards however, the crew
assumed ATC was aware of their
situation and was providing ‘priority’
service. However, the time involved in
being vectored for the approach should
have indicated they were receiving only
routine instrutions.
When the aircraft began its missed
approach, the captain told the first officer,
‘tell them we are in emergency’. But the
first officer first acknowledged an altitude
and heading before adding, ‘...we’re
running out of fuel’. He did not use the
word ‘emergency’ as instructed.
Crash site
17 (4,200 feet)
(2,100 feet)
72 (2,500 feet)
34 (200 feet)
When the tower controller instructed the
aircraft to contact Approach again for
vectors, he did not tell Approach that it
was running out of fuel. But when the
aircraft contacted Approach, the first
officer said again, ‘...we’re running out
of fuel sir.’
Outer marker
55 (2,300 feet)
Runway 22L
67 (3,200 feet)
(5,400 feet)
Although the tower controller did not
follow up the calls about running out of
fuel, the approach controller turned the
flight back on to a downwind leg and
asked if it could accept a base leg 15
miles north-east of JFK. The first officer
responded, ‘I guess so’.
Shortly afterwards, the captain again
told the first officer to, ‘advise him we
have an emergency’. Four seconds later,
the captain asked, ‘Did you tell him?’
The first officer replied, ‘Yes sir, I already
advised him.’ About a minute later, the
captain said, ‘Advise him we don’t have
fuel’, and 20 seconds later he asked
again, ‘Did you advise him that we don’t
have fuel?’ The first officer said again,
‘Yes sir, I already advise him ...’
This indicated a total breakdown
in the crew’s attempts to convey
the situation to ATC. The engines
began flaming out seven minutes
later, but it is obvious that the first
officer had failed to convey the
message the captain intended.
Recorded by FAA:
AVA052 = Flt. 052 radio transmission
CAMRN,R67 = Controller transmission
Recorded by CVR:
CAM1,2,3 = Flightcrew comments
APPR,TWR = Controller transmissions
RDO1,2,3 = Flightcrew radio transmissions
1–Captain, 2–First Officer, 3–Flight Engineer
GPWS = Ground Proximity Warning System
(11,000 feet)
Figure 1. AVA052 flight reconstruction based on
CVR, ATC radar data and ATC communications
0 1 2 3 4 5
Scale in nm
= Event location
= Radar return
1 in. = 5nm
Hazard ID
Part two
In plane sight –
hazard ID and SMS
Once any hazards have been identified, reported, and recorded in
the organisation’s safety management systems, risk assessment
and hazard mitigation occur. Risk assessments are performed in
accordance with the individual organisation’s safety system. Every
organisation should have a risk tolerability matrix and hazards can
be risk-assessed in accordance with this.
CASA safety systems inspector, Leanne Findlay, and ground operations inspector,
David Heilbron, believe that information collected during this process will be useful for
stakeholders throughout the organisation, whether large or small.
The following table lists some of the hazards that can be identified from the
scenarios presented in the first article in this series, published in the July–August issue
of Flight Safety Australia. The first column shows the hazards and the second column
some questions that will assist in identifying specific components of them. More questions
could be needed to ensure that the assessment complies with the requirements of your
organisation’s safety management system.
You may also note that in some cases the hazards relate to requirements that exist
in regulations which have been established to address aviation hazards common to
all operators.
Flight Safety Australia
Issue 88 September–October 2012
Questions that might assist in identifying specific components
of the hazard
Unavailable cabin baggage test
unit at check-in
How are check-in staff made familiar with the cabin baggage policy and restrictions, and
how does the company ensure they understand them?
How are check-in staff made aware of the tools available to monitor cabin baggage?
What is the process to ensure redundancy if there are no cabin baggage test units available?
Passengers attempting to take
cabin baggage on board the
aircraft that does not comply with
your company’s requirements
What information on cabin baggage is easily accessible to passengers? How accurate is
this information?
Passenger on board aircraft
trying ...
Are enough cabin baggage test units available?
How and where is information on cabin baggage policy displayed/available at check-in and
boarding areas?
How does the company try to ensure that passengers understand its cabin baggage policy?
What is the redundancy process for cabin crew to deal with oversize baggage on board?
Dangerous goods being
transported ...
Which information on dangerous goods is easily accessible to passengers?
How accurate is this information?
Do the dangerous goods examples provided make it easy for passengers and staff to
recognise what dangerous goods are?
How is information on dangerous goods legislation displayed/made available at the check-in
and boarding areas?
How does the company ensure that passengers understand what dangerous goods are?
Hazard ID
Changes to passengers seat
allocation ...
Do staff (at check-in and gates) understand your emergency exit seat allocation policy?
What are the contingencies for staff to make alternative arrangements in the event that a
passenger does not meet the criteria for being seated in an emergency exit row?
Is information on the emergency exit row seat allocation policy clear and accessible
to passengers at the time of booking and/or when using web or mobile check-in?
How does the company ensure that passengers understand the airline’s emergency
exit seat policy?
How does the company ensure that cabin crew understand the potential consequences
of not following the company’s emergency exit seat policy?
What contingency process is available to cabin crew to help them adhere to/implement
emergency exit row procedures?
Passenger transporting approved
medical equipment ...
How are staff and crew made aware of what medical equipment is accepted for transport
on the aircraft (in both checked-in and cabin baggage)?
How does your company distribute information about changes to medical equipment that
is accepted for transport on board the aircraft (in checked-in baggage and the cabin)?
What information on company policy re medical equipment accepted for transport as
check-in and cabin baggage is made available to passengers at the time of booking?
Driver distracted by radio ...
What information on driver distraction is included in your human factors program?
Do standard operating procedures (SOPs) indicate tarmac areas where drivers should
not operate a radio because of continuous aircraft traffic? Are these areas clearly marked
and identified?
Passenger wearing earphones ...
How are passengers made aware that they are entering a safety-critical area?
What procedures are in place to ensure that passengers follow safety-related instructions
from ground staff and cabin crew?
Passengers not following cabin
crew’s instructions ...
How do your SOPs ensure that passengers are made aware of the need to comply with
crew instructions?
What process is in place to ensure that all luminescent signs on board the aircraft
are operational?
Is sufficient information available to passengers advising them of their rights and
responsibilities on board the aircraft?
How does the company measure the effectiveness of all these processes and procedures?
Ground Accident Prevention (GAP)
Based on data developed by the International Air Transport
Association (IATA), it is estimated that 27,000 ramp
accidents and incidents – one per 1000 departures
– occur worldwide every year. About 243,000
people are injured each year in these accidents
and incidents – an injury rate of nine per 1000
departures. Ramp accidents cost major airlines
worldwide at least US$10 billion a year. These accidents
affect airport operations and result in injuries to personnel
and damage to aircraft, facilities and ground-support equipment.
Once reported to the safety department, this information should be fed
into the risk assessment and mitigation process and contribute to the
continuous improvement of the safety system. Guidance on hazard
identification released by the European Commercial Aviation Safety
Team (ECAST) in 2009 explains that ‘it is very difficult to declare a
hazard identification process as complete and for this reason; hazard
identification should be periodically reviewed. If there is a significant
change in operations, the organisation, or its staff, the process should
be repeated. Also, it is recommended that hazard identification be
repeated when mitigation measures have been identified in order to detect
unforeseen interactions between mitigation measures and other elements
of the system or in the light of the outcomes of internal investigations’.
Measures might need to be applied to control/mitigate the hazard,
in accordance with the airline’s safety management system. Specific
components of a hazard should be identified to find the most
appropriate mitigating factors to assist in keeping the risk as low as
reasonably practicable.
Flight Safety Australia
Issue 88 September–October 2012
The reported hazards might be useful not only to
departments such as engineering or flying operations,
but also to other departments such as commercial,
marketing or human resources.
The cabin crew and ground staff training departments could
realise that important information is not being included in
training syllabuses. For example, cabin and ground crew
might have reported that they were unable to recognise
the types of oxygen cylinders that passengers are allowed
to carry in the cabin. The training departments might then
review their curriculum and, as a result, include a more
comprehensive module on oxygen cylinders that are
acceptable as cabin baggage.
At first glance, the actions and processes of commercial and
similar departments may not appear to have an effect on safety.
However, once hazards have been reviewed, direct and indirect
links to decisions made by various stakeholders may emerge.
Sharing this information with other internal stakeholders could
allow the collected data to contribute towards improving safetyrelated processes across the organisation.
Findlay and Heilbron recognise that interdepartmental
communication and up-to-date training are integral to effective
hazard identification. Understanding why certain interfaces may
introduce hazards and potential risk is part of this awareness.
The practicalities and culture around safety reporting will
facilitate information flow to the safety department and to other
departments which may initially appear not to have a directly
safety-critical role. However, all departments and the decisions
they make ultimately affect aviation safety.
For example, the department in charge of informing passengers
of the company’s cabin baggage policy might identify that
many passengers are unaware of the company’s cabin baggage
allowances. If staff have identified a high number of hazards
relating to cabin baggage, it might be decided that one way
of mitigating these risks would be to involve the marketing
department. Marketing analysts might then identify that the
quality of information published on the company’s webpage
could be improved to better inform passengers about cabin
baggage limits and their safety implications.
The ICAO Safety Management Manual notes that it is a
common pitfall for safety management activities not to
progress beyond hazard identification and analysis or, in other
cases, to jump from hazard identification directly to mitigation
deployment, bypassing evaluation and prioritisation of the
safety risks.
In contrast, once sources of danger or harm have been
identified, and their consequences analysed, prioritised and
agreed, mitigation strategies to protect against them can
certainly be deployed. This course of action would be correct
if one were only to adhere to the notion of ‘safety as the first
priority’, and focus entirely on the prevention of undesirable
outcomes. However, under the concept of holistic safety
management, agreeing on the consequences of identified
hazards and describing them in operational terms are not
enough for the deployment of mitigation strategies. It is also
essential to evaluate the seriousness of the consequences, in
order to define priorities for the allocation of resources when
proposing mitigation strategies.
The ATSB maintains the safety information database (SIIMS)
on accidents, serious incidents and other incidents, and
publishes a weekly de-identified list of all incidents on their
website: www.atsb.gov.au/aviation/weekly-summaries.aspx
Please send your feedback on this article to fsa@casa.gov.au
Further reading
Part 1 In plane sight–hazard ID and SMS, Flight Safety
Australia issue 87 July–August 2012
CASA’s safety management systems
CASA’s ground operations http://www.casa.gov.au/groundops
ICAO Doc 9859. AN/474 Safety Management Manual
(SMM) Second edition, ICAO (2009), Montreal, Canada
ICAO Doc 9859. AN/474 Safety Management Manual
(SMM) Third edition, ICAO (2012) is due for release shortly
SMS for aviation: a practical guide. CASA resource kit,
published July 2012 www.casa.gov.au/sms.
Flying ops | Maintenance | IFR operations
1. A broadcast area is:
a) a designated area in G airspace in which broadcasts
associated with all operations are made on an
allocated frequency.
b) a designated area in G airspace in which all aerodrome
broadcasts are made on an allocated frequency.
4. At an aerodrome with a 1000m runway, an aircraft
may take off only if the preceding aircraft has reached
a point 600m ahead:
a) and both aircraft have a MTOW of less than 2000kg.
b) and it has a MTOW of less than 2000kg.
c) any area within 10nm of a non-towered aerodrome.
c) and the departing aircraft has a MTOW of less
than 5700kg.
d) any area within 10nm of a certified or registered
d) and the departing aircraft has a MTOW of less
than 2000kg.
2. The vertical upper boundary of a broadcast area is:
a) 5000ft (A050) by default.
b) 8500ft (A085) by default.
c) the base of the overlying CTA.
d) the base of overlying E airspace.
3. When an aircraft is parked for an extended period,
wooden propellers are best positioned:
a) vertically, to allow for even UV exposure.
b) vertically, so that precipitation or condensation
run off readily.
c) horizontally, to prevent the internal moisture
from accumulating at the lower end and causing
a propeller unbalance.
d) horizontally, to minimise precipitation or
condensation entering the hub area.
5. An exhaust gas temperature gauge (EGT) probe
is located:
a) as far as possible from the exhaust ports, so as
to measure the average of the gas temperatures.
b) in the combustion chamber as close as possible
to the exhaust valve.
c) close to the exhaust port, where it measures the
peak temperature of the pulses of exhaust gas.
d) close to the exhaust port, where it responds to
an average of the peak temperature of pulses of
exhaust gas.
6. On a turbo-charged piston engine the turbine inlet
temperature probe is located:
a) at the end of the exhaust riser for the coldest cylinder.
b) at the end of the exhaust riser for the hottest cylinder.
c) close to the turbine inlet, and indicates the temperature
resulting from the hottest cylinder.
d) close to the turbine inlet, and indicates the temperature
resulting from the output of all cylinders.
Flight Safety Australia
Issue 88 September–October 2012
7. In radio communications, an unmanned aerial vehicle
(UAV) uses the prefix:
a) ‘UAV’ as the first word in the call sign.
9. An aircraft with an indicated stalling speed of
41 KIAS will, during a 60 degree banked level turn,
stall at approximately
b) ‘UNMANNED’ as the first word in the call sign.
a) 58 KIAS and this will increase with altitude.
c) ‘DRONE’ followed by a three-digit call sign.
b) 58 KIAS and this will not change with altitude.
d) ‘DRONE’ as the first word in the call sign.
c) 48 KIAS and this will increase with altitude.
8. To avoid controlled airspace, VFR flights in
G and E airspace by day must plan for a navigational
tolerance of:
d) 48 KIAS and this will not change with altitude.
10.ATC will provide separation between parachutists
and non-parachuting aircraft:
a) plus or minus 2nm between the levels of
2001-5000ft AMSL.
a) in the vicinity of certified or registered aerodromes.
b) plus or minus 2nm between the levels of
2001-5000ft AGL.
c) in Class A, C and D airspace but not E and
G airspace.
c) plus or minus 1nm between the levels of
2001-5000ft AMSL.
d) in Class A, C, D and E airspace.
b) in broadcast areas.
d) plus or minus1nm between the levels of
2001-5000ft AGL
1. A three-spool jet engine has three:
a) separate combinations of compressor and turbine
coupled by epicyclic gear boxes.
3. A compass which has deviation errors on the cardinal
points of N -1 degree, E -5 degrees, S 0 degrees and
W +2 degrees, has:
b) separate combinations of compressor and turbine
rotating independently.
a) a coefficient A error of +1 degree. This can be
corrected by rotating the compass on its mounting.
c) stages of both compressor and turbine rotating on
a common shaft.
b) a coefficient A error of -1 degree. This can be
corrected by rotating the compass on its mounting.
d) stages of compressor.
c) a coefficient C error of +1 degree. This can be
corrected by adjustment of the corrector magnets.
2. Referring to a turboprop engine, the starting
electrical load is:
a) higher where the engine has a separately rotating
gas generator because the starter has to drive the
gas generator to a higher speed.
b) higher where the engine has twin spools because
the starter has to drive the propeller.
c) lower where the engine has a separately rotating
gas generator because the starter does not drive
the propeller.
d) lower where the engine has the compressor and
turbine stages coupled on a single shaft because
the starter does not drive the propeller.
d) a coefficient B error of -1 degree. This can be
corrected by adjustment of the corrector magnets.
4. On an ‘I’ section wing spar, the top spar cap is in:
a) tension during flight, but on the ground the outboard
section is in compression.
b) tension during flight and when on the ground.
c) compression during flight, but on the ground the
outboard section is in tension.
d) compression during flight and when on the ground.
5. An instrument that reacts to the pressure differential
across a calibrated restriction is:
a) an altimeter.
b) the portion of an instantaneous vertical speed
indicator (IVSI) that responds instantaneously.
c) a vertical speed indicator (VSI).
d) a manifold pressure gauge (MPG).
Flying ops | Maintenance | IFR operations
6. In an electronic amplifier, the function of a coupling
capacitor is:
9. ATA Spec. 100 Chapter 24-10-xx refers to:
a) a generator drive.
a) to couple the power supply to ground to bypass the
supply impedance at the operating frequency.
b) electrical load distribution.
b) to couple a portion of the output of an amplification
stage to the input in order to provide feedback.
d) fire protection.
c) to transfer the DC component of a signal between
stages, while blocking the AC component.
d) to transfer the AC component of a signal between
stages, while blocking the DC component.
7. In an electronic amplifier, leakage in a coupling
capacitor will have:
c) buffet and galley installation.
10.A part number standard hardware part number
of MS20823 refers to:
a) an elbow, 45-degree flared tube and pipe thread.
b) an elbow, 90-degree flared tube and pipe thread.
c) a plug, square head
d) a reducer, external thread, flared tube.
a) a significant effect on the power supply voltage.
b) no effect, in the case of a vacuum tube amplifier.
c) the potential to change the bias on the preceding stage.
d) the potential to change the bias on the following stage.
8. For its operation, an accelerometer relies on the:
a) density of a mass.
b) inertia of a mass.
c) length of a pendulum.
d) resonant frequency of a pendulum-mass combination.
You are inbound to Wagga (YSWG) from overhead Corowa
(COR) along W524 at 7000 in cloud.
You select the appropriate approach plate and place it in
the clip on the control column.
1. Which of the following is correct concerning this plate?
Your aircraft, a Cessna 402 (Category B) is equipped
with two ILS/VOR, one DME, one TSO 146 GPS and two
fixed-card ADFs.
a) Either ILS-Z or ILS-Y plate can be used.
You are current on all these nav aids for instrument
approaches. However, a defect in the maintenance release
reads ‘DME will not receive on frequencies below 112.0’.
d) ILS cannot be flown because of the DME
unserviceability. Therefore you would need to do an
NDB, VOR or RNAV approach.
You receive the AWIS, part of which reads ‘… cloud broken
500, visibility 3000…..’. Based on this AWIS you decide
to do the RWY23 ILS.
The following questions relate to this approach
(dated 28 June, 2012):
b) Only ILS-Z plate can be used.
c) Only ILS-Y plate can be used.
Approaching top of descent, all radio calls for this stage and
pre-approach checks are completed. You are still IMC.
2. What altitude can you descend to enroute in preparation
for this approach from overhead WG?
a) LSALT of 3200ft.
b) M.S.A. of 4700ft.
c) M.S.A. of 4200ft.
d) GPS. arrival M.D.A. of 1610ft (known QNH).
Flight Safety Australia
Issue 88 September–October 2012
At 5 GPS. to run WG you consider the intercept of the initial
approach track. Your present HDG is 035 M.
3. Which of the following is correct concerning
this manoeuvre?
a) It is a Sector 3 entry. An entry to the hold would
be required prior to commencing the approach.
b) It is a Sector 3 entry. The aircraft can be turned
from HDG 035 overhead WG VOR to intercept the
initial approach track.
c) Prior to the WG VOR the aircraft can be manoeuvred
to the left to intercept the initial approach track.
d) Both a) and c) are correct.
Now established outbound on a track of 080 the descent
is commenced.
4. To what height can the aircraft descend outbound?
c) Maintain 4700ft.
Approaching 8 GPS. WG outbound, your groundspeed is
140kt. You consider the turn to position on base.
5. Which of the following would be correct concerning
this manoeuvre?
NAV 1 selected to 111.1, LOC 230 set on O.B.S.
NAV 2 selected to 115.0, 245 set on O.B.S. Both NAVs
were identified prior to the beginning of the approach.
7. What would the NAV 1 and NAV 2 C.D.I.s respectively
be indicating at the ‘lead radial’?
a) NAV 1 hard scale left, NAV 2 hard scale right.
b) NAV 1 hard scale right, NAV 2 hard scale left.
c) NAV 1 hard scale right, NAV 2 centred, FROM flag.
d) NAV 1 hard scale right, NAV 2 centred, TO flag.
Turning left now to intercept the LOC at 3000, you anticipate
the glideslope intercept from 3000ft.
8. What is the name of this glideslope intercept position
and at what mileage will it occur?
a) Final approach fix, 7.6nm WG DME/GPS.
b) Final approach point, 7.1nm WG DME/GPS.
c) Final approach point, 7.2nm IWG DME/GPS.
d) Final approach point, 7.6nm WG DME/GPS.
Now established on the ILS and descending. Both NAVs are
selected to 111.1 to provide backup, when glideslope failure
flags appear on both.
9. What action will you now take?
a) Continue the approach as LOC only, utilising the DME/
GPS distance versus altitude scale to LOC M.D.A.
a) Start turn to the right onto HDG 350 at 11.5 DME
WG lead distance.
b) Execute the missed approach procedure, utilising the
still serviceable LOC for track guidance.
b) Start turn to the right onto HDG 170 at 8.5 DME
WG lead distance.
c) Execute the missed approach procedure, using the
WG VOR for track guidance.
c) Start turn to the left onto HDG 350 at 8.5 DME
WG lead distance.
d) Maintain the altitude at which the glideslope
failed, track to the MAPt, then follow the missed
approach procedure.
d) Start turn to the left onto 260 as an intercept HDG
for the LOC at 8 DME WG.
Now established on the 10nm ARC at 3000ft.
6. What is the permissible tolerance on this ARC?
a) +/- 1nm
b) +/- 2nm
c) +/- 0.5nm
d) + 2 nm, – 0nm
10.Which of the following is correct concerning the LOC
approach? Note: R408 and R415 are not active.
a) The D.A. is 1370ft (known QNH), visibility 4.4km
and MAPt is from the minima.
b) The D.A. is 1370ft (known QNH), visibility 2.4km
and MAPt is at 2.4nm WG DME/GPS.
c) The M.D.A. is 1370ft (known QNH), visibility 4.4km
and MAPt is at 2.4nm WG DME/GPS.
d) The M.D.A. is 1420ft (known QNH and PEC 50ft),
visibility 4.4km and MAPt is at 1.9nm WG DME/GPS.
Landed safely Wagga.
Dates for your diary
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CASA events
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Flight Safety Australia
Issue 88 September–October 2012
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Flying ops
1. a) GEN 3.2 para 4.6 and
ENR 1.4 para 3.3
2. a) ENR 1.4 para 3.3.1
4. a) ENR 1.1 para 41.2.1
7. b) GEN 3.4 para 4.20
8. b) ENR 1.1 para 19.12
9. b) the KIAS does not
change with altitude.
10.c) ENR 5.5 para 2.2. Traffic
information is provided
to jump pilots regarding
known traffic in E.
IFR operations
1 c)
2 b)
3 d)
4 a)
6 b)
7 d)
8 d)
9 a)
10 c)
Approach Plate ‘Y’. The DME will not receive on the ILS frequency as per defect so ILS ‘Z’ cannot be used,
nor GPS permitted in lieu on this one.
Approach plate ‘Y’. DME (on WG VOR) and GPS to provide positive fix (25 and 10nm).
Note that the GPS arrival might be feasible if AWIS was indicating ‘fair’ conditions for en route cloud break.
AIP ENR 1.5-25 PARA 3.3.4
ENR 1.5-15 PARA 2.2.1
ENR 1.5-16 PARA 2.4.1b
However, the manoeuvring prior to the aid would be the most efficient method (traffic permitting)
of commencing the approach.
Approach plate ‘Y’.
Approach plate ‘Y’. A good rule of thumb (and thus simple) is an initial 90 degree turn from your present
track to get started. Also a good lead-in distance is 1 per cent of groundspeed i.e. 140kt, thus 1.4 nm prior
to the 10nm ARC – that is 8.5 approx.
AIP ENR 1.1-38 PARA 19.6.2
CAO 40.2.1 APPENDIX 1 PARA 3.5(f)
Note that some ARCS may have only a 1nm tolerance due, for example, to airspace constraints.
Check each approach plate e.g. Perth RWY 21 ILS.
The LOC needle on NAV 1 is command sense here but hard scale since you are still 15 degrees off the
LOC. NAV 2 is centred because the lead is the 065 radial or 245 bearing to WG. The 245 selection is
suggested since when you bring up the ILS as back-up on NAV 2 it is less OBS turning to put up the
LOC of 230 in a higher workload situation.
AIP GEN 2.2-9
Definition of final approach point on a precision approach. Note carefully that 7.6 nm (ILS ’Y’) is the
WG DME/GPS reference and not mileage from threshold or 7.2nm (ILS ‘Z’ which couldn’t be used
due to DME unserviceability).
AIP ENR 1.5-35 PARA 7.2b
NAVs 1 and 2 on ILS frequency are thus a good back-up in that if one airborne unit were to fail completely
then the ILS approach can be continued or, in this case, glideslope failure on both units would indicate a
reversion to LOC only. A good rule of thumb for LOC descent is: DME or GPS distance times 3 plus elevation.
e.g. 5 x GPS x 3 + 7 (WG elevation) = 22 i.e. 2200.
Note well that this little sum will not work everywhere due to DME siting on the aerodrome – check each
location concerned.
Approach plate ‘Y’.
AIP GEN 2.2-13 Definition of non-precision approach.
AIP GEN 2.2-16 Definition of M.D.A.
AIP ENR 1.5-19 PARA 2.6.1c (MAPt fix)
AIP ENR 1.5-33 PARA 5.3.2 (QNH source) Note: PEC is only applied to a D.A. (full ILS)
Essential aviation reading
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