TThe war on error
To boldly go where
no man can ...
Should I have flown?
And ... more
EError management for pilots & LAMEs
FFocus on flight planning
coming to a city near you
‘Practical error management for pilots and LAMEs’ – a nationwide road show in June –
brought to you by CASA’s human factors’ team, and featuring:
Keynote speaker - Dr. Tony Kern
multiple award-winning aviation safety expert and the author of ﬁ ve books on aviation
professionalism, including Redeﬁning Airmanship and Flight Discipline.
The full-day seminars are practically-focused for pilots & LAMEs, and cover:
background to human error: physiology and psychology
violation and error-producing conditions & countermeasures for LAMEs & pilots
developing a personal safety management system (PSMS) to integrate seamlessly with
organisational safety management systems
ﬂight discipline & compliance: the cornerstone of professionalism
practical error management – tips & strategies for individuals.
Each seminar participant will also receive:
Blue Threat Fieldbook – tailored to Australian conditions, so that you can track your own
errors & develop personal countermeasures
A year’s free subscription to online assessment tools
ERROR MANAGEMENT ROADSHOW JUNE 2009
10 June 2009
Comfort Inn & Suites, Kessels Road
12 June 2009
123 Esplanade, Cairns
15 June 2009
Darwin Airport Inn
cnr. Henry Wrigley & Sir Norman Brearley Drives, Marrara
17 June 2009
Flight Training Adelaide
Kittyhawk Lane, Paraﬁeld
19 June 2009
22 June 2009
Runway Bar & Café
Eagle Drive, Jandakot
Dingley International Hotel
Boundary Road, Dingley
24 June 2009
Bathurst Street, Hobart
26 June 2009
Bankstown Sports Club
Greenﬁeld Parade, Bankstown
Places are limited, and on a ‘ﬁrst-in, best-dressed’ basis.
So to secure your place, please register:
E: [email protected] or P: CASA human factors via 131 757
ISSUE NO. 67, MAR-APR 2009
MANAGER, AVIATION SAFETY
EDITOR, FLIGHT SAFETY AUSTRALIA
P: 131 757 or E: [email protected]
Flight Safety Australia
GPO Box 2005 Canberra ACT 2601
P: 131 757 F: 02 6217 1950
E: [email protected]
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DESIGN & PRODUCTION
Spectrum Graphics – www.sg.com.au
‘The war on error’
Flight Safety gives an update on error management as a prelude to
CASA’s error management roadshow in June.
CHIEF EXECUTIVE OFFICER, CASA
20 ‘Focus on flight planning’
The importance of having a well thought-out plan before you get
26 ‘To boldly go where no man can’
Part 1 of a new series on developments in unmanned aerial systems.
‘Life cycle of an Australian airworthiness directive’
Roger Alder & Richard Allen track a unique Australian AD – on
‘rudder gust locks’.
39 Win a Snap-on tool kit!
Submit your corrosion defect SDR via the CASA website for a
chance to win.
43 AIP update
Amendments to the AIP as of 12 March 2009
58 AvSafety Advisors 2008
Update on the Aviation Safety Advisors’ activities last year.
Alcohol & other drugs - random testing
New video online demonstrates procedures for AOD testing
62 ‘Should I have flown?’
Dr David Fitzgerald examines the risk of fl ying with an undisclosed
64 ‘What ELT?’
The changeover to 406 MHz emergency locator transmitters.
IPMG (Independent Print Media Group)
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regulatory documents, manufacturers’
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information in Flight Safety Australia should
only be used in conjunction with current
Information contained herein is subject
to change. The views expressed in this
publication are those of the authors, and do
not necessarily represent the views of the
Civil Aviation Safety Authority.
© Copyright 2009, Civil Aviation Safety
Copyright for the ATSB and ATC supplements
rests with the ATSB and Airservices
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Registered–Print Post: 381667-00644.
COVER: Matt Hall Red Bull. Photos: ©
5 Flight Bytes –aviation safety news
ATC Notes – news from Airservices Australia
Accident reports – International
Accident reports – Australian
Airworthiness pull-out section
44 Close call
‘Grey gloom – by George’
52 ATSB supplement
66 Av Quiz
A IR M A IL
A CONTRIBUTION FROM A
READER WHO IS OBVIOUSLY
A MAN OF FEW WORDS!
‘KEVIN’ OF CANBERRA
After recently spending four hours
flying from Adelaide to Bankstown,
I found myself unable to enter the
Sydney basin due to non-VMC.
With just under one hour of fuel left
(plus fi xed reserves), I had to make
some quick decisions. I decided
to turn towards Goulburn with
Canberra (my home) as a backup. I
found Goulburn buried in cloud, so
I proceeded to Canberra. Starting
to feel a bit nervous, I dialled up CB
approach and found the most helpful
and most professional ATC service
I could have hoped for. I explained
my situation (including endurance)
and received first class service in
response. The YSCB ATIS was read
out to me when I was ready, and the
controller helped me feel comfortable.
I’d like to thank ATC for providing the
service they do - especially in times
of need. And to other pilots who get
nervous (sometimes too nervous to
ask for help) - remember that ATC will
give you whatever support they can
whenever you need it.
JUSTIN YOUNG EMAILED
ABOUT AN ERROR IN THE
JAN-FEB EDITION OF
Thank you for the recent FSA
publication (Jan-Feb 2009. I enjoy
receiving them as they are always
insightful and interesting to digest.
I want to draw your attention, though,
to an error in the ‘AvQuiz’ section
under Maintenance, question 8. If the
correct choice is (c) ‘QFE and at full
throttle on takeoff …etc’, then what
is indicated on the answer page (p71)
It says: (c) QNH is the atmospheric
pressure at the aerodrome level. It
should say QFE, which is station level
Ed: As always, thanks to the readers who
find the quiz so worthwhile, and email
their appreciation (and corrections!) –
your comments are forwarded to the
quizmaster, who values your feedback.
We’ll print the response next issue.
AS DID DON GORRIE
The Flight Safety Australia Jan - Feb
2009 FLYING OPS quiz question 6,
did not have a correct answer.
The question was ‘An ELT transmitting
only on 121.5 MHz will:’
The answer given was (b). ‘Not
be detectable by satellite after
01 February, 2009 unless it also
transmits on 406 MHz.’
The question stated that the ELT is
only transmitting on 121.5 MHz, so
including ‘unless it also transmits
on 406 MHz’ is incorrect. The ELT in
question can’t transmit on 406MHz.
The correct answer should have
been ‘Not be detectable by satellite
after 01 February, 2009.’
DAVID KEMP WAS MOVED
TO EMAIL REGARDING ONE
OF THE JAN-FEB ISSUE
‘CLOSE CALLS’ LOSING IT SAVING FACE
I have been employed in aviation
engineering for 30 years, as a LAME
on heavy transports for over 20
years, and more lately as an aviation
I always enjoy reading Flight Safety
Australia and knowing that it is always
sent to my home when published is a
real plus of being a licensed aviation
professional. I look forward to its
arrival and always put away some
quiet time to read it.
As a LAME, I find the magazine
generally entertaining and informative.
Unfortunately it is the opinion of
other engineers that the magazine is
overly focused on pilots in its content
and [why] I believe some of my peers
in aviation engineering don’t read it
or merely flick through it.
I do enjoy FSA and I normally read
the whole publication cover-tocover, even … the stories where
lots publicly or anonymously confess to
their flying ‘sins’; hopefully to share their
experiences for the benefit of others.
On page 48 there was such a pilot
confession of unprofessional behaviour
… He explained … that he had learned
a valuable lesson and he would take
those learned behaviours forward to
improve his airmanship.
He did acknowledge his failings
during the takeoff incident but at
no time did he acknowledge his
unprofessional behaviour of his
actions after the flight. I quote,
(c). QNH is the atmospheric pressure
for a particular area, representing an
average area pressure not specific
coverage representing QFE.
A IR M A IL
‘I WAS RELIEVED TO TUCK
THE AIRCRAFT AWAY
THAT AFTERNOON AND
RETURN HOME TO MY
At no time did he mention that he
considered the potential engine
damage that may have happened to
the Grumman Tiger he was flying.
As he states he ‘tucked away’ the
aircraft, suggesting to the readers
that the incident was not noted in
the technical log of the aircraft, or
even reported to the aircraft’s owner
Using takeoff power with a lean
mixture and on one magneto as he
described in his story is a recipe for
serious engine detonation, which as
most engineers and pilots know is
a highly undesirable and a common
reason for engine destruction. It was
probably due to detonation that the
engine apparently failed to deliver
The fact that he didn’t hole a piston or
do any other damage at that takeoff
(with catastrophic consequences
for him and his passenger) is a
minor miracle, but to park the
aircraft and apparently not report
the event was the biggest single act
of poor airmanship of the day, as the
consequences to other unsuspecting
aviation personnel using this aircraft
may yet prove catastrophic.
A PREVIOUS AIRMAIL
his angle of climb (reference the
Let’s say Hilton was to climb in nil
wind conditions he would have a
climb angle of approximately 12
degrees. If, however, he was climbing
on a day that was blowing 15kts, his
climb angle would be 15 degrees
in a headwind, and 10 degrees in a
tailwind. The wind has no significance
in our rate of climb, but sure does
make a difference in the amount of
ground covered whilst we get to that
Safe flying - Gordon Marshall
Just a quick note regarding a letter
in your airmail section (issue 66)
from Hilton Selvey regarding ‘Rate
of Climb vs Angle of Climb’.
Ed: keep those emails coming in – we’re
only too happy to have the ‘bouquets’,
and want to know the ‘brickbats’ so
that we can continue to improve the
If we were to use Hilton’s figures of
VX of 80kts and assuming an RV6
has a climb rate of approximately
1700fpm, we can approximate
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That was granddaughter, Anna
Holman’s wish for Nancy Bird Walton,
speaking at ‘Nancy-Bird’s’ memorial
service in January. One of the final
links to the early days of aviation in
Australia was broken with the death of
Nancy Bird Walton. Mrs Walton, who
preferred to be known as Nancy-Bird,
was taught to fly by another aviation
legend, Charles Kingsford Smith, and
was the first woman in Australia to
obtain a commercial pilot’s licence.
She pioneered an air ambulance
service in outback NSW, became
the commandant of the Women’s
Air Training Corps during World War
II and was founder and long-time
president of the Australian Women
Pilots’ Association. She was named
a national living treasure in 1997
and her place in Australian aviation
history was recognised last year
when Qantas named its first Airbus
A380 superjumbo after her. She had
been in and out of hospital in recent
months and died on 13 January of
natural causes, in the Sydney suburb
of Mosman, aged 93.
The Australian 14 January
Her flying career, along with those of
seven other women pilots is depicted
in a feature-length documentary:
Flying Sheilas, which gives an insight
into the stories of eight Australian
female military and commercial
pilots. Flying Sheilas depicts their
extraordinary flying careers, and
is a rich visual spectacle showing
where they were fortunate enough to
live and work, both in Australia and
beyond. Their stories are intertwined
through the career of Melbourne
born pilot, Susan Michaelis, who
introduces each of them and shows
how they played a part in her
career. For more information go to
ALL SAFE AS US PLANE
CRASHES INTO HUDSON
A plane carrying 148 passengers and
up to six crew crashed into New York’s
Hudson River and was sinking into
the waters after everyone was safely
rescued. Dozens of frantic passengers
clustered on the wings of the US
Airways plane seeking to stay above
the rising freezing waters as they
were evacuated from the plane onto
waiting boats. The Federal Aviation
Authority (FAA) said all the people on
board had survived and been rescued
after flight 1549 crashed shortly after
take-off from LaGuardia Airport in
New York on its way to Charlotte,
North Carolina on Thursday.
Australian Associated Press 16 January
In February, birdstrike was confirmed
as the cause of the crash, after
experts at the Smithsonian Institute
confirmed that the bird remains
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Canberra Times, 14 February
PILOT DIES IN CRASH
One of Australia’s best aerobatic pilots
died in a fiery plane crash in the NSW
Riverina. Tom Moon was killed when
the single-engine Extra 300 aircraft
crashed halfway along the runway
at Temora, about 80km from Wagga
Wagga, just after 10.30am (AEDT)
on Tuesday 20 January. Australian
Aerobatic Club president Paul Bennet
said Mr Moon, a former president
of the club, was well-liked and wellrespected. He said the tight-knit
aerobatic community was in shock at
the loss of a man considered one of
the most qualified aerobatic pilots in
the country. He was very experienced,
very skilled. ‘There’s not really very
many like him in the country.’ He
started competing in 1988 and won
the Australian National Aerobatic
Championships in 1999, 2000, 2002
Australian Associated Press 20 January
As part of our continuing improvement,
late February will see the launch of a
new-style CASA website. All current
content will be available through an
improved navigation and layout. CASA’s
website will provide the same high
AVIATION DEATHS FELL
The number of deaths in aviation
accidents fell to 502 in 2008 from
692 in 2007, even though more
accidents occurred during the year,
the International Air Transport
Association says. Some 109 accidents
were recorded in 2008, compared to
100 in 2007, with fatal ones increasing
to 23 from 20, the airline industry
association said. North Asia posted
the best record in 2008, with zero hull
losses or severe accidents (in which the
aircraft is destroyed or substantially
damaged). Europe recorded 0.42
hull losses, while North America and
Asia Pacific posted 0.58 each. Africa
reported hull losses of 2.12 in 2008,
marking a substantial improvement
from 4.09 in 2007. A quarter of
the accidents arose from ‘runway
excursions’: when airplanes exit the
runway during take-off or landing.
Thirty per cent of all accidents were
due to ‘deficient safety management’
from the airline, according to IATA.
AND A QUIRKY ‘CLOSER’ …
JUMBO RECYCLING EFFORT
January saw the opening of the
world’s first hostel built onboard a
747-200, and located at the entrance
to Stockholm Arlanda Airport.
The 72-bed Jumbo Hostel offers 25
rooms in all, most containing three beds
(called Jumbo Combo rooms), with all
rooms having a flat screen TV and access
to wireless broadband. Shared showers
and toilets are located in the corridor,
except for the Cockpit Suite, which has
its own shower and WC. The Cockpit
Suite, in which parts of the original
cockpit have been retained, provides
a panoramic view of the airport.
The hostel is the brainchild of Swedish
hostel owner Oscar Diös. The aircraft,
a decommissioned 747-200 built in
1976, was last operated by Transjet,
a Swedish airline; was originally
built for Singapore Airlines, and later
served with Pan Am.
12 January 2009
Australian Associated Press 20 February
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jet were Canada geese. The pilot,
Captain Chesley ‘Sully’ Sullenberger,
was hailed a hero for saving all the
passengers and crew on board with
his quick thinking.
As a prelude to CASA’s nationwide June road show:
‘Practical error management for pilots and LAMEs’,
Flight Safety editor, Margo Marchbank, looks at this
important human factor in aviation safety.
E RRO R
you are going
to make a
trick is not
it a fatal
From the beginning, humans have made mistakes. Icarus, that original
aviator of Greek mythology, perished in a classical CFIT, after flying too
close to the sun. He made the mistake of ignoring the standard operating
procedures set by the design engineer, his father Daedalus. And Roman
writer, Cicero, also recognised this fundamental of the human condition,
when he declared around the year 60 BCE, ‘Any man is liable to err, but
only a fool persists in error’. It’s to mitigate this persistence of error that
the CASA human factors (HF) section have invited error management
expert, Tony Kern, to speak at June’s error management road show,
which will appear at a number of cities around Australia. (See the inside
front cover of this issue for details of dates and venues.)
‘Eventually you are going to make a mistake, that’s a given. The trick is
not to make it a fatal mistake.’ Stephen Coonts The Minotaur
Most will be aware of that oft-quoted figure from the Federal Aviation
Administration (FAA) in the US, which attributes over 75 per cent of
aviation accidents to human error. John Hiles, an FAA aviation safety
inspector specialising in maintenance human factors, points out in
presentations on the topic that since aviation’s beginnings in 1903,
‘machine or mechanical causes of accidents have declined markedly,
while human causes have escalated dramatically’.
Generally, errors made by pilots are characterised differently to
those occurring in the maintenance area. Using the threat & error
management (TEM) model, CASA’s advisory publication on the new
single-pilot human factors and TEM syllabus (CAAP 5.59-1(0), classifies
errors into three types:
aircraft handling errors
procedural errors, and
EXAMPLES OF ERROR
Aircraft handling errors
Manual handling/flight controls: vertical/lateral and/
or speed deviations, incorrect flaps/speedbrakes, thrust
reverser or power settings.
Automation: incorrect altitude, speed, heading, autothrottle
settings, incorrect mode executed, or incorrect entries.
Systems/radio/instruments: incorrect packs, incorrect antiicing, incorrect altimeter, incorrect fuel switches settings,
incorrect radio frequency dialled.
Ground navigation: attempting to turn down wrong taxiway/
runway, taxi too fast, failure to hold short, missed taxiway/
SOPs: failure to cross-verify automation inputs.
Checklists: wrong challenge and response, items missed,
performed late or at the wrong time.
Callouts: omitted, incorrect callouts.
Briefings: omitted briefings, items missed.
Documentation: wrong weight & balance, fuel information,
ATIS, or clearance information recorded, misinterpreted
items on paperwork, incorrect log book entries, incorrect
application of MEL procedures.
Pilot to external: missed calls, misinterpretation of
instructions, incorrect read-back, wrong clearance taxiway,
gate or runway communicated.
Pilot to pilot: within crew miscommunication or
Source: Threat & Error Management, Captain Dan Maurino, 2005
The road show very deliberately caters for both pilots and LAMEs,
targeting low-capacity regular public transport, charter, private and
flying training organisations. As one HF trainer (Gordon Dupont,
a former aircraft maintenance engineer, and investigator for the
Canadian Aviation Safety Board) explains, ‘Human factors training is
nothing more than training a person how to avoid the error they never
intend to make’. It’s all about understanding what can predispose us to
errors, and what steps we can take to prevent an ‘error from occurring,
or prevent that error from causing an accident’.
While much of the work on developing TEM has
focused on airline operations, using the data
from line operations safety audits (LOSA) where
experienced pilot observers undertake and
document line flights, TEM principles are being
applied more broadly to other aviation sectors.
The LOSA archive, as at December 2006, included
more than 5500 TEM-based observations from
28 commercial airlines in over 14 countries
around the world. An earlier analysis of the
4532 flights then observed, revealed that
three quarters involved one or more errors;
of these, one-fifth were mismanaged so badly
that an ‘undesired aircraft state’ resulted, with
significant and detrimental consequences.
And, given the rigorous procedures usually
followed by the airlines studied, a relatively
percentage of procedural errors occurred on 20
per cent of flights, followeed closely by checklist
errors: 18 per cent of fligh
Perhaps the most tellingg statistic to come out
of that study was the fact that ‘flight crews
failed to detect 45 perr cent of all errors’,
reinforcing an importan
nt principle of error
management: ‘An error which is not detected
cannot be managed’.
It’s not rocket scien
nce: effective error
management requires deetection and response,
requiring a focus on such
h areas as:
maintaining good situational awareness
avoidance of error-producing conditions,
for example shift/roster design
standard operating procedures (SOPs)
planning & preparation
review & evaluation.
Not surprisingly, the strategies focus on
‘planning and preparation’ before the flight,
with a critical follow-up after landing: ‘review
and evaluation’ – the debrief.
FIRST AUSTALIAN RECRUIT
The latest recruit joinin
ng the fast-paced world
of the Red Bull Air Racee Championship circuit
is no stranger to thesse error management
strategies. Matthew (M
Matt) Hall became the
first Australian pilot to
o join the Red Bull Air
Race team late last yeear, after a successful
qualifying run in Spaiin. He is one of four
rookies to join the 200
09 competition, where
15 pilots will competee in a series of races
held around the world
d, beginning with Abu
Dhabi on 17 April. This year, there are new
race rules: after two qualifying rounds, the 10
fastest will secure a plaace in the race; on race
day, the five slowest willl race a wild card race
for two extra places. Th
hese ‘top 12’ will then
compete in the first of the finals on race
day: then the ‘super eight’ in the ‘semi’,
aand the ‘final four’, with the winner
earning himself 12 points.
Matt has employed these strategies
and others at the highest level in
the stressful environment of the
aerobatic pilot. He happily confesses
to being ‘anal’ in his approach
to planning and preparation, a
ccombination of his innate character,
(‘I revolve around routine and setting
higgh goals’) and the legacy of 18 years
as a fighter pilot and fighter combat
insttructor. This military experience he
feels stands him in good stead in his
nsition to the Red Bull Championship,
giving a solid grounding in discipline: ‘knowing what’s right and what’s
wrong, and doing what’s right; airmanship, procedures, knowledge
and fitness.’ While he says he’s not a ‘yes sir, no sir type of guy,’ the
military emphasis on procedures has helped in setting parameters.
His preparation for a race is highly structured, blow by blow, second
by second. ‘It’s all thought out on paper, and written down. For an
aerobatic competition, and it will be the same for the Red Bull air race,
I will sit down and pull the flight apart. For a seven or eight minute
flight, I’ll have maybe 10 pages of notes, second-by-second of exactly
what I’m doing: what energy state I’m looking for, what G I’m going
to use, when I’m going to transfer from out in front onto the wing tip,
how aggressively I am going to jolt the stop, what’s going to happen
with the control forces as I’m de-accelerating up the hill. I write it all
down … almost like a script; then I learn the script. Then I’ll start
flying it “slow time” on the ground, and then I’ll start flying it real time.
That’s the big thing I learned in the air force: preparation techniques,
mental techniques and visualisation.’
Matt joins two other ex-military pilots in the series: Mike Mangold,
two-time world champion, from the United States, an ex-fighter pilot
like Matt; and Nigel Lamb, ex-Rhodesian Air Force, flying helicopters,
who represents the United Kingdom. ‘When I talk to those two guys
there’s a distinct difference in the way we talk – everybody’s really good
pilots, but Hannes (Hannes Arch, 2008 series winner) is a bit more freespirited. He’s very focused, but his focus is, “I’m going to try and do this
and see how it goes”, whereas Mike Mangold’s will be “I am going to do
this, and I know how it’ll go”. And the ‘know’ comes from preparation.’
Being very clear on exactly what you’re going to do, an exact and detailed
flight plan, Matt says, means that extraneous factors encountered in
various race venues, such as confined spaces, buildings etc do not
become an issue. ‘I will fly that flight plan having confidence that I’m
not going to hit any of those buildings, or trees. I’m looking at the gate.
I’ll have in the back of my mind if something goes wrong, what I have to
do so I don’t screw up. Kind of like a crop duster pilot: he acknowledges
where the wires are, and then he’s confident that he’s not going to hit
them. Then he’s just got to remember, if something goes wrong, and
he gets distracted, that he’s got to bring that knowledge forward.’
And how does his very structured flight plan cope with a scenario
such as an unauthorised helicopter entering the competition space?
‘In every flight I do, I’ll just think of a couple of ‘what-ifs’, and I won’t
go into them in depth, but I’ll always be thinking “engine failure”.
Typically they will almost always have the same response: roll away,
get away from the crowd, pull the power back and slow down, and stay
within the confines of where you have been operating, until you figure
‘And after that,
results – they’re
definitely my last
if they overtake
no future in it.’
‘The main aim of Red Bull is to entertain people safely,’ he explains.
‘Safety is my first goal – I don’t want to injure myself, or other people, or
damage the aircraft. The second is professionalism – showing that people
can rely on me and my team, both for flying and administration. And
after that, there’s the results – they’re definitely my last priority, because
if they overtake safety or professionalism, there’s no future in it.’
out what the real problem is. Stay straight
above the track, even if you’re on fire, and do
what you’ve got to do.’
He was in America, flying his aerobatics
plane, when this ‘what-if’ became a reality.
The engine caught fire. ‘In fact the fuel lines
broke, with a lot of fuel going out onto the
exhaust; the whole plane was on fire, and
the engine stopped – but I just thought I had
an engine failure. It was low-level aerobatics,
so it was all over really quick – I was on the
ground probably in fifteen to twenty seconds.
I was at an inverted 45 down line, about 500
to a thousand feet, when the engine stopped.
So the reaction was a roll upright, pull back,
quick switches, nothing, then a wingover and
flare. And as I was rolling down the runway, I
realised I was on fire.’
‘I’ll be given the track, so the first thing I’ll do is to work out the entry and exit criteria for each
gate for the most efficient race lines. Then I start writing down how those angles are going to be
achieved. “Say I want a 30 degree angle for gate 2, so I’ll exit gate 1 at this, and then an estimated
two-second delay, and then an 8G turn to roll out just prior to gate 2”. I’ll start plotting it out on a
piece of paper. Then I’ll note estimated speeds; where my eyes are going to be; “I’ll get to here,
transfer gaze to gate 2 or maybe gate three for a quick look – then back to pull to the AMP building,
and when I hit the building, stop roll to it” – writing everything down – what I expect to see.
Once I’ve done that, I’ll sit down for maybe 15-20 minutes; calm myself right down, close my eyes
and visualise it. I’ll see the background, see the terrain, see the AMP building. I’ll start “G-straining”
as well, because it’s that graphic. “Here comes the gates, pull and then stop, unload, roll”. Now
with less than an hour to go, I’ll look at the actual weather conditions – I will correct my lines for
the weather, for some gates you may need to extend slightly to allow for the effects of wind, and
then go into my mental preparation routine, which is really the same as elite sportsmen. I think
positive thoughts; how to calm down or arouse myself depending on where I’m at – whether I
need to fire myself up or calm down. Within 20 minutes of take-off, I’m ready for flight - get my
flying suit on, parachute, do a pre-flight of the plane, which has already been set up, 12 mins to
take off, close canopy, eight minutes, start, do run ups. And then I’m in the plane.
I often have nerves in the plane for the last few minutes, but I ‘remove’ myself from where I am
and play silly kids games in the cockpit, and the nerves go away. There’s no more preparation you
Engine failure is a ‘what-if’ which should be
on all pilots’ radar, but managing G forces is
in the combat or aerobatic pilot’s domain.
Understanding your own tolerance to G
forces, which can vary enormously according
to physiology, fitness and training, is critical to
the aerobatic pilot’s safety. According to Matt,
the main risk from ongoing exposure to high
Gs is spinal damage. While you can mitigate
this to some extent by being physically fit,
especially focusing on core strength exercises,
Matt admits his regular scans show that his
‘L3 and L4 vertebrae are a worry’.
‘Depending on your tolerance – you grey
out, and then you black out - you lose
consciousness because you lose oxygen to the
brain,’ he explains. ‘Up to about four seconds
you can pull an amazing amount of G, but if
you go more than four seconds, the brain and
the eyeballs lose their residual oxygen.
I can pull 12G for about seven or eight seconds
using a straining technique to stay conscious,
but it’s extremely fatiguing: your heart rate is
up to about 230/240. These planes can’t pull
more than 12G for more than 5-6 seconds,
so they’re self-limiting. The 180 degree or
270 degree turns, or the half-Cuban – they’re
the threat areas for consciousness, so if I’m
starting to lose vision, the warning sign – if
I can’t clear it in half a second by using the
straining technique, I’ll come out of the track.
That’s my personal risk management.’
complex aircraft; commercial pressures; the
Matt’s new race plane is an MXS(R), one of
five now flying in the series, and one which
was originally modelled from the Giles. His
will be a second generation version, and he
is grateful that he has the backing of a good
engineer. ‘I’ve got a really good team behind
me – my mechanic has had about three years
on the circuit, and is really experienced, which
reduces a lot of the stress, so I can focus on a
fast plane, a fast track and being safe.’
associated risk of boredom, and resulting
number of personnel working on one aircraft;
communication in such a noisy, dispersed
situation; fatigue; and the difficulty of ensuring
smooth and effective shift handovers. Add to
this the fact that scheduled maintenance is
largely preventative maintenance, with the
mistakes of omission; and unscheduled
maintenance is often performed at night and
subject to intense commercial pressure, and
you have the perfect stage for errors.
maintenance error management. The agency
quotes a Boeing study on the causes of 276
THE WROK OF AN EVIL
That’s how one writer, somewhat dramatically,
but perhaps accurately, has described the
maintenance environment: as the ‘work of an
evil genius’ perfectly designed to encourage
human beings to make errors. Alan Hobbs,
writing in a recent Australian Transport
Safety Bureau (ATSB) report, argues that,
‘As automated systems become increasingly
common, humans are performing less direct
manual control of equipment and systems …
maintenance is becoming a major remaining
point of direct interaction between people
and technology.’ According to Hobbs, the
maintenance environment poses some
significant hazards, which include working
at heights; extremes of cold or heat; and
noise. Other factors with the potential to
induce errors include working in confined
spaces; working on large, increasingly
in-flight shutdowns – incorrect installation
topped the list, representing 33 per cent of
shutdowns. This was reinforced by the Civil
Aviation Authority’s ‘top 5’ errors list:
1. Incorrect installation
2. Electrical wiring
4. Forgotten tools and parts
5. Failure to lubricate.
The odds are stacked
There’s only one way to disassemble
40,000+ ways to reassemble incorrectly
FAA: Maintenance Human Factors DVD presentation
Error management, and human factors
training generally, are now recognised as
being of equal, if not greater importance, in
the maintenance sector. Maintenance is one
of the largest costs facing airlines: it has been
estimated that every hour of flight requires 12
man-hours of maintenance, so maintenance
errors can have a direct and significant effect
on flight safety.
THE DIRTY DOZEN
1. Lack of communication – in good communication, the ‘mental pictures must match’
2. Lack of teamwork – the larger the organisation, the more this can be a problem
3. Norms – short for ‘normal’, or the way things are done around an organisation
4. Pressure – aviation is time-sensitive, but many of the errors result from ‘self-pressure’
5. Complacency – overconfidence
6. Lack of knowledge – even if we use it often, we only retain about 20 per cent of what
7. Lack of awareness
8. Lack of resources
9. Distraction – about 15 per cent of aviation accidents
10. Assertiveness – failing to speak to up when things don’t seem ‘right’
11. Fatigue – we often fail to realise how much our judgement is impaired by fatigue until
it’s too late
12. Stress – our subconscious response to the demands placed on us.
Adapted from: Avoid the dirty dozen with safety nets – Gordon Dupont
The CHC Helicopters Australian business
unit, is the largest such organisation in
Australia, operating in every sphere of air
work, providing, for example, aero medical
and emergency services, transport to the
off-shore resource industry, aircraft to the
Victorian Police and SAR support for the RAAF.
They have 16 operational bases throughout
Australia and East Timor. There’s the heavy
maintenance hub and main store in Adelaide,
as well as a large store in Darwin; each base
also has on-site engineering support.
According to chief engineer, Greg Booth, and
safety auditor, Max Marton, as with many
similar operations, there are posters of the
‘dirty dozen’ on display at every one of their
bases. For CHC, the top three of the dozen,
Greg says, are ‘“pressure” – at least perceived
pressure, which varies greatly from individual
to individual; “distraction”; and compliance
with procedures, or “lack of knowledge” about
changes in document information’. A recentlycompleted audit identified this as an issue, which
Max Marton says means redoubling their efforts
on training to ‘bring everybody up-to-speed’. It’s
also one of the challenges in operating widely-
dispersed bases: ensuring communication is as
effective as possible.
CHC has a ‘robust and sophisticated safety
management system’, with a database
integrating safety and quality reporting. All the
bases are online, and the engineers are trained
to report any deficiencies, or defective product.
‘It gives everybody a voice,’ Max says, ‘a free
and open reporting culture exists within CHC.’
Maintenance manuals have been identified
as being a source of error, with difficulties
arising from translations of manuals into
English; unclear or ambiguous procedures;
and insufficient detail. CHC operates several
types of helicopter, the American (Bell) and
Sikorsky versus the types such as the Agusta
Westland and Eurocopter originating from
Europe. They maintain very close links with
the manufacturers, although Greg admits, that
even with this liaison, ‘translation at some times
can be a challenge’. All their approved data
comes through the CHC head office in Adelaide
through an integrated electronic library system
‘Alert’. This also provides detailed tracking and
distribution of all data to all of CHC’s bases.
electronically, ‘bypassing the busy desk at
a remote base’. Max argues this avoids the
danger with paper-based reports that they can
be inadvertently ignored, or disappear under
an ever-increasing pile. There is a hierarchy of
actions, with select people designated to open
up the report, evaluate it, and initiate a chain
of events, according to the type of issue.
large database of reported occurrences. We also have a weekly cross
to the parent headquarters in Vancouver, so we can compare notes.
We’re lucky too, in that we can learn from their occurrences (other
international CHC sister companies). We get the benefit of combining
experiences through the database and problems have the potential of
being identified earlier, which is good for safety,’ he concluded.
‘Say we had replaced a particular seal for the
third time,’ Max explains. ‘This would then
initiate a discussion within the database, and
the chief engineer (amongst others) would
be invited into the discussion, and determine
what sort of remedial action is required.’
‘Three times a year we review the reporting
database, with a major review conducted
annually,’ Max continued. ‘The system has
been in place for a long time,
e, so we have
CESSNA AIRCRAFT MILESTONE
April 2008 – 1400 employees in Cessna’s nine Citation
service centres in the US completed the first round of a
company-developed, human factors (HF) training program.
This program represents the first stage of one of the first inhouse HF training programs approved for Part 145 certified
repair stations by the FAA.
Aviation Maintenance magazine 1 January 2009
For more information
Tony Kern, 1997. McGraw-Hill.
James Reason, 1990. Cambridge University Press.
Threat & Error Management
Captain Dan Maurino. Coordinator flight safety and human
factors program, ICAO. Canadian Aviation Safety Seminar
(CASS) Vancouver, April 2005.
Teaching & Assessing Single Pilot Human
Factors and Threat & Error Management
Civil Aviation Safety Authority CAAP 5.591(0).
Error Management Training – Defining Best
Matthew JW Thomas, University of South Australia. ATSB
Aviation Safety Research Grant project 2004/0050
On Error Management – Lessons from Aviation
Robert L Helmreich – British Medical Journal, March 2000
(Deportment of Psychology, University of Texas, Austin)
Patrick R Veillette (Ph.D) in Aviation Week Feb 2005
Ashleigh Merritt & James Klinect. University of Texas LOSA
Collaborative, 12 December 2006.
Threat & Error Management
Defensive Flying for Pilots: An Introduction to
Threat & Error Management
Cessna’s Human Factors Training in a Class by
David Jensen. Aviation Maintenance magazine,
1 January 2009.
Introducing an Error Management Program into FAA, June 2001. Downloadable from
An Overview of Human Factors in Aviation
Alan Hobbs. ATSB Safety Report, AR-2008-055. December 2008.
Operator’s Manual – Human Factors in Aviation FAA, June 2005. Downloadable from
Maintenance Human Factors Toolkit
Presentation tool kit on DVD, produced by the FAA
(available from CASA Safety Promotion)
Human Factors: Avoid the ‘Dirty Dozen’ with
Gordon Dupont. Airbeatt magazine, Jan/Feb 2009
Human being pilot - human factors for aviation
David Robson, 2008 Aviation Theory Centre
Pilot Information Nights
increase awareness of
Airways clearance versus
hen ATC issues ‘airways clearance’, this authorises a
flight to ‘operate in controlled airspace along a designated track or route at a specified level to a specified
point or flight planned destination’ (AIP ENR 1.1-2 para 3.6).
If there is no amendment to the airways clearance in the departure
instructions (e.g. “ABC, cleared for take-off, make right turn…”), the
aircraft must comply with the set course requirements, even if the
flight is cleared ‘direct’ to a tracking point or destination as part of
the airways clearance.
ilot Information Nights,
aimed to improve pilot
awareness of Air Traff
fic Services (ATS), are proving
popular with the GA community and are promoting safety responsible behaviour with pilots.
Consisting of small group visits
to Airservices’ Air Traffic Control centres, Pilot Information
Nights are part of our Regional
Aviation Awareness Program.
The safety messages provided
to pilots are based on current
and emerging issues appearing
in safety critical data analysis,
incident reports, investigations
and from other sources.
Pilot Information Nights give
GA pilots, including student pilots and smaller operators, the
chance to experience the workings of the ATS operational environment first hand including
Air Traffic Control and AusFIC;
receive safety information on
topics like Violations of Controlled Airspace (VCA), Runway
Incursions, Flight Planning and
SARTIME management; and
participate in discussions to enhance their awareness of issues
For more information about Pilot Information Nights, or to arrange for one to be held in your
Public Affairs —Melbourne
p: 03 9235 7423
e: [email protected]
Public Affairs —Brisbane
p: 07 3866 3745
e: [email protected]
New phraseology improves runway safety
ecent safety investigation findings support the requirement for a pilot to notify ATC of the taxiway
they are on when requesting a runway crossing.
These phraseology changes will help to mitigate against the
risk of runway incursion and to improve ATC, pilot and vehicle driver situational awareness.
Changes to the Manual of Air Traffic Services (MATS), introduced last November, require a controller to “include the
point of crossing when authorising surface traffic to cross an
The same phraseology provisions will be included in AIP,
and are planned to be introduced in March. They will however, be optional for pilots.
To cross a runway the following exchange will take place between a pilot and ATC:
PILOT: “Tower, C172 request clearance to cross runway
“C172 on Taxiway N cross Runway 17.”
PILOT: “Taxiway N cross Runway 17, C172.”
ATC will always include the location in their phraseology,
regardless of whether the pilot includes it in their request.
Departing from the rules
here have been a number of recent occurrences in the non-radar
environment where Air Traffic
Control (ATC) have had to correct the tracking of a departing
aircraft because it has failed to
set course within 5NM of the
As per AIP ENR 1.1-15 para 7.3
Establishment on Track, ‘unless tracking via a Standard Instrument Departure (SID) or
otherwise instructed by ATC, a
pilot in command must remain
within 5NM of the departure
aerodrome to establish flight on
the departure track as soon as
practicable after take-off.’
ATC rely on aircraft establishing
on the correct track for the purposes of separation. It is imperative that if there are operational
requirements or other reasons
why a pilot requires to be established on track outside 5 NM
from the departure aerodrome,
approval must be given by ATC.
o meet the obligations
of our safety policy
and the regulatory requirements of CASA and ICAO,
Airservices Australia aims to
achieve a number of objectives
in relation to safety. There are
15 objectives within our Safety
Management System (SMS).
These objectives are divided into
three groups, those that help us
achieve good safety outcomes,
those that assist in assuring
good safety outcomes, and one
element requires that we promote safety.
A requirement of the safety
promotion objective is that
Airservices must provide safety
related information which will
assist our stakeholders, customers, contractors and other Air
Navigation Service Providers
(ANSPs) improve their safety
Airservices actively encourages
consultation between us, our
customers and other stakeholders with an emphasis on the
communication of safety lessons.
This is achieved through the exchange of:
t Safety Incident Reports;
t Advice on Air Traffic Services
and Company operational
procedures and practices;
t Summaries of investigations
undertaken with a particular
emphasis on lessons learnt
and recommendations made
to prevent recurrence; and
t Information that will assist
Airservices and Companies in
the conduct of investigations.
To formalise this exchange of
safety related information, the
Airservices Safety Management
group has established Letters of
Agreement (LoA) with a number
of domestic and international
airlines, General Aviation companies and organisations and
also neighbouring ANSPs.
These LoAs outline the manner
in which information will be
exchanged, include necessary
information protection requirements and detail the communications protocols between safety
experts from both organisations
that enter into the agreement.
Airservices Exchange of Safety
Information Letters of Agreement
Additionally, establishment of
the LoA provides an opportunity for companies to be involved
in a range of Airservices Safety
Management activities including participation as subject matter experts in risk management
activities and attendance at regular industry safety forums.
If you would like further information about the Airservices
exchange of safety information
LoA processes or believe your
company may wish to enter into
an agreement please contact
Glen Lang on the details below.
Northern Safety Programs Manager
p: 07 3866 3773
m: 0400 743 928
e: [email protected]
International Accidents/Incidents 07 December 2008 - 15 January 2009
The Learjet was reported as making a 2nd landing attempt, it began
rapid ascent, then nose-dived into the lake.
The Trislander gave a distress call and possibly crashed shortly after
that. It was found the pilot’s licence had been suspended since October
The BN-2A Islander flew into the side of a forested mountain. The pilot
died in the accident; one passenger is still missing.
The Boeing 737 suffered a runway incursion at taxiway WC, went down
a ravine and caught fire. The engine separated from the wing and the
undercarriage collapsed. Thirty-eight occupants were taken to hospital.
Two crew on board the Learjet 45 suffered minor injuries in a landing
accident in snowy conditions.
The Cessna 650 exited the runway at a high speed and came to rest in
the grass approximately 400ft north of runway 08R.
The Cessna was on approach and gear failed to respond. It made a
successful gear-up landing, and slid off the runway into the grass.
Basler BT 67
The Basler was on a trial approach run at 200ft AGL with low visibility.
The pilot inadvertently descended, and flew into the ground.
The Xian undershot the runway on landing. It swerved sharply to the left
when it touched the runway after the initial impact and hit a concrete
barrier, seriously damaging its nose.
The Airbus had a birdstrike with a flock of geese and lost power in both
engines. The captain decided to ditch in the river.
The Ilyushin taxied to the runway; at the same time another Ilyushin
came in to land. The wing of the landing aircraft struck the flight deck
of the stationary aeroplane, ripping away a large part of the forward
fuselage and causing a fire.
The Ilyushin came in to land when another aircraft was on the runway. The
wing struck the stationary aircraft. None of the 31 occupants was hurt.
Notes: compiled from information supplied by the Aviation Safety Network (see www. aviation-safety.net/database/) and reproduced with permission. While every effort is made to ensure accuracy,
neither the Aviation Safety Network nor Flight Safety Australia make any representations about its accuracy, as information is based on preliminary reports only. For further information refer to final reports
of the relevant official aircraft accident investigation organisation. Information on injuries is unavailable.
Australian Accidents/Incidents 01 December 2008 - 29 January 2009
Ind. SV 4 C
Burra (VFR), 030°
M 31Km, SA
W M 37Km, NSW
During the take-off run, the pilot lost directional control of the aircraft and
ran off the runway. The aircraft collided with a ditch.
Torquay (ALA), VIC Nil
During short final approach to runway 27, the pilot could not control the
descent and the aircraft sustained a hard landing. The left main landing gear
strut buckled and collapsed during the landing roll. The aircraft veered off
the runway to the left. After brakes were applied, the aircraft nosed over
and came to rest on the left wing and the left main landing gear strut.
Albury Aerodrome, Nil
SE M 20Km, VIC
While the solo student pilot was conducting a touch-and-go landing on
runway 11R, the aircraft landed heavily, then bounced and veered to the left.
The aircraft became airborne and the pilot reported severe vibration. During
the subsequent landing on runway 11R, the aircraft bounced, veered left and
touched down on the grass before becoming airborne once more. The left
wing dropped and the wing tip touched the ground causing the aircraft to
cartwheel into the ground. The aircraft came to rest on runway 11C.
During the initial climb, the helicopter struck a powerline and sustained
Insufficient power was applied to effect a backtracking turn along the
runway and the aircraft taxied into a ditch, striking a concrete culvert.
During the landing roll, the brakes locked up. The aircraft subsequently
nosed over and came to rest inverted.
During the taxi, the nose landing gear sheared off at the oleo.
Australian Accidents/Incidents 01 December 2008 - 29 January 2009
Cessna 182P Peak Hill (ALA),
near Two RN
It was reported that a Liberty XL-2 and a Cessna 152 collided near
Bankstown. The Liberty XL-2 returned to Bankstown. The Cessna 152
collided with terrain. The investigation is continuing.
Boggabilla (ALA), Nil
Oakey Aerodrome, Minor
W M 8Km, QLD
Immediately after becoming airborne, the left wing stalled, striking the
ground. The aircraft struck a channel bank and came to rest in a paddock.
Immediately after departure, the helicopter yawed to the right and
impacted terrain. The pilot and passenger sustained minor injuries.
M 9Km, WA
During the cruise the aircraft experienced a total power loss, resulting in
a forced landing.
Scone Aerodrome, Fatal
276° M 63Km,
While en route in reported marginal weather conditions, the aircraft
collided with terrain. The passenger was fatally injured with the pilot
receiving serious injuries. The investigation is continuing.
Shortly after departure, the aircraft struck a power line and collided with
terrain. The pilot, who was the sole occupant was fatally injured.
During takeoff, the helicopter’s rotor RPM reduced and the pilot lost
control. The helicopter landed heavily and rolled onto its right side,
sustaining serious damage.
During circuit training, the non-flying pilot inadvertently selected the gear
up while the aircraft was on the take-off run. The nose wheel collapsed.
Shortly after the landing gear was retracted, the pilot noticed that the
aircraft was not climbing normally. The pilot stopped the climb, checked the
engine controls but the engine power did not increase. The pilot carried out
a forced landing into a paddock, but on late final approach the left wing tip
contacted an obstacle and the aircraft impacted the ground.
During aerial agricultural operations, the aircraft collided with terrain.
The pilot was fatally injured. The investigation is continuing.
Airport, 091° M
During cruise, the transmission low oil pressure warning light illuminated
and the pressure gauge indicated low oil pressure. Approximately 10
seconds later the transmission chip light illuminated. The pilot completed
an emergency landing. After shutdown, the crewman reported smoke
from the rear of the helicopter.
During the approach, the pilot observed fire from the engine & smoke
entering the cockpit.
Okecie M-18A M 36Km, NSW
Beech F17D Jamestown
Staggerwing (ALA), SA
near Bald Hills
Mast (VFR), QLD
During the approach at 150 ft AGL, the helicopter’s engine sustained a total
power loss and the helicopter landed heavily.The main rotors impacted
with the tail section and the helicopter sustained serious damage.
M 25Km, VIC
The aircraft collided with terrain. The pilot sustained fatal injuries.
During aerobatic manoeuvres, the aircraft collided with the runway. The
aircraft caught fire and the pilot sustained fatal injuries.
Ban Ban Springs
During mustering operations, the pilot landed the helicopter to shut a
gate. All the required cyclic friction and collective friction locks were
secured and the pilot left the helicopter. On returning to the helicopter,
the pilot observed the station manager coming towards the helicopter
and got out of the helicopter without resecuring the helicopter. The
helicopter’s RPM surged and it became airborne, hovered backwards, the
tail rotor struck the ground and it rolled on its side.
During the cruise at low level due to low broken cloud, the helicopter
struck a powerline that impacted the windscreen and its side supports.
The pilot conducted a forced landing in a nearby quarry.
While passing over the threshold for landing, the aircraft descended
rapidly and bounced several times, before running off the edge of the
runway. The aircraft came to rest back on the runway, where the pilot
and passengers evacuated without injury.
On short final the aircraft encountered sudden cross-wind turbulence,
resulting in the aircraft contacting a fence.
Text courtesy of the Australian Transport Safety Bureau (ATSB). Disclaimer – information on accidents is the result of a co-operative effort between the ATSB and the Australian aviation industry. Data
quality and consistency depend on the efforts of industry where no follow-up action is undertaken by the ATSB. The ATSB accepts no liability for any loss or damage suffered by any person or corporation resulting
from the use of these data. Please note that descriptions are based on preliminary reports, and should not be interpreted as findings by the ATSB. The data do not include sports aviation accidents.
An important aspect of any
flight away from home base is
thorough flight planning. Having a
well thought-out plan before you
get airborne will help you enjoy
the flight, arrive refreshed and
Even if you are going somewhere familiar, having some key details
worked out beforehand, and then getting the most up-to-date weather
and NOTAMs, is a must.
BEFORE THE FLIGHT
Begin pre-flight planning several days in advance.
Study the applicable charts and plan the route. Then plan for
Refamiliarise yourself with the AIP and your legal requirements.
Check the weather forecasts.
If you are taking the aircraft away from
home base, check if there are enough
hours left on it to complete your flights.
Know your aircraft and its systems. Are
you familiar with the systems fitted to the
Seek out some local knowledge on the routes and destination.
Navigation aids (know how to use them
Ask yourself whether the proposed flight is within your capabilities?
Update your personal minimums to reflect your currency levels.
Autopilot (if fitted)
Brief your passengers about the realities of flying in light aircraft.
Transponder (if fitted)
TCAS or TCAD (if fitted)
While the shortest distance between two
points is a straight line, this may not be the
safest, or the wisest, route when flying. By all
means draw the straight line on the chart, but
then think about:
what terrain you are flying over;
airspace you are flying through;
aerodromes you are in the vicinity of;
the weather that will affect your flight –
especially cloud; and
Then consider a practical route which takes
into account these factors.
Think about the best way to depart the airfield
and arrive at your destination. It may be that
you can’t go straight there – you may need
to go via reporting points (VRP), for example.
Plugging the VRPs straight into your GPS has
advantages, but consider how many other
people are doing exactly the same thing. Be
particularly careful when arriving exactly
overhead VRPs for this very reason.
While in this preliminary flight-planning
phase, you should make provision for at least
one other safe alternative route – a plan ‘B’. In
planning this alternative route, take the same
level of care as you do with your primary
route. Having a well-researched plan ‘B’ takes
a lot of pressure off if the weather deteriorates
and you have to use it.
CONSIDER THE AIRSPACE EN
Ensure that you apply the correct tracking
tolerances to avoid controlled or restricted
airspace. (AIP ENR 1-1. PARA 19.11)
Controlled airspace – vertical and
Restricted airspace – is it active? Check
ERSA & NOTAMs
CTAF/Rs – are you overflying or passing in
the vicinity of one? (CAR 166A)
Will you need a refuelling stop on the way? If you
do, allow plenty of time for this, as invariably it
will take far longer than you think to refuel, let
the passengers out for a toilet break, and then
get them back into the aircraft.
Check that fuel (suitable for your aircraft)
is available at your planned fuel stops
Is there a call-out fee?
Can you use a credit card?
Do you need a CARNO?
Allow for taxi fuel
Consider applying the recommended fi xed
& variable fuel reserves (CAAP 234)
Plan for alternate and any required holding
fuel (INTER or TEMPO)
In flight, lean the fuel mixture in accordance
with the flight manual.
Prepare a flight log with as much relevant
information as you can: legs, distances, tracks,
cruising altitudes, radio frequencies,
fuel, and so on. You can fill in a lot of information
beforehand, and then finish the calculations, once
ve the up-to-date we
weather on the day.
Now turn your attention to studying the AIP.
It is important that you check the AIP
P and the
sections of the AIP supplements
to determine if there is any information
that might affect your flight. Don’t just rely
on getting the area NOTAMs on the day, as
they are not the sole source of all temporary
aerodrome and airspace inform
On your flight log, make a note of each
enroute ATC VHF frequency and a change
over position or time.
Make a note of all CTAF
AF & CTAF/R
frequencies en route
Make a note of the frequencies of all ontrack (and off track) navigation aids.
AIP ENR 1-10 paragraph 1.1 essentially says
that, before a flight, the pilot-in-command
must obtain and become familiar with, all
PLANNING THE ROUTE
information concerning that flight, including:
current meteorological information;
NOTAMS and supplements;
ON THE DAY
Allow plenty of time on the day to be sure
that final pre-flight preparation is not rushed,
and be realistic about the time you need to
plan, get your passengers ready, and any
intermediate stops en route.
engine inoperative procedures; and
Obtain the most recent weather and
NOTAMs and check them carefully. If in
doubt, discuss the conditions with a more
one engine inoperative performance data.
File a flight plan.
Brief yourself on your other requirements, for example: fuel reserves,
cruising altitudes and VFR met minima.
Make sure the aircraft has all the equipment
you will need for the whole time you are away:
aircraft performance data;
and in the case of twin-engine aircraft –
CHECK THE WEATHER
Take a look at the long-range forecast to get an idea of whether the
flight is feasible.
Lifejackets and survival equipment;
TALK TO A LOCAL
It can be worth getting some local knowledge on the area or your route
(including aerodrome information) well before the trip. Most local
operators are very happy to provide information and will probably
offer you plenty of other advice and tips.
Think about visibility restrictions, terrain, possible turbulence, and the
effects of these on your workload, and handling of the aircraft – and
you will realise why it is important to set personal minimums.
Personal minimums take into account a wide range
ange of criteria,
particularly pilot, aircraft, environment
nvironment and external pressures. They
are an invaluable tool in assisting you to decide if a particular
(route, weather, aircraft type, etc), is within your personal limits.
When you aree worki
working out how long it will take you to get ready and airborne
n this flight,
ig allow some time to go through the ‘I’M SAFE’ checklist.
BRIEF YOUR PASSENGERS
Discuss the vagaries of light aircraft trips with your passengers
Departure and arrival times ca
cannot be guaranteed – the weather
may have other plans.
The weight of baggage they can bring is limited – anything over
their limit will be left behind.
Turning back, taking an alternative route, or diverting, is always a
What your contingency plans will be if you are delayed, diverted, or
have to cancel.
Something to clean the screen with.
There is a real danger in focusing on the
gain of reaching your destination compared
with the lossess associated with not going, or
turning back. For example, extra costs, missed
appointments, disappointed passengers, etc.
Don’t fall into this trap – look for the gainss from
the alternative action – being alive and safe with
an intact aircraft (with probably very relieved
passengers), having avoided the potential major
losss (and cost) of bent metal,
al, injuries, or worse.
You must obtain the most up-to-date weather
before your flight. Weather issued on the
morning of an afternoon
n flight is good for
sing the trends, but should be up
It is equally important to devote a generous
amount of time
me to weather
specially when conditions are borderline –
so that you can consider how the conditions
might affect your flight. Using a highlighter
pen to mark the key points as you read the
forecast is useful.
There are two distinct steps you need to follow
when looking at the weather and deciding if it
is good enough for your flight.
Firstly de-code the weather briefings, making
sure you look up any codes you don’t recognise
(the GEN section of the AIP, the Bureau
of Meteorology and Airservices Australia
websites, and the weather interpretation card, all have information to
help de-code aviation weather forecasts).
Secondly, build a mental picture of what the weather forecasts and
reports are saying, and how this will affect your flight. Be honest with
yourself when trying to form a picture of what is happening. If you’re
not sure, ask someone who has more experience to help you.
If you decide to proceed with the flight – with the intention of seeing
what the conditions are like – do it only on the basis that you will divert
or turn back when they surpass a specified value (e.g., ‘I will divert or
turn back if the visibility and cloud base deteriorates below X’).
If you do not feel comfortable with the conditions, it’s time to tell
your passengers the flight is off. Making such a decision requires a
fair amount of personal discipline, but this can be made considerably
easier by having a robust set of personal minimums to guide you.
Having the latest NOTAMs is very important.
TALK TO A LOCAL
If the weather conditions on the day aree approaching yo
minimums, call the local operator(s) again, to gauge their assessme
of the conditions en route and at the destination.
FILE A FLIGHT PLAN
We highly recommend you file a flight plan,
an, or at a minimum organise
your own flight following service. Tell someone where you are going
and when you are planning to get there. Provide written instructions
on what, specifically, to do if you don’t check in with them by a certain
time. If you are asking a family mem
member to complete this task, be
aware that the stress of you not checking-in could make this very
difficult for them.
Filing a flight plan will ensure that someone will miss you if you don’t
arrive, so that search and rescue operations can start immediately.
Equally, when you have filed a flight plan, remember to amend the
SARTIME, or terminate the flight plan when you do arrive safely.
DON’T FORGET TO CANCEL SARTIME
Contact CENSAR on 1800 814 931
E is the time nominated by a pilot for the initiation of a search
and rescue action if a report has not been received from the pilot by the
nominated Airservices Australia unit. Although you don’t have to submit
a SARTIME, it makes sense to let someone know where you’re going, and
when you’re planning on getting there.
Your SARTIME is logged with the centralised Airservices database –
CENSAR. If a fl
ight is over the designated SARTIME, the first
first step is for
Read the NOTAMs carefully – highlighting the ones tha
hat will affect
ATC to put out calls to aircraft in the area, to
keep a lookout for the missing plane. Fifteen
minutes after the SARTIME has elapsed, the
information goes to AUSSAR, and a formal
search is initiated.
Why should I cancel it?
The majority of searches happen because
of failure to cancel SARTIME, leading to a
massive waste of time and resources. It’s
easy to lodge SARTIME, and then at the end
of a flight, become distracted with all the
necessary checks and procedures, and forget
to cancel SARTIME.
So, to cancel your SAR, contact CENSAR on
1800 814 931.
IN THE AIRCRAFT
Gather your kneeboard with the completed
flight log, your pre-folded charts, any
aerodrome pages you could need, and any
other useful information. Arrange them so
that you have them nearby, and in the order
you will need them.
An important part of in-flight management is
to review the situation continually, and update
alternatives during the flight. For example,
reviewing the cloud base in relation to enroute
terrain, or reviewing surface wind conditions
at the destination, are important points to
consider. Even if the weather ahead seems
fine, you must always maintain an awareness
of what the weather is doing behind you, and
be able to recognise when the conditions are about to fall below the
limits you’ve set.
Draw 10 nm rings around airfields you will pass nearby, so you will
know whether your track takes you into their area, and you need to
speak to them on the radio.
Use a highlighter pen to mark relevant weather and NOTAMs.
Put 10 nm distance markers along the track line to help you keep track
of time and distance travelled, distance from/to features, and drift.
Draw wind vectors on your chart to remind yourself of the general flow.
Prepare groundspeed checks along your track. By choosing easily
identifiable features there is more chance you will remember to do
them, and they will be more accurate.
Mentally note a reciprocal compass heading just in case you need
to turn back.
Always have an alternate aerodrome in mind – and sufficient fuel to
Avoid flying close to aerodromes unless you need to, as they tend to
be the busier airspace.
FOR MORE INFORMATION
NOTAMs & meteorological information
NAIPS (Airservices Australia) www.airservicesaustralia.com/brief
AvFax (ERSA: En Route Supplement Australia)
Bureau of Meteorology website (www.bom.gov.au) and go to ‘Aviation
Services’ DECTALK (ERSA)
Adapted from Vector, November-December 2008, with kind
permission of the Civil Aviation Authority of New Zealand.
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They’re almost the stuff of science fiction, but,
specialists argue, the next ten years will see
enormous growth in their civil use. In the first of
a series of articles, Flight Safety
editor, Margo Marchbank, explores
developments in unmanned aerial
systems (UAS), described as ‘the
fastest growing area of aerospace
research and development globally’, and the
implications such systems have for aviation safety.
Unmanned aerial systems (UAS), often known
as UAVs, (unmanned aerial vehicles), can range
from something the size of a dragonfly on
steroids to large aircraft of B747 proportions.
They are more correctly referred to as UAS, since
the components make up a ‘system, consisting
of the UAV or ‘flight vehicle’; the ground station;
and the communication or data links.
UAS IN AUSTRALIA
Last year was a significant one for UAS in
Australia on several fronts. The first was the
successful trial of the Israeli-manufactured
Heron (pictured above, and opposite)
conducted over six weeks in May-June by
Australian Customs’ Border Protection
Command. During the trial, the 8.5 metre
long Heron, which has a wingspan of 16.6
metres, and a range of more than 1800km,
flew from Weipa in far north Queensland,
over the Gulf of Carpentaria, Torres Strait and
the Grreat Barrier Reef, testing its potential for
maritiime surveillance and border protection.
CASA staff in Canberra and Cairns were
ved, along with Airservices, Customs
he Israeli manufacturers, in what CASA’s
Gary Carr describes as a ‘huge effort and a
Unlike manned aircraft, according to Customs,
the Heron can fly ‘low and slow, down to 65
knots, allowing its cameras to pick up small
detail such as the name of the ship on the hull,
and the crew (so as to determine their ethnic
heritage), or whether there is livestock on the
ship’. Currently border patrol is carried out
using the Dash 8, whose carbon footprint, in
the current environmental climate, could be a
factor in the Heron’s favour, with the Heron’s
Rotax 912 engine burning far less fuel than
the Dash 8’s twin turbo-props. Following the
trial, the Government is assessing the longterm viability of UAS for coastal surveillance.
Diagrams Juanita Franzi - Aero Illustrations p26, 28, 29
CASA has been a leader in the
area of UAS from the start, beginning
in the late nineties with work to write
regulations encompassing areas such as UAS,
operations, maintenance and ground control
requirements. CASR Part 101, a first in the
world, which came into effect in
2002, gave a framework
under which all classes
of UAS could be
regulated. Mal Walker,
then a Canberrabased flying operations
driving force behind the development of Part
101, something which was recognised last
year. He and another UAS ‘pioneer’, Filippo
De Florio, became the first recipients of the
‘De Florio & Walker Pioneer Award’ created in
their honour by Unmanned Vehicle Systems
International, a worldwide UAS organisation
representing 35 member countries.
In 1997, Mal led a team reviewing legislation
concerning operation of various unmanned
aircraft, and saw a need for consistent
legislation to allow the progressive integration
of such aircraft into civil airspace. Together,
Mal and his team successfully implemented
Photo: Australian Customs
Australia is well placed to contribute to the
growth of UAS, and capitalise on forecast
growth of a $53 billion spend worldwide on
UAS (both military and civil) over the next
five years. Unlike many countries around
the world, European nations in particular,
Australian airspace is not congested. Australia
has several UAS-designated areas: West Sale
in Victoria; Marulan in NSW – the University
of Sydney’s ‘test site’; and a proposed area in
Queensland around Kingaroy. The Queensland
State Government is giving considerable
support to UAS development, and is funding
the joint venture Australian Research Centre
for Aerospace Automation (ARCAA) with
research partners, the Queensland University
of Technology (QUT) and the Commonwealth
Scientific & Research Organisation (CSIRO).
A new custom-built laboratory facility at
Brisbane Airport’s Da Vinci precinct, housing
the ARCAA, is due for completion later
the new regulations, and he oversaw UAS
activities until he retired from CASA in 2007.
Other agencies are more conservative in their
approach. Nicholas Sabatini, former associate
administrator with the U.S Federal Aviation
Administration, prefaces remarks about the
‘integration of UAS’ by quoting medicine’s
Hippocratic Oath, ‘First, do no harm’ as
exemplifying the FAA’s approach. ‘Working
with our international counterparts, the FAA is
committed to do no harm as it addresses the
safe integration of unmanned aircraft in civil
airspace,’ he states.
UNMANNED AIRCRAFT – THE BEGINNING
Unmanned aircraft are not new. Balloons fitted with explosive devices
had been used in conflict between Austria and the Venetians in 1849,
with limited success – when the wind blew the Austrians’ balloons
fitted with timers, off course. During the American Civil War, both
Union and Confederate armies were similarly unsuccessful in their
balloon bombing attempts. Around the time of the First World War,
Englishman, Archibald Low, acknowledged as the ‘father of radio
guidance systems’ was working on a radio-controlled aircraft. From
that time, UAS have continued to evolve, and until relatively recently
in their history, have been used mainly for military purposes, such as
weaponry platforms, reconnaissance or surveillance. Recent conflicts,
in Iraq and Afghanistan for example, have seen the widespread use of
UAS such as the Predator, loaded with Hellfire missiles, which can stay
in the air for around 40 hours; and the jet-powered Global Hawk, which
operates at 60,000 feet, with an endurance of about 24 hours. The
Jane’s Defence News quotes an Israeli Air Force (IAF) officer as saying
that, ‘Out of 28,000 operational flight hours [for the IAF] in 2005,
18,000 were conducted by UAVs [which is] about 65 per cent’. Another
former IAF spokesman said, ’By the end of the next decade ,
I believe that more than half of IAF platforms will be unmanned.’
However, UAS are coming into their own in the civil sphere, and as
a consequence, according to CASA’s Gary Carr, ‘aviation authorities
around the world see the integration of UAS into civil airspace as
one of the most significant current safety challenges’. Whereas UAS
in the military context, Gary says are ‘mission-centric’, with safety
and retrieval not being the main focus, in the commercial sphere,
it’s completely different. They are particularly suited to the many
operations which can be classified as ‘dull, dirty or dangerous’: for the
routine, boring tasks, and data-gathering in environments too risky for
humans, such as volcanoes, hurricanes and bushfires.
© Kendal McGuffie – Aerosonde trial at Hamilton
THE ‘DULL, DIRTY AND DANGEROUS’ DOZEN:
Weather research/monitoring – flying into hurricanes, tornados,
Environmental research – volcano investigations, Arctic/Antarctic
cryospheric research; tracking wildlife populations
Mineral exploration – aerial survey across desolate terrain, not
‘friendly’ to humans; pipeline leaks
Locating of unexploded ordnance/artillery, especially land mines
Agriculture – crop spraying, monitoring, e.g. detecting fungus on
wine grapes; spraying rice crops at night, with the possible wire
obstructions identified and pre-programmed.
Coast and border surveillance – as in the Customs’ trial
Telecommunications – UAS operating as mobile relay platforms,
almost like a disposable satellite, or in disaster zones for emergency
News/media – news-gathering, video footage
Maritime research – eg tracking whale populations, locating schools
of fish to catch, oil spill tracking
Powerline inspections – often conducted using micro- or very small UAS
Traffic control – both ground and ATC, monitoring traffic and
accidents over major highways, and traffic over busy airports
An Australian UAS success story is the Aerosonde, pictured ((left
opposite), which was used in a joint project with the US National Oceanic
& Atmospheric Administration over the northern hemisphere summer
last year (South Florida Sun–Sentinel). The propeller-driven Aerosonde,
with a three-metre wingspan, is manufactured in Melbourne, and is
well-suited to its meteorological research role. It has a 1.6hp engine, a
flight management computer, and cruising at around 100kph covering
almost 3700km, uses a meagre 5.68 litres of fuel. With its tough polymer
construction, it is designed to withstand the eye of the hurricane, and has
been clocked enduring the buffeting of a hurricane for more than 20 hours,
providing valuable and potentially life-saving data for meteorologists.
Its capacity to fly as low as 300ft above the ocean, not possible for
manned aircraft, means that the Aerosonde can capture surface
temperatures, wind, barometric pressure and humidity readings from
that vital ‘slice’ of the atmosphere.
However, the FAA, concerned about manned aircraft safety, and
the potential for collision with small aircraft which might have been
evacuating from the path of the hurricane, would not allow the
Aerosonde to fly near the US mainland during the 2008 summer
hurricane season. Gary Carr argues that ultimately ‘economics will
drive the uptake of UAS’, as they have the potential to offer cheaper
alternatives to manned aircraft for a variety of tasks, given the rising
cost of fuel for manned aircraft, and environmental considerations
such as emissions and carbon trading. However, he says, there are
still a number of hurdles to be overcome before civil UAS can be safely
integrated in shared airspace.
Aerial photography – real estate marketing, sports events, stadium
There are several issues facing regulators and
Unmanned Systems, a Dutch initiative, set up to establish standards
for UAS under 150kg.
Lance argues that by 2020, there will be limited commercial UAS
operations, mainly because of the pace of regulation internationally.
The necessity to get individual countries to line up and agree creates
some significant legal hurdles, but the commercial push from industry
is likely to pick up pace, in the face of major cost savings offered by
future UAS operations.
The radio frequency spectrum - available
bandwidth. The radio spectrum is swamped
already, with only a very limited bandwidth
allocated for UAS, which require massive
bandwidth to transmit information. The
Australian Communications & Media
Authority (ACMA) controls bandwidth in
Australia. The FAA’s Nicholas Sabatini says
that the issue of bandwidth for UAS should
also be an agenda item for the 2011 World
The ‘holy grail’ for UAS is how Gary Carr
describes the requirement for them to
be capable of ‘sense and avoid’. It’s one
thing for the UAS to ‘sense’ that another
aircraft is in the vicinity, but not so easy
for manned aircraft to detect a UAS,
given the variation in size and operating
requirements of UAS.
The concept of ‘equivalent safety’ has been
mooted, that is, UAS should be ‘as safe’ as
manned aircraft, but that creates another
set of issues, in defining and understanding
manned aircraft safety. What criteria do
you use to assess ‘aviation safety’? Fatality
rates? Mid-air collisions?
Public and industry acceptance of UAVs,
reassuring the public in particular, that
Australia’s high aviation safety standards
would not be compromised by the
introduction of UAS to civil airspace. Any
new technology is regarded with suspicion
in some quarters, and UAS are no different.
These considerations and others are why CASA
is continuing involvement on an international
level with the development of standards and
protocols for UAS. Lance Thorogood is the
CASA representative on the various working
groups set up by the International Civil Aviation
Organization (ICAO) to look at international
UAS operations. There are four working groups
examining: airworthiness; operational issues;
dangerous goods & airspace; and a recentlyestablished group which Lance heads, given
the task of bringing together all the acronyms,
abbreviations and definitions in the area, in an
effort to create standardisation in the industry.
There is also the JARUS working group,
the Joint Authorities for Rulemaking on
AUSTRALIA’S UAS CLASSIFICATION
CASR Part 101’s operating rules identify three classes of UAS
Micro UAS – under 100g
Small UAS – 100g to 150kg
Large UAS – 150kg and above
The regulatory interest is chiefly in the large UAS, which require
personnel approval and a UAS operating certificate; a certificate of
registration; a maintenance program; and a special certificate of
airworthiness, either in the experimental or restricted category.
For further information
Centre for Aerospace
‘Small unmanned aircraft to
fly into hurricanes to assist
South Florida Sun-Sentinel
4 April 2008
Brief history of UAVs
List Lab, University of Florida
‘Attack of the drones’
Flight Safety Australia, NovemberDecember 2002 p56-58
‘Unmanned aerial system
World Airnews, January 2009 p15-22
Evaluation of UAV Safety
Reece Clothier & Rodney Walker,
QUT, 2006. Accessed from
‘UAV 2003 – a roadmap for
deploying unmanned aerial
vehicles in transportation’
US Department of Transport/
Research & Special Programs
Administration – Volpe Center
‘Unmanned aircraft in
Australia – a regulatory
Gary Carr, Certification Programs
Heli Pacific presentation, May 2008
Systems - International
International not-for-profit association
of manufacturers and researchers in
the unmanned vehicle field
UAS - the global perspective
UVS International & Blyenburgh
& Co. 2007
Life cycle of
Our story begins when the maintenance controller of a fleet of Fairchild
(Swearingen) SA226 and SA227 series aeroplanes (Metroliners) made
an urgent phone call to CASA’s Airworthiness Engineering Group. The
caller described how, on final approach to landing, the rudder on a
Metroliner became completely locked in the neutral position. The
operator’s engineering staff made an immediate investigation into
the rudder control system and discovered that the rudder gust lock
assembly had failed in such a way that it became fully engaged.
The Metroliner gust lock assembly is essentially a spring-loaded
plunger. When the cockpit control is moved to the ‘lock’ position
by the pilot, the housing moves forward and the spring presses the
plunger against the locking quadrant of the flight control, ready for the
hole in the quadrant to line up with the plunger. When the hole lines
up, (when the control surface is in the neutral position) the pin drops
in, and the flight control is locked.
The Airworthiness Engineering
Group’s Roger Alder and Richard
Allen tell the story of how a
service difficulty report (SDR)
became a unique Australian
airworthiness directive (AD) and
how that AD, having served its
purpose, came to be cancelled.
The spring-loaded plunger is retained in the
housing by a roll pin. The roll pin moves in a
slot in the housing. In this case, the housing
had failed, allowing unrestricted movement
of the p
This then fired out of the
housing and engagged with the control surface
quadrant, even th
hough the cockpit control
was still in the ‘un
The caller also reported that they had
inspected the rest of the aircraft in their fleet
and had found mo
ore cases of rudder gust lock
housing cracking,, the pre-condition to the
failure that they haad just experienced.
The Metroliner is widely used, not only in
Australia but throu
ughout the world. This unsafe
condition which haad come to light through the
ntroller’s proactive service
difficulty reporting had not been addressed
by any existing F
Fairchild (now M7) service
bulletin or FAA
A airworthiness directive,
so CASA decided
d to issue an emergency
Australian airworthiness directive, which
became AD/SWSSA226/96 - Rudder Gust
Lock. This uniquee Australian emergency AD
was drafted on th
he basis that this gust lock
failure had not occu
urred because of inadequate
maintenance, poor design or a manufacturing
defect, but was an
n ageing aircraft issue.
Many aircraft op
perating in the commuter
category in Australia, including Metroliners,
are considered ‘fl
fleet leaders’ because they
d very high flight times times which are well
w in excess of any other
aeroplane of the same type in any other
untry in the world. These aircraft are of
speecial interest to
t manufacturers because
deffects related to time
in service - such as the
gust lock - are mo
ore likely to be found in the
e leaders’ first.
ASA calculated a retirement life for the gust
locck, and required any gust locks that had
excceeded the retirrement life as published in
thee AD to be removved from service within 100
ght hours after the effective date of the AD.
gust locks had been removed to meet
the requirements of the AD, the AD also gave
approval to conttinue operation, provided
there was a suitab
ble alternative to secure the
rudder against dam
mage from wind gusts while
Continued on page 38
SELECTED SERVICE DIFFICULTY REPORTS
Airbus A319115 Escape slide unserviceable.
LH over-wing escape slide unserviceable. The slide
failed tests with all tubes having excessive porosity
on almost all seams and surfaces.
P/No: D3186511. TSN: 9,512 hours/7,253 cycles. TSO:
2,484 hours/505 cycles.
Airbus A330201 Landing gear steering system
faulty. Ref 510007722
Nose wheel steering system faulty. Brake and
steering control unit (BSCU) and nose wheel steering
servo valve replaced.
Airbus A330202 Air data computer ADIRU
faulty. Ref 510007664
No2 Air data inertial reference unit (ADIRU) faulty.
P/No: 46502003030316. (1 similar occurrence)
Airbus A330203 APU wiring FOD. Ref 510007556
APU wiring loom located in cargo compartment
unserviceable. Investigation found that a dog had
escaped from its crate and had bitten through
wires in the loom. Dog had also made a mess in the
cargo compartment which required cleaning before
departure. Investigation continuing.
Airbus A330303 Captain’s seat belt strap and
buckle separated. Ref 510007693
Captain’s LH side seat-belt strap and buckle
separated from seat.
Airbus A330303 Hydraulic pressure line swage
fi tting failed. Ref 510007513
Loss of ‘green’ system hydraulic fluid. Investigation
found No.5 spoiler hydraulic pressure line failed at
Airbus A330303 Passenger compartment
lighting - smoke/fumes. Ref 510007570
Smoke and fumes emanating from lights in forward
galley overhead panels. Investigation could find
no faults, but found evidence of insects and moths
behind the lighting panel.
BAC 146200 Landing gear selector suspect
faulty. Ref 510007612
Landing gear failed to extend with normal selection.
Emergency selection of landing gear carried out.
Suspect either selector switch/handle or rotary
actuator on hydraulic valve. Investigation continuing.
(1 similar occurrence)
BAC 146300 Flight compartment windshield
cracked. Ref 510007735
RH co-pilot’s ‘B’ windshield outer ply cracked.
P/No: NP1701022. TSN: 787 cycles. (7 similar
Boeing 717200 Engine and APU fire bottle
squibs open circuit. Ref 510007483
Engine and APU fire bottle squibs (5off6) failed functional
test. All six squib circuits open circuited. Further
investigation found an additional nylon gasket had been
installed between the squib discharge housing and squib
discharge housing retainer, preventing a continuous
ground path to the extinguisher bottle.
P/No: 891501. (1 similar occurrence)
Boeing 727277 Ground proximity system
transceiver unserviceable. Ref 510007575
Radio altimeter transmitter/receiver failed
operational check following fitment.
Boeing 737229 Leading edge slat mount holes
worn elongated. Ref 510007656
No. 5 slat inboard mount attachment holes worn.
P/No: 6546422268. (1 similar occurrence)
Boeing 737376 Escape slide malfunctioned.
No1R door slide raft malfunctioned during test. The
slide inflated but rotated 90 degrees blocking doorway.
Actuator inlet struck the fuselage scratching protective
finish aft and below door cut out.
P/No: 737M25651015. TSN: 38,361 hours. TSO: 688
hours. (8 similar occurrences)
Boeing 737376 Hydraulic system, main hose
burst. Ref 510007700
Hydraulic hose located between ‘B’ system pressure
module and acoustic filter burst. Loss of system ‘B’
hydraulic fluid. Investigation continuing.
Boeing 737476 Landing gear selector
contaminated. Ref 510007574
Landing-gear red indicator lights failed to extinguish
following landing-gear ‘Down’ selection. Landing gear
extended normally. Investigation found debris in the
landing-gear selector handle preventing it from fully
contacting switches in the ‘Down’ detent.
Boeing 737476 Pitot/static system faulty.
Pitot/static system faulty. Pitot heat switches cycled
with no effect. Problem corrected itself on descent.
Boeing 737476 Trailing edge flap control system
torque tube worn. Ref 510007679
Trailing edge flap torque tube worn due to contact
with slat return hydraulic line.
P/No: 657327117. (3 similar occurrences)
BAC Jetstm3206 Gust lock damper pivot pin/
bush corroded. Ref 510007653
Rudder gust lock pivot pin PNo 137502F7 and bush
PNo FCT39X1-2 heavily corroded and pivot bracket
PNo 137502F8 cracked. P/No: 137515F407.
Boeing 73776N Air conditioning compartment
door separated. Ref 510007473
LH air conditioning pack fan check valve access door
separated from aircraft. Investigation continuing.
Boeing 717200 APU FOD. Ref 510007658
APU oil filler cap loose and nil oil evident in sight
glass. During compressor inspection, FOD damage
noted on compressor wheel. Suspect high frequency
vibration on camloc on borescope access panel with
one receptacle missing.
P/No: 4502440. TSN: 14,402 hours/14,962 cycles. (1
Boeing 73776N APU failed to start. Ref 10007616
APU failed inflight start. Investigation continuing.
P/No: 38007021. TSN: 12,850 hours/12,326 cycles. (5
Boeing 7377Q8 Battery faulty. Ref 510007674
Main battery removed due to fault indications.
Workshop investigation found very low electrolyte
levels in all cells, with three cells internally shorted
and welded to surrounding cells due to extremely high
temperatures. Investigation continuing.
P/No: CVH531KA. (1 similar occurrence)
Boeing 737838 Battery discharged – suspect
faulty charger. Ref 510007561
Battery discharged. Suspect faulty battery charger.
P/No: 893003. TSN: 19,572 hours. TSO: 19,572 hours.
(2 similar occurrences)
Boeing 737838 Fuel storage fuel system suspect
faulty. Ref 510007571
Fuel system imbalance. Suspect fuel pump lost
priming. Investigation continuing.
Boeing 737838 Fuselage skin damaged.
Fuselage skin damaged/torn in area of upper LH
static port located aft of L1 door. Skin holed for
approximately 25.4mm (1in). Damage is located in a
critical area at Stn 389 to Stn 392 - WL208 to WL212.
Investigation continuing. (11 similar occurrences)
Boeing 73786N Landing gear selector
unserviceable. Ref 510007589
During climb, crew were unable to retract the landing
gear. Investigation continuing.
(1 similar occurrence)
AIRCRAFT ABOVE 5700KG
Boeing 717200 Cabin cooling system sleeve
ruptured. Ref 510007687
RH air conditioning pack flexible sleeve on ducting
from temperature control valve ruptured
Boeing 7378BK Landing gear brake hydraulic
line ruptured. Ref 510007553
RH main landing gear No. 3 brake hydraulic supply
Boeing 7378FE Fuel storage nut cracked and
corroded. Ref 510007527
RH wing fuel tank access panel 632CB leaking.
Investigation found cracked dome nut.
(2 similar occurrences)
1 December 2008 –
31 January 2009
Boeing 7378FE Landing gear brake system hose
leaking. Ref 510007634
LH main landing-gear upper brake hose leaking. Loss
of system ‘A’ hydraulic fluid.
Boeing 747438 Emergency power supply bottle
incorrectly fi tted. Ref 510007627
Door 3 RH emergency power supply (EPS) bottle
incorrectly installed. Investigation found the mounting
bracket fitted inside out, and safety bolts left in the
trigger-firing mechanism. Further investigation found
door 3 LH mounting bracket also fitted inside out.
Boeing 747438 Engine pylon strut fuse pin panel
missing. Ref 510007665
No. 4 engine pylon outboard strut fuse pin panel
missing. Investigation continuing.
P/No: 65B8968642. (12 similar occurrences)
Boeing 747438 Potable water system hose
ruptured. Ref 510007472
Potable water hose ruptured at drain valve. Loss of
Boeing 747438 Potable water system indicator
suspect faulty. Ref 510007601
Potable water indicating zero. Nil leaks in system.
Potable water indicator suspect faulty.
Boeing 747438 Rear toilet waste bin smoke/
fumes. Ref 510007493
Smoke from R5 rear toilet waste bin. Fire extinguisher
discharged. Investigation found a discarded cigarette
butt in the bin.
Boeing 74748E Air conditioning compartment
air inlet door missing. Ref 510007698
No. 2 air conditioning pack ram air inlet door forward
section missing. The aft section of the door remained
in place. Inlet door actuator attachment bolt to door
operating arm also sheared off. The forward hinge for
the door was also damaged.
Boeing 767336 Wing fuel feed tube bonding out
of tolerance. Ref 510007555
LH wing front spar fitting fuel feed tube bonding
out of tolerance. Found during incorporation of EI
767-028-0053R02. (2 similar occurrences)
Boeing 767338ER Auto throttle system failed.
Auto throttle system failed. Investigation found nil
interface with thrust management computer (TMC).
System tested normal following TMC re-rack.
(1 similar occurrence)
Boeing 767338ER Seat electrical headrest
wiring burnt. Ref 510007666
Wiring located in seat 5E electrical headrest, chafed
and burnt. Investigation continuing.
(1 similar occurrence)
Boeing 767338ER Strut inboard access panel
missing. Ref 510007626
RH strut inboard access panel missing. Panel found
on runway with all fasteners in secured position.
P/No: 311T106576. (8 similar occurrences)
Bombardier DHC8202 Cabin cooling system
aircycle machine seized. Ref 510007645
Aircycle Machine (ACM) seized.
P/No: 78279018. TSO: 3,091 hours/638cycles/23
months. (11 similar occurrences)
Bombardier DHC8315 Aircraft structure lightning strike. Ref 510007621
Aircraft suffered a suspected lightning strike.
Inspection could find nil damage.
(1 similar occurrence)
Bombardier DHC8402 Baggage door handle
incorrect stowed. Ref 510007595
Forward baggage door handle incorrectly stowed, causing
door light to illuminate. Investigation found the door to be
fully locked and the handle had not moved towards the
unlocked position. Suspect handle incorrectly stowed
when door closed. (7 similar occurrences)
Bombardier DHC8402 Elevator tab control
system actuator failed. Ref 510007675
RH elevator pitch trim actuator failed.
TSN: 624 hours/694 cycles. (1 similar occurrence)
Bombardier DHC8402 Flight compartment
windshield inner pane shattered.
Ref 510007489 (photo below)
First officer’s windscreen inner pane shattered.
(2 similar occurrence)
Bombardier DHC8402 Landing gear door
incorrect operation. Ref 510007566
Main landing gear hydraulic bypass door in ‘Open’
position preventing retraction of landing gear.
RH main landing gear safety switch internal short
circuit between terminal 1 and terminal 5. Switch was
a new item fitted before this flight.
Dornier DO328100 Fuselage skin corroded.
Upper aft fuselage skin corroded in area between
skin and copper bonding plate across composite
TSN: 16,987 hours/14,776cycles/156 months.
Beech 200 Rear pressure bulkhead stringer clip
cracked. Ref 510007740
Rear-pressure bulkhead stringer clip cracked. Found
during inspection iaw AVCON SB08-01. Crack length
approximately 6.35mm (0.25in).
TSN: 1,936 hours/3,212 landings. (4 similar
Dornier DO328100 Wing skin cracked.
RH wing lower skin cracked in forward section
outboard of engine. NDT inspection confirmed the
crack. Investigation continuing.
TSN: 24,567 hours/22,071 cycles. TSO: 24,567
Embraer EMB120 Landing gear door unlatched
and open. Ref 510007533
LH main landing gear door unlatched and open after
Embraer EMB120 Landing gear selector handle
unserviceable. Ref 510007619
Landing gear selector handle seized preventing
landing gear from being selected ‘Up’.
Embraer EMB120 Passenger compartment
lighting holder smoking/arcing. Ref 510007730
Fluorescent lighting holder located between rows
1BC and 2BC smoking and arcing.
P/No: BC10047005. (1 similar occurrence)
Fokker F28MK1000 Power lever throttle stuck.
Throttle controls blocked during attempt to increase
thrust. Throttles eventually unblocked. Extensive
investigation could find no defects.
Fokker F28MK1000 Rudder control system
suspect faulty. Ref 510007648
Rudder fault messages appeared. Rudder limitermonitor unit P/No EARLM8504-413 removed as a
precaution for investigation. Investigation continuing.
Israel 1124 Fuselage bulkhead web cracked.
Bulkhead web located in rear cabin cracked.
TSN: 34,804 hours/24,515 cycles.
Saab SF340B Nose landing gear downlock
actuator faulty. Ref 510007608
Nose landing gear downlock actuator preload tension
Saab SF340B Pneumatic system duct cracked.
RH bleed air supply to air conditioning pack rubber
duct cracked at clamp attachment area.
AIRCRAFT BELOW 5700KG
Beech 200 Fuselage door hinge lugs cracked.
Cargo door hinge aft lugs located on airframe side of
door hinge cracked. Cracks confirmed by NDI.
P/No: 1014301973. TSN: 9,348 hours/14,939 landings.
Beech 200 Landing gear position and warning
system switch short circuit. Ref 510007738
Beech 200 Wing attachment bolt cracked.
LH lower forward wing attachment bolt cracked in
bolt head radius. Found during NDT inspection iaw
P/No: 10140241S. TSN: 10,303 hours/8,527 cycles/8,527
landings/178 months. (2 similar occurrences)
Beech 58 Landing gear actuator brush
damaged. Ref 510007536
Landing gear electric motor brushes chipped and
broken. Brushes had been replaced approximately
two hours previously.
P/No: 35175A. TSN: 2 hours.
Beech B200C Trailing edge flap actuator drive
shaft broken. Ref 510007669
LH inboard trailing edge flap actuator
Britten Norman BN2A26 Aircraft fuselage
cracked and corroded. Ref 510007701
Aircraft corroded/cracked in the following areas:- 1.
RH flap nose cap ribs 2. rudder trim tab hinge
3. elevator leading edge 4. RH leading edge of
horizontal stabilizer 5. crack in LH horizontal stabilizer
spar 6. centre belly skin 7. centre floor 8. rear fuselage
frame 9. left centre floor. Found during inspection iaw
Cessna 172 Brake disc faulty manufacture. Ref
Newly supplied brake discs oversized. Discs will
not fit into wheel half bores. Removed “old” (2off)
disc hub diameters measured at 139.1285mm and
139.1031mm (5.4775in and 5.4765in). Supplied “new”
disc hub diameters (4off) measured at 139.331mm,
139.382mm, 139.293mm and 139.293mm (5.4855in,
5.4875in, 5.484in, and 5.484in). Existing wheel half
bore diameter 139.217mm (5.481in).
Cessna 210N Hydraulic pressure switch failed.
Hydraulic pressure switch failed.
Cessna 401B Wing spar cap corroded.
LH wing front spar upper spar cap corroded. Found
when upper wing skins removed to investigate
bulging at butt joint
P/No: 082250049. TSN: 2,987 hours.
Cessna 402C Electrical power wiring corroded.
Main wiring loom located under floor short
circuited and corroded between wires L54B20,
L32D20, H363A20 and H311B20 causing numerous
TSN: 16,998 hours.
Cessna U206F Horizontal stabiliser spar bracket
cracked. Ref 510007510
Horizontal stabiliser rear spar reinforcement bracket
cracked from lower bolt hold to the edge of the
bracket. Found during inspection iaw CAP 55-10-01.
Cessna U206F Main landing gear legs cracked.
LH and RH main landing gear legs P/No 1241117-1
and P/No 1241117-2 cracked in numerous places.
Investigation found the cracking was only in the
plating and not in the leg itself. Plating of the leg is an
Cessna U206G Starter lead damaged.
Starter lead chafed through by mixture cable. Starter
lead and mixture cable badly damaged. Battery
showed signs of excessive heat.
Gulfstream 500S Wing spar cap cracked. Ref
LH wing lower spar cap cracked. Crack located at WS
24.00. Found during inspection iaw AD/AC/42 Amdt7
and SB 90C.
P/No: 1800037. TSN: 17,915 hours/468 months. (1
PAC 750XL Electrical panel locknuts damaged.
Electrical distribution panel locknuts damaged and
loosened due to heavy current flow melting the nylon
locking feature in the nuts.
PAC 750XL Vertical stabiliser attach pickup and
upper lugs corroded. Ref 510007632 (photo below)
Vertical stabiliser attachment pickup assembly and
LH and RH upper lugs contained severe exfoliation
P/No: 11104391. TSN: 2,711 hours.
Pilatus PC12 Engine oil temperature wire
damaged. Ref 510007558
Engine oil temperature wire 2E21B24 damaged in
cannon plug at the oil temperature bulb. The wire was
split under the insulation of the shielded wire.
P/No: WIRE2E21B24. TSN: 8,164 hours/6,759 cycles.
Piper PA28161 Nose landing gear fork failed.
Nose landing gear fork failed allowing nose wheel
to separate. Nose landing gear collapsed causing
damage to aircraft and propeller.
P/No: 3512302. TSN: 15,613 hours. TSO: 15,613 hours.
(1 similar occurrence)
Diamond DA40 Firewall to fuselage corroded.
Disassembly of firewall from fuselage found the
fireproof ceramic matting saturated with water. The
engine mount bolts were heavily corroded on the bolt
shanks. Suspect caused by inadequate attachment
and sealing of the firewall.
Gippsland GA8 Horizontal stabiliser ribs
cracked at pivot mounts. Ref 510007663
No1 tailplane rib cracked at the forward channel
mount bolt hole. Found during inspection iaw SBGA8-2002-02.
(2 similar occurrences)
Swearingen SA227AC Hydraulic transducer
failed. Ref 510007683
LH hydraulic pressure transducer failed. Loss of
hydraulic fluid. Hydraulic pumps changed and filter
inspected due to nil fluid.
Swearingen SA227AT Elevator tab control
system actuator intermittent. Ref 510007718
Elevator pitch trim actuator intermittent in operation.
P/No: DL504M6. TSO: 2,488 hours. (1 similar
Swearingen SA227DC Cabin door seal out of
adjustment Ref 510007732
Main cabin door seal out of adjustment. Loss of cabin
Bell 206B Main rotor transmission mount
bearing loose. Ref 510007676
Main transmission mount drag assembly bearing
loose due to failure of staking.
Bell 212 Main transmission failed.
Main transmission low oil pressure. Approximately
10 seconds later, the chip detector illuminated. After
landing, the crewman reported smoke from the rear
of the helicopter. On attempting to tie down the main
rotor it was discovered that the rotor was seized
and would not turn in either direction. Investigation
TSN: 4,024 hours/324 months. TSO: 775 hours/41
Cirrus SR20 Nose landing gear cracked. Ref
Nose landing gear cracked. Found during inspection
P/No: 11907005. TSN: 501 hours/62 months. (9 similar
Diamond DA20C1 Aileron control bellcrank
incorrectly fi tted. Ref 510007481 (photo below)
RH wing aileron control bellcrank incorrectly installed
into bracket P/No 20-2710-00-01. Bellcrank was held
in position in bracket by the tension of the AN4-16
bolt instead of the bolt being inserted through the
hole in the bellcrank.
P/No: 2027100002. TSN: 2,000 hours.
Swearingen SA227AC Flight compartment
power supply failed. Ref 510007695
Cockpit lighting power supply failed.
Piper PA31 Emergency exit separated. Ref
Emergency exit separated from aircraft during flight. Nil
damage to surrounding structure. Investigation found
the operating system handle bent slightly forward.
P/No: 5525921. TSN: 9,838 hours.
Piper PA31 Landing gear downlock hook stiff.
RH main landing gear downlock hook stiff in
operation. Bolt P/No 400-188 through hook found
to be tight.
P/No: 4198300. (1 similar occurrence)
Bell 412 Collective control cylinder servo valve
seized. Ref 510007697
Collective control cylinder servo valve seized in the
P/No: 212076005105. TSN: 2,522 hours/152 months.
TSO: 160 hours/18 months.
Eurocopter AS332L Main transmission chip
detector illumination – suspect contaminated
water. Ref 510007607
Main transmission chip detector light illuminated.
Investigation found no evidence of metal
contamination and it is suspected that the detector
was contaminated by rain due to poor protection of
detector from weather.
Eurocopter AS350B2 Rescue hoist cable cutter
activated. Ref 510007613
Rescue hoist cable cutter fired during hoist pre-flight
P/No: Y1265111. TSN: 10 hours/14 cycles.
Eurocopter EC135 Main landing gear skid shoe
cracked. Ref 510007739
LH rear skid shoe assembly cracked and split apart.
One of the attachment clamps was also split.
P/No: L321M1025101. TSN: 3,891 hours/5,934
cycles/5,933 landings/96 months.
Cessna A152 Wing attachment fi tting worn.
Main wing attachment fittings P/No 0422405-5, P/
No 0722707-1 and P/No 0523309-5 worn in the
P/No: 04224055. TSN: 8,520 hours.
Grob G115C2 Alternator drive belts too small faulty manufacture. Ref 510007661
Newly supplied alternator drive belts P/No
37A19773-376 found to be too small in diameter
and when fitted does not allow adequate clearance
between alternator and engine case. The belts have
identical part numbers to the old belts manufactured
in Korea. The new belts are manufactured in the EU.
Cessna 441 Cabin cooling system duct
separated. Ref 510007528
Air cycle machine (ACM) outlet duct separated.
Aircraft had just completed a major inspection.
Robinson R44 Engine exhaust pipe holed. Ref
Engine exhaust pipe bulged in area of exhaust pipe to
P/No: C16932. TSN: 435 hours.
Robinson R44 Tail boom skin cracked and
corroded. Ref 510007736
Tail boom skin cracked and corroded in area under
VHF COMM antenna. Severe corrosion and several
cracks were found with one crack over 50.2mm (2in)
in length. Found during removal of the antenna when
sealant deterioration was found.
TSN: 1,700 hours.
Robinson R44 Tail rotor pedals jammed – pitch
control slider severely corroded. Ref 510007673
Tail rotor pedals jammed. Investigation found the tail
rotor pitch control slider severely corroded (rusted).
Aircraft operates in a corrosive environment.
P/No: C0311. TSN: 136 hours/12 months.
Continental GTSIO520M Engine cylinder
induction tube cracked.
Ref 510007529 (photo below)
No. 4 and No. 5 cylinder induction tubes cracked. One
tube also deformed around clamping face. Engine had
recently been overhauled. Suspect damage caused to
engine during transit.
TSO: 40 hours.
end nipple is welded to the line at the manifold end.
Suspect caused by fatigue due to insufficient support.
P/No: 630657. TSO: 1,150 hours.
Continental IO520D Engine crankcase nut
cracked. Ref 510007662
Crankcase through bolt/cylinder hold-down bolt nut
cracked and bolt loose.
P/No: 6152541. TSN: 228 hours. (1 similar occurrence)
Continental IO520F Engine camshaft worn. Ref
Camshaft lobe worn. Metal contamination of oil filter.
TSO: 268 hours.
Continental IO520L Engine cylinder piston
broken. Ref 510007521
No. 6 cylinder piston skirt broken away. Metal
contamination of engine.
P/No: SA631475. TSN: 718 hours. (4 similar
Continental IO550N Engine cylinder piston pin
broken. Ref 510007714 (photo below)
No. 2 cylinder piston pin broken. Polish marks on
cylinder walls. Metal contamination of oil system.
P/No: 630046. TSN: 712 hours.
Continental LTSIO360E Engine oil pump drive
shaft broken. Ref 510007593
RH engine oil pump drive gear shaft broken. During
start-up the engine failed and the propeller feathered.
TSN: 4,937 hours. TSO: 882 hours.
Continental GTSIO520M FCU pressure service
port blanking cap separated. Ref 510007743
RH engine fuel control unit fuel pressure service port
blanking cap separated from fitting. Cap had been
incorrectly fitted during engine installation. Minor oil
leak was also noted from VAPC controller to engine oil
return line due to defective packing PNo MS28778-6.
Continental IO360E Engine fuel pump incorrect
data. Ref 510007583
Incorrect release certificates received with new fuel
Continental IO360E Engine fuel pump out of adjust.
Newly fitted engine fuel pump could not be adjusted.
P/No: 64936851A4. TSN: 5 hours.
Continental IO360E Engine fuel pump out of
adjust. Ref 510007582
Newly fitted engine fuel pump could not be adjusted.
P/No: 64936851A4. TSN: 5 hours.
Continental IO360K Engine fuel distribution
injector line broken. Ref 510007542
No. 6 cylinder fuel injector line broken at area where
Continental O300C Engine cylinder worn.
Engine cylinders worn resulting in excessive oil
consumption, fouled spark plugs and excessive blow
by. Found during inspection iaw AD/Eng/4 Amdt 10.
Lycoming IO360A1A Engine cylinder cracked.
Engine No1 cylinder cracked at top spark plug hole. Found
during compression tests, iaw AD/Eng/4 Amdt 10.
TSO: 594 hours.
Lycoming IO360L2A Engine FCU contaminated.
Engine fuel control unit blocked with contaminant.
Found during inspection iaw CASA AWB Engines 73.
See also SDR 510007691 and SDR 510007692.
P/No: 25765362. TSN: 2,106 hours. TSO: 510 hours.
(3 similar occurrences)
Lycoming IO540AE1A5 Engine exhaust pipe
holed. Ref 510007712
Engine exhaust pipe bulged in area of exhaust pipe to
P/No: C16932. TSN: 435 hours.
Lycoming IO540AE1A5 Engine fuel pump faulty.
Engine-driven fuel-pump diaphragm faulty. Leaking
oil from drain.
P/No: LW15473. TSN: 594 hours. (9 similar occurrences)
Lycoming IO540AE1A5 Engine muffler
collapsed. Ref 510007576
Muffler collapsed and deformed at junction with tailpipe.
P/No: C16932. (1 similar occurrence)
Lycoming LTIO540J2BD Engine cylinder
exhaust valve broken. Ref 510007672
RH engine No3 cylinder exhaust valve broken.
P/No: LW16740. TSN: 780 hours/12 months. (3 similar
Lycoming O235H2C Engine fuel pump failed. Ref
Engine driven fuel pump valve swage failed.
Plate, spring and seal loose inside pump. Metal
contamination of carburettor inlet filter.
P/No: LW15472. TSN: 1,728 hours.
Lycoming O235H2C Engine fuel pump failed. Ref
510007470 (photo below)
Engine-driven fuel-pump valve swage failed.
Plate, spring and seal loose inside pump. Metal
contamination of carburettor inlet filter.
P/No: LW15472. TSN: 1,728 hours.
Lycoming O540E4C5 Engine cylinder base stud
fractured. Ref 510007592
No. 4 cylinder upper forward base stud fractured.
Remaining nuts on the cylinder held normal torque.
P/No: 5015. TSO: 1,615 hours. (1 similar occurrence)
Lycoming TIO540AJ1A Engine starter casing
cracked and corroded. Ref 510007639
Starter motor mount casing cracked. Cracking was
as described in Cessna SB08-80-02 and Lycoming
mandatory Service Bulletin 577A.
TSN: 43 hours.
Lycoming TIO540J2BD Engine crankshaft
counterweight attachment broken.
Ref 510007685 (photo below)
GE CF348E5 Engine compressor section fan
module vibrates. Ref 510007726
No.1 engine fan module excessive vibration at 4.1
units. Vibration then dropped to 3.5 units after
approximately five seconds. All other engine data
normal. Investigation continuing.
GE CF680C2 Engine fuel distribution tube
leaking. Ref 510007694
No. 4 engine fuel tube leaking at mid-tube connection.
Tube located between fuel flow transmitter and hydro
mechanical unit (HMU). Leaking fuel damaged fire
retardant material on thrust reverser cowl.
GE CF680C2 Engine MEC suspect faulty.
RH engine failed to shut down when selected.
Suspect faulty main engine control (MEC).
Investigation continuing. (4 similar occurrences)
GE CF680E1 Engine starter drive shaft sheared.
No. 1 engine low oil quantity. Suspect caused
by overboard dump via the starter drain pad.
Investigation found that the starter drive shaft had
sheared and migrated aft, allowing an oil leakage
path across the starter adapter pad.
Rolls Royce RB211524G Engine air inlet section
damaged. Ref 510007650
No. 4 engine acoustic panel damaged and
delaminated at approximately 9 o’clock position.
Panel contained two holes of approximately 76.2mm
(3in) diameter. A rubber spinner tip was also found
embedded in the panel. Spinner had been changed on
27 December, 2008 due to missing tip. Investigation
found four outlet guide vanes (OGV) cracked beyond
limits in an area directly aft of the damaged panel.
Cracks ranged between 152.4mm and 177.8mm
(6in and 7in). Cracked OGV’s necessitated an
Rolls Royce RB211524G Thrust reverser faulty.
No. 4 engine thrust reverser faulty. Investigation
continuing. (5 similar occurrences)
Rolls Royce TAY65015 Engine low power. Ref
LH engine failed to achieve take-off power.
Investigation and ground runs carried out with
no faults found. Outside air temperature was 43
degrees C and is suspected that the extreme ambient
temperature was the cause of the problem.
GE CF680E1 Engine suspect faulty.
No. 2 engine spooled down to approximately 60 per
cent. Investigation continuing.
(2 similar occurrences)
Hamilton Standard 14RF19 Propeller hub
section nuts loose. Ref 510007707
LH propeller retaining bolt nuts (6off12) under
required torque. Propeller hub P/No 814721-1 requires
NDT inspection. Found during inspection iaw AD/
PHS/18 Amdt 3.
GE CFM567B Engine fuel distribution filter
contaminated. Ref 510007496
No. 2 engine fuel filter contaminated. Filter bypass
light illuminated. Investigation continuing.
P/No: ACC462F2038M. (6 similar occurrences)
Hartzell HCB3TN3 Propeller controlling cable
clip separated. Ref 510007688 (photo below)
RH propeller control cable-securing clip separated.
Loss of propeller control.
GE CFM567B Engine fuel pump leaking.
No. 2 engine-driven fuel pump leaking beyond limits.
P/No: 8283005. (9 similar occurrences)
over-pressurised due to a suspected constant speed
TSN: 91 hours.
McCauley 3FF32C501 Propeller assembly
damaged. Ref 510007611
RH propeller feathered following shut down. Propeller
was removed and sent to overhaul facility. Following
examination the following faults were found:
1. latch screw sheared 2. other latch screw bent towards
propeller centre 3. sheared portion of latch screw
embedded into latch plate by the piston 4. repairable
damage to piston skirt 6. minor internal scoring on
cylinder. Propeller had been fitted for four hours
following repair for similar problems on another aircraft.
P/No: 3FF32C501. TSO: 1,499 hours.
McCauley 4HFR34C652 Propeller governor
suspect faulty. Ref 510007532
LH engine nil oil pressure. Engine shut down and
emergency single engine landing carried out. Suspect
faulty propeller governor. Investigation continuing.
P/No: 89741016. (4 similar occurrences)
Eastern Aero Marine T9 Life Raft EAM T9 EPIRB
incorrect part. Ref 510007541
Incorrect EPIRB fitted to life raft. Model MRB4 EPIRB
fitted is not authorised per CMM(25-60-19). The
approved model is MRB3. EPIRB has worn a hole
between the left and right chamber assembly. A list
of other problems was also found
Goodrich rescue hoist faulty. Ref 510007729
Rescue hoist was being used for training. The cable
was routed over the cable cut switch and activated
the cable cutter. The cable was incompletely cut.
Investigation found cable cutter P/No 300414-1 was
P/No: 42325120. TSO: 1,377 cycles.
Kelly Aerospace 4091709001 Turbocharger
turbine wheel separated.
Ref 510007706 (photo below)
Exhaust turbocharger turbine wheel separated from
shaft at ring groove area. Turbocharger was on first
flight since fitment.
IAE V2527A5 Engine anti-icing system duct
split. Ref 510007478
No. 1 engine anti-ice duct split. Hot air caused
overheating of electronic engine control (EEC).
P/No: D36110013500200. TSN: 2,268 hours/1,542
cycles. TSO: 2,268 hours/1,542 cycles.
PWA PT6A114 Engine AD requirement.
Engine inspected iaw AD/Eng/5 Amdt9. Nil defects
(5 similar occurrences)
PWA PW123E Engine over-torqued.
No. 1 engine over-torqued to approximately 130–135
per cent, with propeller RPM approximately
Hartzell HCC3YR1 Propeller CSU unserviceable.
Propeller cylinder unit P/No E7157-1RB2281 separated
from hub unit causing oil leak and problematic
pitch control/operation. Piston was also cracked.
Investigation found that the P/No A2420-6) fine
pitch stop had been crushed mechanically in the
propeller indicating that the propeller cylinder was
Note: occurrence figures based on data received
over the past five years.
450–500rpm followed by an uncommanded
auto-feather. Investigation could find no definitive
cause for the over-torque, but numerous items were
changed. (5 similar occurrences.)
LH engine crankshaft counterweight attachment
broken, allowing the counterweight to move and
contact camshaft. The bent camshaft then broke
the cam followers and holed the crankcase. Loss of
Continued from page 32
parked. The AD was deliberately written
in such a way to give operators flexibility
to use a range of measures to achieve the
life for the same item listed in the FAA
approved limitations section of the Metroliner
maintenance manual. (The FAA did not raise
an AD in this case.)
At the same time, CASA also engaged in
urgent communication with the manufacturer
and the FAA, advising them of the problem
and of the action that CASA had taken. The
manufacturer agreed the action was justified,
and within two weeks, Fairchild had issued
a service bulletin placing a life on the gust
lock and fully supporting the actions taken
When CASA became aware that the
manufacturer had published a mandatory
retirement life on the gust lock, the AD, its
safety role performed, was cancelled.
‘The AD was
deliberately Later, the manufacturer amended the
Section Chapter 05 of the
written in Limitations
maintenance manual for the Metroliner so
such a way to that it now included a retirement life for the
give operators gust lock assembly.
use a range This was a good result: the unsafe condition
of measures that had been covered by CASA’s emergency
airworthiness directive was now adequately
to achieve the addressed, so there was no need for a
desired result.’ continuing AD to mandate a retirement
After an aircraft is pushed out of a hangar,
and into service, having been given its type
certificate; inevitably, problems are going to
arise which the designer and/or manufacturer
did not, or could not, anticipate, and which
consequently are not covered in the
original manuals. When these problems are
discovered, and reported by means of SDRs
and other industry feedback, airworthiness
directives such as the unique emergency
‘rudder gust lock’ case above, work to
mitigate the risk of such unforeseen ‘unsafe
conditions. Compliance to the AD mitigates
the risk created by this unanticipated
‘unsafe condition’, effectively returning the
aircraft to the original design standard of its
Fill out the form with the details of the corrosion defect.
In the description field of the SDR enter the word ‘SNAPON’ to be in the running to win a Snap-On Expandable
¼ drive General Service tool set with two socket sets
(Imperial and Metric) valued at over $800. Remember to
fill in the submitter’s details so that we can contact you if
verification of any detail is required.
A valid entry MUST:
Identify an account of corrosion that ‘would not’ have
been found whilst performing a current published
inspection procedure and has the potential to affect
the structural integrity of the aircraft if left untreated.
If you have submitted an SDR in the past, and you feel
that the occurrence was a good example of a corrosion
defect that currently has no inspection to catch it and
was found during an unrelated maintenance task then
you can notify us of the SDR number (or aircraft rego
and approximate date) via email to [email protected]
with a brief description of the defect (don’t forget to
mention ‘SNAP-ON’ in the subject title).
Include some pictures of your example to point out
the corrosion finding. (pictures and movies can be
attached after submitting the SDR, limited to 2MB for
There is no limit to the amount of times a participant
can enter, but each entry must relate to a separate
CASA reserves to the right to verify and investigate
information submitted via the SDR system.
The winner will be judged by a panel of CASA
Airworthiness experts and their decision will be final.
The best entries will be published in the May-June 2009
issue of Flight Safety with any pictures and description
of aircraft, owner’s or operator’s details removed for
Submit your corrosion SDR and be in the running to
win this expandable tool set with two socket sets
(RRP over $800) courtesy of SNAP-ON TOOLS
TO REPORT URGENT DEFECTS
97BB0 ')'-+- <7N0
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
To enter the competition, simply submit your SDR via the
website Visit http://casa
index.htm and click on the ‘SDR and SUP online form’.
Be received o
n or before the closing date of 09 April
Be the first reported case of the defect if multiple
reports are received.
NOT be fro
om employees, associated agencies or
ili off CASA
As a safety initiative, CASA, Flight Safety magazine and
Snap-On Tools are running a ‘corrosion competition’ to
encourage the reporting and identifying of airworthiness
concerns such as structural corrosion.
APPROVED AIRWORTHINESS DIRECTIVES
12 March 2009
Part 39-105 - Lighter Than Air
There are no amendments to Part 39-105 - Lighter
than Air this issue
Part 39-105 - Rotorcraft
Bell Helicopter Textron 205 Series Helicopters
AD/BELL 205/3 - Main Rotor Blade - Modification CANCELLED
AD/BELL 205/9 - Servo Cylinder Upper Control Tube
Fittings - CANCELLED
AD/BELL 205/16 - Fire Detection System - Audible
Warning - CANCELLED
AD/BELL 205/21 - Swashplate Scissors Lever Bolts Inspection - CANCELLED
AD/BELL 205/29 - Main Rotor Blade Bolt Washer Inspection - CANCELLED
AD/BELL 205/33 - Synchronised Elevator - Inspection,
Modification and Retirement - CANCELLED
AD/BELL 205/36 - Fuel Boost Pumps - Inspection CANCELLED
AD/BELL 205/41 Amdt 1 - External Cargo Suspension
Kit - Load Restriction and Modification - CANCELLED
AD/BELL 205/42 - Main Rotor Hub Inboard Fitting Life Reduction - CANCELLED
AD/BELL 205/47 - Hydraulic Servo Cylinder Assembly
- Spanner Link Assembly Inspection and Rework CANCELLED
AD/BELL 205/49 - Elevator to Horn Assembly
Attachment - Modification - CANCELLED
AD/BELL 205/50 - Main Rotor Grip/Blade Bolt Inspection and Rework - CANCELLED
AD/BELL 205/51 Amdt 1 - Vertical Fin Spar Cap CANCELLED
AD/BELL 205/59 - Swashplate Outer Ring CANCELLED
AD/BELL 205/75 - Swashplate Support Assembly
Bell Helicopter Textron Canada (BHTC) 206 &
Agusta Bell 206 Series Helicopters
AD/BELL 206/130 Amdt 3 - Main Landing Gear Cross
Bell Helicopter Textron 212 Series Helicopters
AD/BELL 212/14 - Fuel Boost Pumps - Inspection CANCELLED
Eurocopter AS 332 (Super Puma) Series
AD/S-PUMA/83 - Hinged Door Upper and Lower
Eurocopter AS 350 (Ecureuil) Series Helicopters
AD/ECUREUIL/71 Amdt 3 - Tail Rotor Blade Trailing
AD/ECUREUIL/134 - Starter-generator Damping
Eurocopter AS 355 (Twin Ecureuil) Series
AD/AS 355/60 Amdt 3 - Tail Rotor Blade Trailing Edge
Kawasaki BK 117 Series Helicopters
AD/JBK 117/31 - Tail Rotor Balance Weights
Part 39-105 - Below 5700 kg
AD/PC-12/54 - Fuselage Overboard Vent Installation
Aerospatiale (Socata) TBM 700 Series
AD/TBM 700/51 - Wiring Harness Inspection
Piper PA-36 (Pawnee Brave) Series Aeroplanes
AD/PA-36/4 - Flap Control - Modification CANCELLED
AD/PA-36/5 Amdt 1 - Pre-Certification Requirements Modifications - CANCELLED
AD/PA-36/7 - Wing Main Spar Centre Section Modification - CANCELLED
AD/PA-36/8 Amdt 1 - Forward and Aft Wing
Attachment Fittings - Inspection and Modification
AD/PA-36/10 - Spray Pump Windmill - Modification CANCELLED
AD/PA-36/11 - Muffler Clamp - Installation CANCELLED
AD/PA-36/13 - Fuel Tank Vent - Inspection CANCELLED
AD/PA-36/16 - Control Rod End Bearings Replacement - CANCELLED
AD/PA-36/18 Amdt 1 - Wing Main Spar Carry Through
Assembly - Inspection
AD/PA-36/20 Amdt 2 - Engine Mount Attach Brackets
- Inspection and Modification
Airtractor AT-300, 400 and 500 Series
AD/AT/24 Amdt 2 - Overturn Skid Plate
Beechcraft 200 (Super King Air) Series
AD/BEECH 200/67 Amdt 5 - Fuselage Rear Pressure
Cessna 170, 172, F172, FR172 and 175 Series
AD/CESSNA 170/85 - Alternate Static Air Source
Selector Valve Placard
Cessna 177 Series Aeroplanes
AD/CESSNA 177/34 - Alternate Static Air Source
Selector Valve Placard
Cessna 180, 182 and Wren 460 Series
AD/CESSNA 180/94 - Alternate Static Air Source
Selector Valve Placard
Cessna 185 Series Aeroplanes
AD/CESSNA 185/50 - Alternate Static Air Source
Selector Valve Placard
Cessna 188 (Agwagon) Series Aeroplanes
AD/CESSNA 188/20 Amdt 2 - Aileron Control Cables
Cessna 206 Series Aeroplanes
AD/CESSNA 206/66 - Alternate Static Air Source
Selector Valve Placard
Cessna 207 Series Aeroplanes
AD/CESSNA 207/40 - Alternate Static Air Source
Selector Valve Placard
Cessna 208 Series Aeroplanes
AD/CESSNA 208/24 - Alternate Static Air Source
Selector Valve Placard
Cessna 210 Series Aeroplanes
AD/CESSNA 210/75 - Alternate Static Air Source
Selector Valve Placard
Cessna T303 Series Aeroplanes
AD/CESSNA 303/14 - Alternate Static Air Source
Selector Valve Placard
Cessna 336 Series Aeroplanes
AD/CESSNA 336/15 - Alternate Static Air Source
Selector Valve Placard
Cessna 337 Series Aeroplanes
AD/CESSNA 337/31 - Alternate Static Air Source
Selector Valve Placard
Dornier 228 Series Aeroplanes
AD/DO 228/12 Amdt 1 - De-bonding of Surface
Protection on Rudders and Elevators
Gippsland Aeronautics GA8 Series Aeroplanes
AD/GA8/5 Amdt 2 - Horizontal Stabiliser Inspection
Pilatus PC-12 Series Aeroplanes
Piper PA-46 (Malibu) Series Aeroplanes
AD/PA-46/1 - Aft Rudder Cable - Inspection CANCELLED
AD/PA-46/2 - Interface of Elevator to Horizontal
Stabiliser - Inspection and Modification - CANCELLED
AD/PA-46/4 Amdt 2 - Wing and Wing to Fuselage
Fairing Rivets - CANCELLED
AD/PA-46/34 - Stall Warning Heat Control
Part 39-105 - Above 5700 kg
Airbus Industrie A330 Series Aeroplanes
AD/A330/95 Amdt 2 - Air Data Inertial Reference Unit
AD/A330/99 - Centre Wing - Frame 40 Rear Fitting
Avions de Transport Regional ATR 42 Series
AD/ATR 42/25 - Wire Bundles in the Rear Baggage
Bombardier (Canadair) CL-600 (Challenger)
AD/CL-600/54 Amdt 1 - Overwing Emergency Exit
AD/CL-600/104 Amdt 1 - Inboard Flap Actuator
AD/CL-600/107 - Angle of Attack Transducer
Bombardier (Boeing Canada/De Havilland)
DHC-8 Series Aeroplanes
AD/DHC-8/144 - De-Ice Busbar Sealant
Cessna 560 (Citation V) Series Aeroplanes
AD/CESSNA 560/10 - Angle of Attack System
Embraer EMB-135 and EMB-145 Series
AD/EMB-145/22 - Landing Gear Electronic Unit
Fokker F100 (F28 Mk 100) Series Aeroplanes
AD/F100/93 - On-Ground Wing Leading Edge Heating
APPROVED AIRWORTHINESS DIRECTIVES CONTINUED.......
Part 39-106 - Turbine Engines
CFM International Turbine Engines - CFM56
AD/CFM56/28 - Low Pressure Turbine Rear Frame
Rolls Royce (Allison) Turbine Engines AE 3007 Series
AD/AE 3007/6 Amdt 1 - High Pressure Turbine
Stage 2 Wheels
Turbomeca Turbine Engines - Arriel Series
AD/ARRIEL/30 - Digital Engine Control Unit
AD/ARRIEL/31 - Reduction Gear Box
Part 39-107 - Equipment
AD/EMY/8 - Life Jackets - Inspection and
Modification - CANCELLED
AD/EMY/9 - Life Jackets - Modification - CANCELLED
AD/EMY/17 - Life Jackets - Retirement - CANCELLED
AD/EMY/19 - Life Jackets - Inspection - CANCELLED
AD/EMY/21 - Life Jackets (RFD) - Inspection CANCELLED
Fuel Supply and Metering Equipment
AD/FSM/31 Amdt 2 - Fuel Injection Servo Plugs
Instruments and Automatic Pilots
AD/INST/1 - Gyro Horizon Indicators Power Failure
Warning Flag - Modification - CANCELLED
AD/INST/7 - H14 Automatic Pilot Servo Housing Inspection - CANCELLED
AD/INST/12 - SEP 6 Automatic Pilot Roll Computer
Clutch Circuit - Modification - CANCELLED
AD/INST/13 - Venting of SEP 2 Servomotor Clutches Modification - CANCELLED
AD/INST/14 - SEP 6 Automatic Pilot Pitch Computer
Clutch Circuit - Modification - CANCELLED
AD/INST/16 - King KG 102 Directional Gyro Modification - CANCELLED
AD/INST/17 - King K1 525 Indicator - Modification CANCELLED
AD/INST/18 - Collins PN-101 Pictorial Navigation
System Slaving Accessory 328A-3G - Modification CANCELLED
AD/INST/20 - Sep 2 Automatic Pilot Trim Servomotor
Venting - Modification - CANCELLED
AD/INST/21 - King KFC200 - IAFCS - Bridle Cable
Clamps - Inspection - CANCELLED
AD/INST/25 - Aerosonic Encoding Altimeters Replacement - CANCELLED
AD/INST/26 - Navomatic 200A Automatic Pilot
Computer - Amplifier Nav Input - Modification CANCELLED
AD/INST/28 - A.R.C. PA1050A Actuator and DA1050A Decoupler Adapter - Cessna 1050A I.F.C.S.
- Inspection and Modification - CANCELLED
AD/INST/33 Amdt 1 - King KAP/KFC 200 Autopilot CANCELLED
AD/INST/35 - Collins APP-80/80A Autopilot Panel CANCELLED
AD/INST/36 - Collins ALI-80( ) Barometric Altimeter
Propellers - Variable Pitch - Dowty Rotol
AD/PR/33 Amdt 3 - Hub Assembly
There are no amendments to Part 39-106 - Piston
Engines this issue
Part 39-106 - Piston Engines
AIRSERVICES UPDATE - AL58 EFFECTIVE
12 MARCH 2009
The International Civil Aviation Organization’s (ICAO) regional
supplementary procedures (Doc 7030) require that pilots are advised
of SIGMET up to two hours’ flying time ahead. The AIP and Air Traffic
Services (ATS) manual have been amended accordingly.
‘Aviation special weather’ - SPECI, which can be obtained from an
automatic broadcast service (ABS), no longer needs to be ‘directed’ or
‘broadcast’ to aircraft by ATS. The availability of SPECI from an ABS
meets the requirement for in-flight information service. If an ABS is
not available, pilots may request weather information from ATS as
part of the on-request flight information service.
Owing to difficulties in identifying aircraft using area forecasts (ARFOR)
for operational control, and to capture all possible users, amended
ARFOR will be communicated by broadcast only. The broadcast will
be repeated at H+15 and H+45 to ensure adequate dissemination.
There is new, clearer wording for the ‘Hazard Alert’ paragraphs.
‘MAINTAIN’ and ‘AMENDED’ - GEN 3.4 paras 4.7, 5.5 and 5.14.6
Previously, the word ‘MAINTAIN’ instructed aircraft to climb to
their initial level on departure. However, when issuing level change
instructions, ICAO specifically precludes using ‘MAINTAIN’. When
allocating levels in departure instructions, controllers will use the phrase
‘CLIMB TO …’ However, ‘MAINTAIN’ will still be used by clearance
delivery in airways clearance and on pre-departure clearance.
Clearing an aircraft at an ‘amended level’ in an airways clearance to
provide a ‘paper stop’ for air traffic control (ATC) separation will also
cease. Aircraft will be cleared at an initial level, or at their planned
level, unless there is an operational reason to do otherwise. Therefore,
the prefi x ‘AMENDED’ will not be used:
A. when an initial level for ATC traffic management purposes has
been issued as part of an airways clearance – in which case
‘MAINTAIN’ shall be used; or
during normal progressive climb/descent instructions.
Including location with runway crossing request - GEN 3.4 para 5.14.5
To further mitigate runway incursions, and to improve the situational
awareness of ATC, other pilots and vehicle drivers, pilots can include
their location on the manoeuvring area in their runway crossing
request. This change complements similar ATC phraseology changes.
SIGMET and AIRMET dissemination - GEN
3.5 para 5.1.3 and 5.3.3
The issuing of a SIGMET or AIRMET report
by the Bureau of Meteorology does not meet
the conditions for ATC to issue a ‘Hazard
Alert’. Although this change was made in
2007, these AIP paragraphs were accidentally
left out from that change. Air traffic control
will continue to disseminate SIGMET and
AIRMET reports as part of ATC-initiated flight
Content of a clearance - ENR 1.1 para 3.19.2
The updated paragraphs describing the
contents of a clearance now mirror ICAO’s
and align AIP with the ATS manual. There is
no change in operational practice.
Approach expectation - ENR 1.1 para 11.5.2
Air traffic control informs pilots of the type
of approach to expect via the ATIS. However,
pilots wishing to conduct a specific approach
should request it prior to standard instrument
arrival (STAR) clearance issue, or prior to top
of descent for arriving aircraft not on a STAR
SARTIME cancellation - ENR 1.1 para 67.2.3
Cancel SARTIME by calling CENSAR on 1800
814 931, to reduce multiple message-handling
and reduce frequency congestion.
PJE broadcasts - ENR 5.5 para 2.1.3
Pilots must complete all necessary parachute
jumping exercise (PJE) broadcasts (CASA
Instrument 278/97 and current AIP). Air traffic
control cannot do this, and often will not have
access to all the frequencies required, so the
last part of para 2.1.3 has been deleted.
Hazard Alerting, SIGMET, SPECI and amended ARFOR - GEN 3.3 para 2
by Kris McLean
I started flying in sailplanes thirty years ago,
wondrous flying machines which can go great
without an engine. From there
ve into powered fi xed wing: C172s,
Warriors and the like.
ally I got into helicopters. I soon learned
re flying m
machines of a different pedigree
o ther; there are
ar a lot more moving parts
hey are harder to m
They are also
as er to overload: d
n a ttwo-seater with full
mmer can not
nly make you illegal,
k it impossible
bl to get airborne.
Turning is different too; left pedal turns in
American-built machines are accomplished
with iincreased tail rotor pitch and consume
than right pedal turns. Despite
hi left turns are generally preferred as they
are less inclined to accelerate than right pedal.
Furthermore, rotary wing aircraft can be easier
to tip over than planks, so much so that the
training syllabus has a section on not doing it.
‘Avoiding dynamic rollovers’ it’s called.
The big day was fine but
y, so I was
to land into wind because
two up in a 22 at
ssix and half thousand
d feet don’t leave much
in the way of that great saviour of average
pilots - surplus power margin! We had a ball,
checked out all the Victorian ski fields, then
filled up at Hotham and did Kosciusko too.
were on the way home when I got the idea
us one more picture. What is it about
n nature that makes us greedy? We’d
had a great, safe day’s flying, but I had to push
my luck for one more photo opportunity.
As we approached up-slope to a hilltop, the
snow was heaped up into a long drift that
looked steeper the closer we got to it. The
wind had dropped during the day to just five
to eight knots, so I decided to turn down
wind and try for some more level ground.
Instinctively, I turned left. Big mistake, the
low-rotor RPM horn came on mid-turn, and
by the time I’d got us pointing down slope, the
machine settled with power at 35 knots and
started to slide. I tried to wind on some more
throttle, but the governor had already maxxed
it out. Slipping downhill, I racked my brain for
some ideas on what to do next. It occurred
to me that there hadn’t been a lesson in my
training on what to do when careening down
a steep, snow-covered slope in a helicopter.
Clearly I needed to do something before I
ended up with a bent whirly-bird.
I attempted to raise the collective. The lowrotor RPM horn came on again, so I tried
lowering it. The skids started to dig in and
it felt like we might nose over. Finally, in
desperation, I kicked in a boot full of left
pedal. The bird slewed, slowed immediately,
but started a dynamic rollover to the right. I
actually breathed a sigh of relief. For the first
time in the last five, terrifying seconds, I knew
exactly what to do. I floored the lever and
pushed in as much up-slope stick as I could.
We plopped back onto two skids &and I looked
over to my
hey?’ he said
and flashed me
a wan smile.
I felt like a W
cloth, but I knew i
we couldn’t stay
there; we had a
list and it would be
dark in a few more
hours. I booted junior
gr ’d had a
out and handed him
the mobile phone in We
case I came to grief
extracting myself from the g
y ’s d
predicament I’d put us in.
I took a few deep breaths,
I ha my
calmed myself, then raised bu t
the lever and wiggled the
pedals to free up the skids. t
or o to
The bird unstuck clumsily and I
lu e pho
had cyclic everywhere till I got a
hover. Next I tried for some out- m o
of-ground-effect manoeuvring to
check there was nothing wrong op
with the engine. Lastly, I put down
facing into wind on the edge of a
precipice so I could nose over after
I picked up my passenger. The rest of
the day was uneventful.
So what’s to learn? Well I needn’t have
taken on full fuel at Hotham, and I
definitely shouldn’t have used left pedal,
or turned down wind at altitude. I should
maybe have shut down, got out and given
the helicopter a thorough inspection before
taking off again. I’m very grateful to have
escaped the episode unscathed. All I can say
is, if you take a chopper to the snow be careful,
do a reserve power check and always land into
wind, because it’s no fun scaring the daylights
out of yourself and your passengers.
After nine hundred hours in my little R22,
most of it at 500ft, I finally decided I knew
enough about the vagaries of the helicopter to
try my hand in Australia’s bit of high ground,
the Snowy Mountains. With a max altitude
below 7000ft, the destination seemed low
enough to be safe if I was cautious,, so w
the opportunity to do some high country flying
with my sibling presented itself, I grabbed
by Patrick Fogarty
but I knew
I was over the moon. My recently-acquired PPL represented the
culmination of a lifetime’s passion for flying. Desp
pite only being able to
afford a lesson or two a month, I went solo after six hours and earned
my PPL with a minimum of fuss in just on minimu
mum hours. I may not
have been flying often, but I was practising radio ccalls and checklists
in the car every day.
The day started fairly innocuously. I was to fly down to Nowra to see
some guys, a good chance to get a couple of hours up and
nd visit a new
airport. I knew the scenery on the coast was well worth seein
was looking forward to the trip. As I got to the airport I was looking
to the sky with an optimist’s eye. The forecast was for scattered cloud
at 1000ft with a few at 3500ft, and I imagined lots of blue between
the grey (even if it wasn’t there). Once I had checked out the plane
and got clearance, I took off and climbed on my initial track to Lake
George South. At 800ft above Canberra airport (2600 QNH), I was just
pushing the bottom of the few at 1000, so I radioed the tower to stay
at 2600. The tower gave me clearance ‘special VFR, track as required
At this point I felt the first twinge. I knew that special VFR suggested
that the weather was not that flash, but I knew the area well and still had
good clearance over my track. Besides, once I reached Lake George,
the country flattened out to Goulburn, and I would make a call then
whether to cross
the ranges to
Nowra or return.
As I picked a route
between the ridges to
Lake George I was forced
to lose 100ft, then another
100ft, in order to stay out
of cloud. The cloud base was
pushing me down. It was certainly
no longer a few clouds. After being pushed to
2500 ft, I made the decision that I would get
clearance and return as soon as I got to Lake
will fly themselves perfectly well if pilots
As I crossed the southern edge of Lake George
I breathed a sigh of relief. Then suddenly my
whole world went wrong - my world went
grey, all grey!
which was workload I didn’t need. I first
I had been navigating with reference to the
ground and in truth, for some time, hadn’t
looked at the horizon. When I crossed the
boundary of the lake the ground became
the same grey as the sky, exactly. The feeling
was incredible; my stomach was gripped
with intense nausea and my eyeballs pushed
through the windshield looking for a feature I
could use, any feature. I was seeing things. In
the absence of a good reference, my brain was
happy to cling to anything, with potentially
and suggested I might consider following the
I would like to think that it took two to three
econds to get a grip, but in reality I think it
ve to 10 seconds. I knew the statistics.
I had read that
at VFR pilots last an average of
45 seconds when faced with unexpected IFR,
and at 300ft above the water I knew I didn’t
have that long. I also knew the other rule:
trust the instruments, no matter what.
I had the advantage that it was a fairly still
day and the aircraft was in perfect trim
before I crossed the lake edge (a leftover
from my glider experience). I knew I had the
coordination skills to fly IFR easily, but the
mental aspect was incredible. I fell back to my
glider days. My instructor used to say ‘planes
would just leave them alone’. I got a T-pattern
going and nudged the plane up a hundred or
so feet. In truth, I had no idea if I was in cloud
or not. The grey water was a perfect match for
the sky. I knew that about half way across the
lake there was a visible fence at a true right
angle to my flight path, and that if I stuck to
the instruments till then I would get a muchneeded visual reference for reinforcement.
the grey murk and concentrate on the dials.
I had to call for clearance back to Canberra,
called approach on 124.5 and was redirected
back to Canberra tower as I could not get to
3000ft. Tower cleared me by whatever route,
main road back. A great idea and not one I
was in any condition to think of myself.
As the fence loomed up I noted it with relief,
but stuck to the dials and did a gentle left
turn to follow the road. From there I followed
the road along the lake edge and through the
cuttings to the northern suburbs of Canberra. I
then cut across to join a right circuit for runway
30. As I joined the circuit, the tower had me
look out for a green bird dog in front of me
in the circuit. I had no chance. The emotion
I felt at seeing the tarmac with its little white
dashes meant I would have struggled to see a
7 on finals,
nals let alone a small camouflaged
war bird. I lande
ded on R30 and got back to the
office before 9.30a
That night I wrote the couple
of words on the
line that have often reminde
nded me that I was
lucky; sometimes you only get one
I took the incident as an incentive to do an IFR
rating, and although I now live in the UK and
haven’t flown enough to finish it, I believe all
pilots should keep their IFR skills in good nick
if they intend to fly in anything other than
wrong - my
This thought helped me stop ‘seeing things’ in
by Geoffrey Gibbons
It was a good day for a VFR flight from
Bankstown to Maroochydore and I was
healthy and well-trained. The twin-engine
Piper Seminole I was about to fly was brand
new. The baggage was loaded, and a close
friend and two beautiful blondes were ready
to climb aboard. I turned to board and froze
when my gut feeling said ‘drop everything and
go home now’. However, it was a momentary
thing, and the laughter of the girls snapped
me out of it.
Although quite new to multi-engine flying, I
was starting to settle down after an uneventful
departure. As we transited the light aircraft
lane, Sydney was clothed in a twinkling haze
out the starboard window. The passenger in the back carefully opened
a thermos and poured me a coffee. Yes! She’d remembered to be
mindful of the change in air pressure. The passenger beside me lit
a cigarette and stuck it in my mouth. Setting the autopilot, I almost
missed her provocative grin.
Man! This is what being a pilot is all about! A good friend, beautiful girls
and a zip up the coast in an aircraft expensive enough to let me pretend
that I was smarter, stronger, richer and better looking than I am.
Then, like most, a life-threatening problem began in a small way.
Overhead Port Macquarie my friend asked, ‘Aren’t these trips
measured in engine hours, Geoff? What are the chances of putting on
a bit more power?’ The engines were already set at cruise. Mixture,
manifold pressure and props were at a setting where the Lycomings
were purring comfortably and I had no intention of changing anything.
I gave him a ‘She’ll be right mate,’ and he settled down.
But, things were getting worse in our tightly-confined space: the
chatter in the cockpit was decreasing, and the level of discomfort
increased exponentially. However, I was oblivious to it all, as we were
approaching Coolangatta and I was thinking about our passage past
the western side of the Brisbane primary control zone.
This man had been my friend for two years, but when I
turned to speak to him he was almost unrecognisable.
In my earlier working life I’d done a little nursing in a
psychiatric ward, and at 1500ft AMSL it was all there.
With his lips pressed flat together, eyes granite hard and
shoulders set for the swinging of a punch, I could see that
the friend I had loved like a brother was no longer aboard
the aircraft. Before I could speak, his growing rage surfaced,
and he growled. ‘It wouldn’t kill you to put some power on
and save us some dough!’
The dominoes were falling rapidly around me. I decided to give
him what he wanted: the first order of business was to fly the
My eyes were ‘hard out’ the port side of the aircraft, when the
sound of the engines jumped, increasing suddenly. With a start I
turned, just in time to see my friend’s arm slip back into the rear
cabin. I reset the power immediately, but I was utterly stunned;
I’d never had a passenger do that to me. In fact, I had never
even heard of such a thing! For a passenger to touch
the controls of an aircraft in flight without the consent
of the pilot is a breach of protocol the size of the Great
Australian Bight. I wanted to say something, but what?
I felt heaviness in the pit of my stomach and a burning
behind my eyes because I finally realised just how much
the mood in the aircraft had changed. The two girls had
stopped talking completely. Quite a lot of time had passed
since my earlier refusal and my friend had been ‘stewing’
ever since. The right thing was to keep cool, turn around and
say something firm but polite. It was important to resolve this
situation because Brisbane CTR was coming up fast.
W ith a
just in d,
plane safely. Hunched up and afraid, the
girls sat curled in their seats and their white
faces finally convinced me. Time to pour on
I reached for the throttles and then had a
shattering realisation. The scene outside the
windows had changed radically. The ocean
wasn’t where it was supposed to be. Pushing
my forehead against the window, I saw, directly
below, a huge Boeing RPT aircraft parked on
the ground adjacent terminal buildings. I felt
my heart jump as I began to hear the words
of the anxious flight service officer for the
first time in some minutes. A few minutes
doesn’t sound like much, but horizontal
movement across the ground at around 4500
metres per minute will put you over a control
zone boundary in a flash. Brisbane airport
was below, and the flight service officer had
my undivided attention. He vectored me to
Redcliffe airport. I increased the prop rpm,
then pushed the power almost to the gate. The
shout of approval from my mate in the back
irritated the hell out of me!
We cleared the control zone quickly, and it
wasn’t long before the Hornibrook Viaduct
hove into view. However, I wasn’t even
close to breathing a sigh of relief, because I
desperately wanted to get this bloke on the
ground. He was laughing; but it wasn’t
healthy laughter, or the gentle mirth of
to put some
I blew into the circuit at Redcliffe
airport like a rocket. Punching
holes in the air crosswind
at 160 knots, I stood the
Seminole on its wing and
turned for a left downwind
for runway 07. My turn for
base wasn’t a base at all, but
a single teardrop onto final.
Loading the wings to wash
off speed, I dropped gear and
full flaps as I lined up with the
runway. Oh that beautiful runway!
It looked like it had just been laid
by God Himself for a hapless pilot
who’d just been dropped into a
meat grinder. The threshold swept
by, and for the first time that day I
did something truly great; the landing. It was
so gentle and centred that I didn’t even feel
the wheels touch the ground. In all the flying I
have done (including sailplanes), it really was
my best landing ever.
We were down and safe. But I couldn’t help
thinking about how much safer those paying
passengers were in Brisbane primary control
zone. As we got out of the Seminole in front
of the terminal building, my friend had settled
into a cheerful mood - almost as if nothing
had happened. The girls were strained and
quiet, and although I was shell-shocked
myself I straightened up, spoke in a level
voice and calmly walked the three of them
into the terminal. Not long before a kindly
old ex-Qantas pilot had told me that the ‘op’
isn’t over until your passengers are cleared
from the surface movement area. When the
passengers were settled with a coffee, I rang
the number I’d been told to ring while still in
the middle of the CTR. The angry air traffic
controller said, ‘Next time, put the crazy
bastard in the baggage compartment!’
It was over.
However, there is a postscript. Three weeks
after this incident that ‘friend’ of mine took a
switchblade to a man who was a gentle soul,
and carved the nose right off his face. The
same knife he had with him on the day of my
CTR incursion. My licence was temporarily
suspended, because crossing a control zone
boundary without first obtaining an airways
clearance is one of the big ones. I filled out the
Form 225 in a simplified manner because I
was afraid of what this bloke might do to me if
there was any further investigation. However,
I did stand in front of the flight standards
examiner, look him in the face and tell him
every appalling detail.
Fellow pilots: it is not for me to tell you how
to conduct your operations. But I humbly urge
you. Know something about the mental state
of your passengers. Know something before
it’s too late for you, them and the Boeing 747
you collide with. Never forget: you are ‘pilot in
command’ and the buck stops with you.
Mh_j[ je ki WXekj Wd Wl_Wj_ed
Write about a real-life incident that you’ve been
involved in, and send it to us via email: [email protected]
gov.au. Clearly mark your submission in the
subject ﬁeld as ‘CLOSE CALL’
Articles should be between 450 and 1,400 words. If preferred, your identity will be kept confidential. Please do not submit articles regarding
events that are the subject of a current official investigation. Submissions may be edited for clarity, length and reader focus.
Executive Director's Message
On 2 December 2008, the Minister
for Infrastructure, Transport, Regional
Development and Local Government
released the National Aviation Policy
Green Paper. One of the Paper’s
stated objectives was to strengthen
the governance arrangements for the
Australian Transport Safety Bureau
52 The Government has decided to
establish the ATSB as a statutory agency
ncy and to introduce
a Commission structure to enhance its independence. This
will ensure that it continues to conduct the most thorough
investigations possible and to foster appropriate safety action. It
will also enhance the quality of the Bureau’s relationship with the
industry and the aviation community. Legislative amendments
to the Transport Safety Investigation Act 2003, to give effect
to the governance changes, are expected to be introduced into
Parliament in early 2009, with the new Commission to be in
place by 1 July 2009.
The Government is currently developing an Aviation White Paper
to guide the aviation industry’s growth over the next decade and
beyond. The Government aims to give industry the certainty and
incentive to plan and invest for the long term, to maintain and
improve our excellent aviation safety record, and to give clear
commitments to travellers, airport users, and the communities
affected by aviation activity. The Government is now inviting
comments on the Aviation Green Paper to be considered in
the development of the White paper which is expected to be
released in the second half of 2009.
The Green paper is available on the internet, at <http://www.
Meanwhile, on the legislation front, the Aviation Legislation
Amendment (2008 Measures No.2) Bill 2008 is currently before
the Parliament. This Bill contains important measures to address
matters concerning the maintenance of Cockpit Voice Recorders
and the reporting of safety incidents that arose out of the ATSB’s
investigation of the fatal accident at Lockhart River on 7 May
2005. Both sets of amendments seek to ensure Australia is in
the best possible position to learn from accidents and incidents.
Kym Bills, Executive Director
Aircraft depressurisation – what
cabin crew need to know
epressurisation, also called decompression, is the reduction of
atmospheric pressure inside the cabin of a pressurised aircraft.
ft depressurisation events are rare, but they can occur with
little or no warning.
An ATSB safety bulletin for cabin crew, published in January 2009,
provides an overview of aircraft
ft depressurisation events, highlighting
key information that cabin crew should know in the event of an aircraft
depressurisation or failure to pressurise. The
Th aim of this bulletin is
to increase cabin crew’s knowledge about depressurisations and to
supplement their airline’s emergency procedures.
A review of the ATSB’s aviation safety database identified
fi 310 accidents
and incidents between September 1998 and August 2008 where a
pressurisation problem occurred. High capacity passenger aircraft
involved in 124 of those occurrences.
The public’s perception of depressurisations is of rapid depressurisation,
in which there is a sudden change in cabin pressure causing objects
to be ‘sucked’ out of the aircraft.
ft Thankfully, rapid or explosive
depressurisations and the significant
ft damage associated with
them are very rare. Only two Australian accidents since 1998 involved a
rapid or explosive decompression.
However, a real danger lies in gradual or subtle depressurisations. These
are caused by a slow air leak from the pressurised cabin, such as through
an improperly sealed door. As gradual depressurisations occur over a
longer time, they can be diffi
fficult to detect before oxygen masks fall from
the cabin ceiling. Sensors fitted
to commercial aircraft
ft will provide the
flight crew with a cockpit warning if the air pressure in the cabin drops
to the equivalent of 10,000 feet. Passenger oxygen masks are designed to
automatically deploy before cabin pressure reaches 15,000 ft.
Once a pressurisation problem is identifi
fied by the flight crew, all cabin
crew and passengers should immediately don their nearest oxygen mask.
Cabin crew should always put their own mask on before instructing or
helping others with their masks, as there is not always time to assist others
before becoming unconscious. Staying calm and breathing normally are
important, as hyperventilating uses up more oxygen. Once breathing
through an oxygen mask, cabin crew should secure themselves as best as
possible. Cabin crew must put their safety first by remaining secured. If a
crew member puts their safety at risk and is injured, there will be one less
trained safety professional who can assist if the situation escalates.
The ATSB safety bulletin also provides supplementary information to
cabin crew on common physical effects
of depressurisation and how to use
an oxygen mask. Q
ATSB Research and Analysis Report AR-2008-075(2)
FSA Mar-Apr 2009.indd 48-49
Aviation Safety Investigator
Cirrus changes parachute system design
blanking cap had probably
been inadvertently fitted
test port on the engine during
maintenance and that the plastic
cap had detached from the test
port just prior to the accident.
ft the aircraft
ft impacted terrain
close to the M7 motorway. Witnesses
reported that the aircraft
ft appeared to
be attempting to land on the motorway
but, just prior to impact, it veered away
from the road to the right and struck
the ground in a nose-down, right winglow attitude. Th
ft was seriously
damaged and both occupants sustained
Some of the emergency services personnel
who attended the aircraft
ft accident had
no prior knowledge of the CAPS and the
potential dangers it posed, if it had not
been deployed. The
Th ATSB warned the
attending police site controller of the
existence and potential danger of the
CAPS. Following consultation with the
ATSB and an aircraft
representative, emergency service
personnel subsequently cut through
the roof of HYY to remove the injured
An examination of the wreckage
indicated that the aircraft
ft struck several
trees before heavily impacting rising
Th impact completely detached
the right main landing gear assembly
and fractured the fibreglass laminate
structure of the left
ft main landing gear.
Both wings were extensively damaged
and both internal wing fuel tanks
were breached. The rear fuselage and
empennage assembly broke away from
the main fuselage at a point behind the
rear baggage compartment and came to
rest alongside the main wreckage. Th
flight control cables between the rear
fuselage and the main wreckage remained
Th investigation determined that
the engine stopped due to the loss of
a blanking cap from the un-metered
fuel pressure test port in the engine
fuel system. Testing showed that the
engine would not operate with the cap
missing. The investigation revealed that,
instead of the normal steel cap, a plastic
The pilot had activated the
CAPS at an estimated height
of 90 to 120 ft above ground
level, well below the aircraft
decision altitude for successful
parachute deployment. The
fired, however the
parachute did not deploy and
the rocket became entangled
in the aircraft
ft’s empennage. It
is possible that the entanglement of the
rocket and deployment harness around
the tailplane and fl
flight controls may have
the controllability of the aircraft
resulting in the aircraft
ft diverting from
the intended flight path.
n 5 February 2007, a
Cirrus SR22 aircraft
with a pilot and one passenger on board, was being
operated on a private fl
from Canberra, ACT to
Bankstown, NSW. As the
ft approached the Cecil
Park area, at a height of
800 ft above ground level, the
pilot reported to air traffic control (ATC) that the
engine had lost power and
he was attempting a forced
ft was fitted with
a Cirrus Airframe Parachute System
(CAPS) designed to recover the aircraft
and its occupants to the ground in the
event of an in-fl
flight emergency. The pilot
informed ATC of his intention to deploy
the CAPS, after
ft which no further calls
were received from the pilot.
Following examination of the CAPS
components from this aircraft
further functional testing of production
CAPS components in the US, the aircraft
manufacturer issued an Alert Service
Bulletin incorporating design changes to
the CAPS in the worldwide fl
fleet of Cirrus
ft and engine manufacturers
are also making a number of changes to
their processes and procedures based on
lessons learnt from this accident.
The Australian Transport Safety Bureau
will forward copies of this report to the
relevant state emergency authorities
to alert them to the dangers posed by
ballistic parachute systems in light
ATSB Investigation Report 200700361
28/1/09 2:27:16 PM
Collision with terrain
Collision with terrain
Collision with water
On 9 December 2006, the pilot of an
Air Tractor Inc. AT802A aircraft,
registered VH-CJZ, was conducting
night agricultural spraying operations
under the night visual flight rules, at
a property 19 km NE of Collarenebri,
NSW. In conjunction with a pilot in
another agricultural spraying aircraft,
the Air Tractor pilot was utilising an
airstrip located on the property as a base
for the operation. At about 2140 Eastern
Daylight-saving Time, the aircraft
returning to the airstrip when it impacted
the ground 1.4 km from the landing strip.
The pilot was fatally injured. The aircraft
was destroyed by impact forces and a
At about 0730 Western Daylightsaving Time on 17 November 2007, the
wreckage of a Cessna Aircraft
ft registered VH-TCS, was
discovered on the side of a hill, at Uaroo
Station, in the Pilbara region of WA,
about 500 m from the property air strip.
ft had been destroyed by impact
forces and a post-impact fire.
fi The pilot,
the sole occupant, was fatally injured.
On 17 November 2007, the owner-pilot
of a Cessna Aircraft Company C337G,
registered VH-CHU, was conducting
a private flight in accordance with the
visual flight rules (VFR) from Moorabbin
Airport, Vic. to Merimbula, NSW. The
pilot, who had three passengers onboard,
had indicated that he would be tracking
along the coast. The aircraft did not
arrive at Merimbula and on 19 November
2007 aircraft wreckage and three of
the deceased occupants were found on
a beach between Venus Bay and Cape
Liptrap, Vic. There were no survivors.
Earlier, the pilot had made a 20-minute
from the operator’s
base at Wee Waa, NSW, to the airstrip.
The pilot then conducted two 30-minute
with a short period
on the ground. Th
running while that replenishment was
conducted. The accident occurred when
the pilot was returning at the conclusion
of the second flight.
Examination of the aircraft
revealed no evidence of an in-fl
fire or any mechanical fault with the
ft, engine, or systems which may
have contributed to the occurrence.
The intensity of the post-impact fire,
deformation to the integral wing fuel
tank structure and ground marks,
indicated that there was suffi
fficient fuel on
board the aircraft
ft for the operation. There
was no evidence that the aircraft
trees or powerlines.
It could not be conclusively determined
why the aircraft
ft impacted the ground.
It was possible that the pilot may have
experienced a medical event that was not
evident during the post-mortem medical
examination. However, based on the
evidence available, it is probable that the
pilot experienced spatial disorientation
and a subsequent loss of control of the
ft resulting in it impacting the
FSA Mar-Apr 2009.indd 50-51
Information obtained from persons who
knew the pilot indicated that he had most
likely departed from the airstrip during
the morning of 16 November 2007,
however, the actual time of the takeoff
could not be determined. There were no
reported witnesses to the takeoff,
subsequent flight, or the accident. Tyre
marks made by the aircraft
ft indicated that
ft had departed from runway 27
to the west.
Th was no evidence of an engine or
ft system problem which could have
contributed to the accident. There
Th was no
evidence that the pilot had a pre-existing
physiological condition that could have
contributed to the accident. The
manufacturer’s tabulated take-off
showed that the aircraft
ft should have had
fficient performance to take off
runway 27 and climb clear of terrain.
There was evidence to indicate the
possibility of adverse meteorological
phenomena such as strong wind gusts
and ‘willy-willies’ in the area on the
days before, during and subsequent
to the accident. The willy-willies were
reported to be diffi
fficult to see, forming
and dissipating rapidly, and travelling
in the same direction as the prevailing
Th air within willy-willies is very
unstable, with rapid rising thermals and
While the reason that the aircraft
impacted terrain could not be
conclusively determined, it is probable
that the aircraft
ft encountered adverse
meteorological phenomena such as strong
wind gusts and willy-willies, just after
The investigation found that while
manoeuvring over water at low level in
conditions of reduced visibility, the pilot
probably became spatially disorientated
and inadvertently descended into
the water. A contributing factor was
the pilot’s lack of instrument flying
qualification and minimal instrument
flying training and experience.
The operation of visual flight rules
flights into instrument meteorological
conditions (IMC) continues to be
a significant risk factor in general
aviation, but there are a number of
countermeasures which can be used to
reduce the risk. The Civil Aviation Safety
Authority (CASA) advised, in relation
to VFR into IMC safety promotion
activities, that in 2005 and 2006 they
conducted a number of special workshops
for private and commercial pilots,
which included how to avoid weather
emergencies, what to do if caught out in
worsening weather, and how to maximise
chances of survival if a crash occurred.
Media discs (CDs and DVDs) produced
by CASA related to weather and decision
making, Weatherwise, Weather to fly,
Inflight decision makingg and Setting
your own standards are available. Also
available is a VFR into IMC ‘briefingin-a-box’ for flight schools and a video
titled 178 seconds to live. Furthermore,
a number of products with a focus on
human factors such as airmanship and
decision making were being developed. Q
On 20 December 2006, a Kawasaki
KH4 helicopter lost collective pitch
control and impacted terrain while
performing agricultural aerial spray
operations approximately 21 km NE of
Mount Gambier, SA. The helicopter was
substantially damaged but the pilot was
uninjured. When the accident site was
surveyed, the main rotor mast and main
rotor blade assembly were found to have
separated from the helicopter. They were
located a short distance away.
Examination of the wreckage revealed
that the helicopter’s main rotor mast
thrust bearing had failed catastrophically
in flight. That bearing was a critical
item for safe operation and continued
airworthiness. It supported the full weight
of the helicopter and transferred thrust
loads generated by the main rotor blades.
The bearing had performed satisfactorily
for a considerable time in service and it
was not considered a premature failure.
The investigation was unable to establish
conclusively the factors that led to failure
of the mast bearing. No evidence was
found of manufacturing or material
defects. Nor was there any evidence of
improper installation procedures or
In view of the apparent absence of
similar failures in Australian and North
American databases, and the absence of
any contrary evidence, the failure appears
to be an isolated event and unlikely to
be an indicator of an airworthiness issue
with the helicopter type.
Despite the low probability associated
with a mast bearing failure of this type,
the consequences of such an event could
have been fatal for the pilot onboard. This
report has been provided to Australian
operators and maintainers of Kawasaki
KH4 and Bell 47G3 series helicopters as a
future alert for this type of occurrence. Q
Uncontained engine starter
On 24 October 2007 at Darwin
aerodrome, an Airbus A330-300,
registered VH-QPE, made two
unsuccessful attempts to start the right
engine. A review of the Quick Access
Recorder data indicated that the fi
automatic start attempt lasted
1 minute 10 seconds and resulted in an
engine start fault and no N2 rotation.
Th second attempt was a manual start
lasting 6 minutes, at which time smoke
and sparks were observed from under
the engine cowls. Subsequent inspection
of the engine revealed an uncontained
failure of the starter turbine and
secondary damage to the integrated drive
On 24 July 2007, at 1500 Central Standard
Time, a Robinson R22 Beta helicopter,
registered VH-VHQ, with the pilot as the
sole occupant, departed from a helipad
fi Station, NT, in order to
recommence cattle mustering activities.
Visitors to the station, who had recently
participated in a number of short local
flights, were still in the general area of the
helipad during the departure.
Th pilot reported that, during the initial
ff, and at a height not
above the tops of the surrounding trees,
the helicopter was struck by a gust of wind
that resulted in height loss and activation
of the helicopter’s ‘low RPM’ warning
ft was fitted with two General
Electric CF6-80E1-A3 turbofan engines.
The starter, part number 3505468-4, was
reported to have been in service for
flight hours and 2,428 cycles.
Th starter was returned to the
manufacturer to conduct a failure
Th starter manufacturer’s internal
investigation report of the uncontained
starter failure found that the damage
sustained by the starter components was
consistent with a crash engagement. Crash
engagements result in signifi
to the clutch, and can also damage the
overrunning bearing and lead to further
Th failure scenario provided by the
starter manufacturer noted that the crash
engagement resulted in the overrunning
bearings being damaged, with continued
normal operation cycles contributing to
further bearing deterioration. Although
operation of the starter in this condition
with no load for an extended period of
time ultimately resulted in the starter
failure, the starter was designed to
separate the blades from the turbine
disk and contain them in such an event.
Damage to the surrounding components
therefore occurred because the starter
design failed to contain the separated
Th manufacturer has proposed corrective
actions involving design changes to
the starter, to reduce the likelihood of
uncontained starter events. Q
In response to the warning horn, the pilot
reported that he opened the throttle, with
ff of over-riding the engine RPM
governor, lowered the collective lever, and
pushed forward on the cyclic stick.
Th pilot stated that the low RPM resulted
in a loss of altitude and airspeed before he
was able to recover control of the aircraft.
Loss of control
During the recovery manoeuvre by the
pilot, one of the visitors was struck in the
head by the helicopter’s main rotor and
was fatally injured.
On-site examination of the helicopter, its
engine and flight control systems found
nothing that would have contributed
to the development of the accident.
Results obtained during the ground test
of the engine and its associated systems
following the accident, suggested that the
non-completion of three overdue routine
maintenance items had similarly not
contributed to the accident.
This accident highlighted the hazards
associated with conducting helicopter
operations in close proximity to people
and the need for positive coordination
and control of those people at all times. Q
28/1/09 2:27:21 PM
Australia’s voluntary conﬁdential aviation reporting scheme
REPCON is established under the Air
Regulations 2007 and allows any person
who has an aviation safety concern to
report it to the ATSB confi
Unless permission is provided by the
person that personal information is
about, the personal information will
not be disclosed. Only de-identified
information will be used for safety action.
To avoid doubt, the following matters are
not reportable safety concerns and are not
(a) matters showing a serious and
imminent threat to a person’s health
(b) acts of unlawful interference with an
(c) industrial relations matters;
(d) conduct that may constitute a
Note 1: REPCON is not an alternative
to complying with reporting obligations
under the Transport Safety Investigation
Regulations 2003 (see www.atsb.gov.au).
Note 2: Submission of a report known
by the reporter to be false or misleading
is an offence
under section 137.1 of the
If you wish to obtain advice or further
information, please call REPCON on
1800 020 505.
Operator maintenance human
The reporter expressed concerns about
the operator’s engineering human
factors training. The
Th refresher training
is conducted on-line using a training
package with an assessment test.
Individuals are required to conduct
the training in their own time and it is
expected to take approximately 2 hours to
Th reporter was informed that
the training is required to comply with
European standards, European Aviation
FSA Mar-Apr 2009 indd 52-53
Safety Agency (EASA) 145 and the soon
to be introduced Australian legislation,
Civil Aviation Safety Regulations (CASR)
145. The reporter claims to have observed
a range of shortcuts being taken during
the assessment test including: the test
being conducted by a different
sharing of answers; and the test being
completed without reading the training
material. In addition, the reporter
claims that some managers indicated
they did not care how the training was
completed as long as it was recorded as
being completed. The
Th reporter expressed
concerns that computer-based training
for human factors is inappropriate,
and the lack of adequate time allocated
to complete the training means that
shortcuts might/will be taken.
Reporter comment: The
Th human factors
training needs to be carried out again in a
class room situation otherwise the whole
training package has been a ‘box ticking’
This report was published in the
November December 2008 Flight
Safety Australia magazine including
the operators response. Subsequent to
that response, the ATSB has received a
response from CASA which is included
REPCON contacted CASA and supplied
them with the de-identified
fi report and
a version of the operator’s response.
CASA advised that human factors
training is included in the Civil Aviation
Order (CAO) 100.66 (Module 9), and
was introduced in February 2007 as
the precursor of the proposed Civil
Aviation Safety Regulations (CASR)
Part 66 (Personnel Licensing) and 147
(Maintenance Training Organisations).
The CAO is voluntary for those
individuals and industry organisations
that may benefi
fit from early access to
the licensing and training based on the
EASA Category A, B1 and B2 licence
Th CAO is not mandatory as
it operates in parallel with the existing
Civil Aviation Regulation 31 licensing
regime. However, if a decision is made
to use the CAO, all the requirements for
the licence must be met including human
CASA also added that in terms of the
proposed future human factors training,
there is a requirement that all future
licence holders (CASR Part 66 licences)
receive human factors training as part of
gaining a licence and that maintenance
organisations (CASR Past 145) provide
ff with initial and ongoing
(refresher) human factors training.
Training for CASR Part 66 licence
issue is delivered by CASR Part 147
(Maintenance Training Organisations)
using national competency-based
standards. An underpinning knowledge
of human factors is required for an
individual to be assessed as competent
before they can be issued and initial
licence. These standards are available
on the National Training Information
Service website www.ntis.gov.au.
The foundation of CASR Part 145
is to replicate EASA Part 145 as far
as practicable for use in Australia.
Therefore, it is not expected that the
area of human factors will change from
the requirements that EASA currently
require to comply with at 145.A.30(e) in
their legislation. The
Th Acceptable Means
of Compliance and Guidance that EASA
has published on 145.A.30(e), would
allow for the development of a program
to suit any prospective Australian 145
organisation. Until CASA Part 145 is
in legislation, CASA do not
have the regulatory powers to approve
organisations inclusive of human factors
CASA also advised that the operator
is one of the leaders in the country in
fi and has established a very
thorough system to deal with human
factor issues and manage human factors
training in maintenance-related areas.
Engine failure during takeoff
The reporter expressed concerns about
a Cessna 404 (C404) aircraft
experienced a series of engine failures
during attempts to take off
ff at an airport.
The reporter claims that during the
ft’s first attempt to take off
engine failed shortly after
ff and the
ft settled back onto the runway.
fter the engine was restarted, the
ft was taxied back to the threshold.
A further four attempts to take off
made with similar results. The reporter
indicated that no checks were conducted
to determine why the engine had failed.
This report was published in the
November December 2008 Flight
Safety Australia magazine including
the operators response. Subsequent to
that response the ATSB has received a
response from CASA which is included
REPCON supplied CASA with the
fied report and a version of
the operator’s response. CASA advised
that they undertook an operational
surveillance of the operator and intend
to take no further action. CASA believes
that there was a fuel vapour lock problem
and have confi
firmed that there was only
one engine failure during the initial
ff The pilot was aware of the
problem and correctly diagnosed what
had occurred and took acceptable action
before completing a second takeoff
operator had checked and adjusted the
ft fuel system.
CASA also reported that two to three
times a year, the operator’s C404
engines experience ‘bog down’ which
is caused by the ambient temperature
and humidity conditions that occur
in summer affecting
the fuel system.
This is a known issue and the operator
maintenance organisation have a
practice of checking the fuel pressures in
the engine fuel injection system if a bog
down is reported. The operator’s C404
ft are checked if it happens and
fuel pressures adjusted in accordance
with the Aircraft
ft Maintenance Manual
and a Manufacturer’s Service Bulletin
which addresses this problem. After
summer, the engine fuel pressures are
checked again and adjusted as necessary.
Catering loading procedures
The reporter expressed safety concerns
about a cabin crew notice applicable to
some of the operator’s aircraft,
allows catering staff
ff to start loading
produce during refuelling operations as
long as any obstruction can be pushed out
of the way. The example given is towards
Th reporter believes that this
is in direct contravention of CASA Civil
Aviation Order (CAO) 20.9 that requires
aisles and exits to be unobstructed during
Reporter comment: CAO 20.9 requires
that all exits be unobstructed while
refuelling with passengers on board and
pushing an item from door L2 toward
door R2 would clear door L2 but obstruct
door R2 if an evaluation was required.
REPCON contacted the operator and
supplied them with a copy of the deidentified
fi report. The operator responded
that they were trialling new procedures
for the disembarkation of passengers
from the left
ft rear of the aircraft
ft and the
cabin crew notice quoted in the REPCON
report detailed the procedures utilised in
Th operator also indicated that their
investigation found the reporter had only
selectively stated some of the procedures
in that notice and so the report was not a
true representation of the intended trial
procedures. The reporter did not state
that the notice stipulated the time when
the caterers could board, that is, only
fter a signifi
ficant number of passengers
had disembarked. The procedures also
what catering could be loaded
while the remaining passengers were
disembarking so that an ‘obstruction’
situation as detailed in Civil Aviation
Order (CAO) 20.9, would not occur. Th
reporter also did not mention that the
notice included specifi
fied procedures on
other refuelling-related issues including,
but not limited to, the requirements with
the galley carts, stairs at the aircraft,
precautionary disembarkation, refuelling
zone requirements and related cabin crew
responsibilities plus the duration and
place for the trial.
Th operator believes that the cabin crew
notice was within and above the intent
of CAO 20.9. Th
The notice and procedures
were retired when the trial finished over
5 months ago and the operator reported
that they have reverted to the formal
documented procedures in its manual.
REPCON reports received
What happens to my report?
It is also believed that the system has
been independently reviewed by Boeing.
The comment related to computer based
training versus face-to-face is valid.
There is a UK Civil Aviation Advisory
Publication that identifies
facilitated training as preferable to online
computer based training (CBT). Face-toface facilitated training maximises the
achievement of learning outcomes. Some
CBT modules do not provide sufficient
access to participant experiences and
discussion. As the training in question in
this instance is refresher training, CBT
may be appropriate. Concerns about this
approach might arise if the operator were
not to follow its own published guidelines
or standard operating procedures. From
the response provided by the operator, it
does not appear that this is the case.
For Your Information issued
Alert Bulletins issued
Who is reporting to REPCON?
Aircraft maintenance personnel
Air Trafﬁc controller
Facilities maintenance personnel
# 29 Jan 2007 to 31 December 2008
* examples include residents, property owners, general
How can I report to REPCON?
On line: ATSB website at <www.atsb.gov.au>
Telephone: 1800 020 505
by email: [email protected]
by facsimile: 02 6274 6461
by mail: Freepost 600,
PO Box 600, Civic Square ACT 2608
For further information on REPCON, please
visit our website <www.atsb.gov.au> or call
REPCON on: 1800 020 505.
/09 2:27:21 PM
2008 round up
In late 2006, CASA appointed six aviation
safety advisors (ASA): Albert Fleming, Charles
Galea, Lloyd Mais, Tim Penney, Andrew
Warland-Browne and Michael White, whose
brief was to ‘move about the industry to
provide practical safety education, advice
and support’. In 2008, following the success
of the program in 2007, they were joined by
Peter Ball, Teraya Miller, Stephen Nota, Mark
Richardson and Malcolm Wardrop, allowing
1: AvSafety seminars by topic - Australia-wide
So what have the aviation safety advisors
been up to in 2008?
The annual review of the aviation safety
advisor program includes looking at what the
team has been doing out with the industry:
activities such as the AvSafety seminar
program, as well as visits to operators and
fielding industry enquiries.
2: AvSafety seminars by location
The following series of graphs highlights the
efforts in 2008. A total of 145 seminars was
conducted in 2008, up from 81 in 2007, and
dealt with topics ranging from operations
at non-towered aerodromes, to fuel-related
accidents and pilot maintenance.
The first two graphs show the number of
seminars – a total of 145; firstly by topic
and then by state. The ‘overseas’ section of
graph 2 represents the ‘fuel-related accidents/
incidents’ series of seminars Andrew WarlandBrowne co-presented with the Civil Aviation
Authority of New Zealand in April, 2008.
The following two graphs then show how
many people in each state attended the
AvSafety seminar program – a total of 5209 –
and how many attended each seminar.
But this data about the AvSafety seminars does
not tell the whole story. Equally important to
the program is the amount of time the ASA
team spends in contact with the industry – a
3: Participants by state
total of 1575 visits and 2600 contact hours in
2008. This graph shows on average how much
time the team spends with operators in each
of the regions.
From both the visits and general enquiries
the team receive, we track the topics of
interest to the industry. This feedback is vital
in understanding the needs and concerns
of industry, which in turn assists CASA to
develop targeted and improved education
and communications products now and in
DANGEROUS GOODS TRAINING
• Dangerous Goods Awareness Courses
via Correspondence and Company tutorial
• Dangerous Goods Acceptance and
26th and 27th March
25th and 26th May
Melbourne 14th and 15th May
6th and 7th August
12th and 13th May
17th and 18th Sept
CREW RESOURCE MANAGEMENT
• Company speciﬁc tutorial courses
• Correspondence courses also available
SAFETY MANAGEMENT SYSTEMS
• Safety Management Training (1 week)
8th to 12th June
Melbourne 13th to 17th July
• Safety Management Workshop (2 day)
4th and 5th May
• Risk Management (2 day)
27th and 28th July
• Accident & Incident Investigation (2 day)
29th and 30th July
PRINCIPLES AND METHODS
5: ASA Visits per state and average hours per visit Australia-wide
• 2 Day Training Course
28th and 29th May
Check website for new course dates and locations!
• Operations Manuals
• Dangerous Goods Manuals
• Safety Management Systems
1800 754 774 FREECALL
08 9274 8277 (P)
4: Participants by topic - Australia-wide
5: Talking points at ASA visits - Australia-wide
6: Enquiry topics for ASA - Australia-wide
To contact your regional ASA
Victoria & Tasmania
Cairns & Northern QLD
0403 063 864
Brisbane & Southern QLD
0407 402 117
Northern NSW & Brisbane QLD 0411 659 242
y & Southern NSW
Sydney & NSW
0403 063 488
0434 558 088
Melbourne & Victoria
0403 063 931
Melbourne, Victoria & Tasmania 0403 063 998
0434 559 861
Perth & WA
Perth & WA
0434 559 830
0434 220 568
Adelaide & SA
0434 568 752
You can view details of 2009 AvSafety seminars at www.casa.gov.au/advisors/ or see the listing in the 2009 calendar
on page 70 of this issue.
Video highlights AOD testing
With this random testing due to commence in
pril 2009, CASA has produced the video to
outliline the procedures involved in the testing of
e who are performing, or available to perform,
y sensitive aviation activities (SSAA).
video covers who may be tested,
demonsttrates how the tests for alcohol and drugs
rmed, and details the legal requirements
necessary for aviation personnel to meet their
obligations under Part 99. It also discusses the
consequencees of refusing to undergo a test
(when requestted to do so by an approved tester),
or interfering with a test, as well as what happens
after a positive te
CASA intends to
o test 6,000 workers carrying
ive’ aviation activities in the
first year of testing,
g, and is providing extensive
tester training to ensure the rigour and integrity of the program.
View the video - go to www.casa.gov.au/AOD, where you will als
lots of useful information on the AOD program.
RANDOM TESTING FOR ALCOHOL
Explaining the testing process
The random breath test
IIf the test is positive
The follow-up, evidential test
he evidence report
RANDOM TESTING FOR ‘OTHER DRUGS’
g a mouth swab
If the sw
wab ‘turns blue’
The tampeer seal
10. Sealing the
A new video on CASA’s random alcohol and othe
drug (AOD) testing is now available online for
viewing and download at www.casa.gov.au/AOD
Dr David Fitzgerald, CASA medical officer,
examines the risks of flying with an undisclosed
SHOULD I HAVE FLOWN?
Flying safely depends on the parts of the ‘system’ working without
fault, or risk of failure. This applies just as much to the human pilot as
it does to the mechanical parts of the aircraft itself, or the electronic
or human elements of the air traffic control system.
Here, taken from the American National Transport Safety Board
(NTSB) records, are a couple of examples of the failure of the human
part of the system:
On Friday, 5 September 1986, a pilot crashed his Luscome 8C in Lavonia,
Georgia. The pilot, who was the sole occupant, was fatally injured. The
aircraft hit a wooded area in a near vertical attitude. Examination of
the wreckage failed to disclose any aircraft malfunction or failure. The
pilot had been diagnosed with a brain tumour and was taking 300mg of
Dilantin, a medication to control seizures. He had suffered a ‘grand mal’
seizure about two months before the accident. He told his mother on
the phone before departure that he had taken his morning dose
of Dilantin prior to departing.
On 30 April, 2001 during daylight hours, in visual
conditions, a Piper PA-28 was destroyed by an in-flight
collision with rising terrain near Afton, Virginia. The
Piper was on a flight from Leesburg to Pittsfield, a
distance of approximately 185 miles on a track of
344 degrees magnetic.
Review of the ATC radar data indicated that the aircraft
was identified at 1156, some 11 miles from the departure
airport on a track of 340 degrees. It continued on that
track for about 15 minutes, when it began a track of 360 degrees.
Three minutes later, it began a turn to the left, and during the next
hour it performed three consecutive left-hand orbits. After the final
orbit, it continued on a ground track of 240 degrees for approximately
40 minutes before it made a right 360-degree turn, to return to the
240 degree track for another 12 minutes. The last identification occurred
at 1412. The aircraft was located by the National Park Service during
firefighting operations on 1 May, 2001.
The aircraft came to rest in mountainous terrain at an elevation of
The pilot held a commercial pilot certificate with ratings for singleengine land and instrument aircraft. He also held a flight instructor
certificate. He has over 5000 hours of total flight experience, 15 in
the last six months.
The pilot’s most recent medical certificate was issued on January
In a telephone interview, a friend of the pilot stated that the
pilot had ‘passed out’ three times in the two weeks prior
In a telephone interview, the pilot’s doctor stated that he began treating
the pilot after he passed out at his computer on November 12, 2000.
The pilot was hospitalised and extensive testing was performed to
determine what triggered the episode. No particular source or ‘trigger’
was identified. The pilot was released from the hospital within a few
days and he was given children’s Aspirin to take in place of Zestril,
which he had been previously prescribed to treat high blood pressure.
Additionally, the doctor instructed the pilot ‘not to fly his airplane’
until they could determine a cause for the episodes. He informed the
pilot that it would not be safe to fly, since he was susceptible to passing
out at any time or place.
After he was released from the hospital, the pilot continued to pass out.
He underwent additional tests, including ‘tilt-table’ and stress tests.
The pilot also had an EEG (brain wave test), and no seizure disorders
were noted. He was also told to resume taking the Zestril for his blood
pressure, since it was found not to be making his condition worse.
The pilot was diagnosed with ‘vascular syncope’ on 3 January, 2001.
The doctor reported that the dysautonomic episodes which the pilot
had experienced were a nervous system, or ‘vasovagal’ reaction, where
the heart rate and blood pressure dropped for no apparent reason.
These episodes were hormonally driven, and didn’t occur because of
any particular event.
In a telephone interview, the co-owner of the aeroplane stated that the pilot
had just received a medical certificate; however, he had also undergone
a variety of medical tests. The co-owner reported that doctors could
not identify any particular medical problem with the pilot, and the only
medication he was aware of the pilot taking was Zantac for heartburn.
The co-owner stated that the pilot would often ‘doze-off’ during flights,
and would then comment that he was ‘just resting his eyes’.
On the pilot’s last Federal Aviation Administration (FAA) medical
application dated 26 January 2001, he listed his current medications
as Zantac 75 and Aspirin. He also stated on the application that he
had never experienced dizziness or fainting spells, unconsciousness,
or high blood pressure. According to every FAA medical application on
file, the pilot had never reported any health problems.
The above two are rather unusual and somewhat dramatic examples
of likely medical incapacitation accidents, but at the same time
concerning. Both of these pilots were quite obviously aware that they
had suffered significant medical events in their recent past, and at least
the second individual had been instructed by his doctor not to fly.
Whilst examples like this are thankfully rare, it is not infrequent for
aircrew to turn up to their DAME for their usual aviation medical,
some months down the track from having
some significant event, having continued to
fly. Some recent examples include:
a helicopter pilot flying with disseminated
a flying instructor having had a
conservatively treated pneumothorax
a pilot with unexplained fainting and loss
of consciousness episodes
a number of pilots having had bypass
surgery or coronary stents
aircrew being diagnosed and treated for
significant mental illnesses, including
those requiring hospital admissions
a pilot having a head injury with intracranial
a number of pilots being diagnosed with,
and treated for, Parkinson’s disease
a number of pilots having had retinal
detachments who do not meet the visual
a number of pilots having had serious heart
a pilot having had a stroke.
CASR 67.265(3) requires a class 1 medical
certificate holder to notify CASA or a DAME
about any medically-significant condition that
continues for more than seven days (or for
class 2 and 3 medical certificates, this is 30
days) as soon as practicable after the seven or
30 days. CASR 67.265(5) also prohibits a pilot
with such a condition that may impair their
ability to do an act authorised by their licence,
from using the licence until a DAME certifies
the holder can safely do such acts. In some of
the examples above, the aircrew should not
have waited until their next aviation medical
examination before informing them of their
medical event. Where there is any possibility
that CASR 67.265 applies, it is in the aircrew’s
interests that they notify CASA or the DAME in
the time required by the regulation. This will
avoid the commission of a criminal offence, but
more importantly, will ensure that no medical
condition will prejudice aviation safety.
Consider that flying with an undisclosed
medical condition not only puts you at possible
risk should anything go wrong, but you also
may put at risk the lives of your passengers, or
even innocent people on the ground, and your
insurance company may not cover you in the
event of an incident.
to the accident. She reported that each time he ‘passed out’, she would
lie him flat, and he would ‘come right back’. She stated that the day
before the accident, the pilot ‘passed out’ again, and when he regained
consciousness, he had no recollection of what had happened. The
pilot’s friend insisted that he visit his doctor when he returned home
to Pennsylvania, and he agreed that he would. During the weekend
visit, the pilot checked his blood pressure and took his blood pressure
medication every morning. Additionally, the pilot’s friend reported that
the pilot had recently planned a trip to Spain; however, he was advised
by his doctor not to take the trip due to his medical condition.
New rules concerning the carriage of emergency
locator transmitters (ELTs) have recently come into
force. This article provides some background
behind the operation of ELTs, and clears up
some of the common misunderstandings
surrounding the changees.
ELTS AND SEARCH &
Carriage of emergency locator transmitters
(ELTs) in aircraft has been mandatory in Australia
since 1995. Prior to 1 February 2009, these ELTs
were required to transmit, when activated in
an accident, on the frequency 121.5 MHz. The
analogue signal was detected by orbiting satellites
and processed by the Australian Maritime Safety
Authority (AMSA). Some ELTs also transmitted
an analogue signal on the frequency 243 MHz
(used mainly for military purposes).
There were a number of limitations with this
First, the time for the satellite system to
detect a signal could be up to 90 minutes
from the time of activation.
Secondly, the location of an activated
beacon could only be pin-pointed to within
a radius of approximately 5NM.
Additionally, no information could be
obtained about what aircraft, or type of
aircraft, the activated beacon belonged to.
These limitations are now a thing of the past,
with the new system fully operational and
incorporated into civil aviation regulations.
THE NEW AGE OF ELTS
Digital ELTs, which transmit on the frequency
406 MHz, have been available for some
time and have been detected by the CospasSarsat system (the satellite system used
internationally to locate distressed aircraft for
search and rescue purposes) in parallel with
the analogue system.
These digital ELTs offer distinct advantages
over the older analogue (121.5 MHz) beacons.
the location accuracy is much better (2NM
specific aircraft details are able to be
the digital characteristics of the beacon
also allow GPS data to be transmitted,
allowing search and rescue crews to locate
a downed aircraft precisely.
Cospas-Sarsat, in cooperation with the
International Civil Aviation Organization
(ICAO), determined that it would be beneficial
to adopt this digital system and decommission
the analogue system. Therefore all ELTs would
need to transmit distress signals on 406 MHz
to be detected by the satellites. The switchover date of 1 February 2009 was decided
upon. Since this date, distress signals on
121.5 MHz have not been detected by the
Australian Maritime Safety Authority. Registration is a free service,
and is required by law. Beacon registration can be done online at
While satellite detection would only apply
to the 406 MHz transmissions of an ELT,
it is also necessary for ELTs to transmit on
121.5 MHz when activated. This is in order
for search and rescue crews to home in on
an activated beacon. Special direction finders
are used for this purpose and only a 121.5
MHz transmission is capable of being found
by this equipment. Aircraft crews can also
monitor the emergency frequency to alert air
traffic control of a potential emergency.
Certain aircraft and aircraft operations are exempt from the carriage
of an ELT. Refer to the Regulations for further information.
In order to reflect the changes to international
standards, the Civil Aviation Regulations were
recently amended. From 1 February 2009,
most aircraft operating in Australia require
the carriage of an ELT which operates on 406
and 121.5 MHz.
Most newer, digital ELTs transmit on both 406
MHz and 121.5 MHz, but operators should
confirm with the ELT manufacturer’s technical
data that it does in fact operate on 406 and
121.5 MHz. Operators should also confirm the
beacon complies with the required technical
standards which are contained in the Civil
Aviation Regulations (refer to CAR 252A).
For a digital ELT to work effectively,
beacons must be registered with the
WHAT TO DO WITH OLDER BEACONS
The correct disposal of old ELTs which operate on 121.5 MHz is
essential. Never play with the device or deliberately turn on the device
to see what happens. Remember, 121.5 MHz transmissions from
beacons are still detected by aircraft and sensitive search and rescue
It is important that the battery of your old device is physically
disconnected from the beacon to eliminate the chances of inadvertent
activation. Devices and batteries can be disposed of at Battery World
stores around Australia.
Go to www.casa.gov.au/elt, the CASA website, for further details of the
changes, as well as a summary of the new rules.
CASA has received feedback from many pilots individually, and
through AOPA, which suggests that demand has outstripped supply
for the new 406 beacons. A short-term general exemption is currently
under consideration which would be conditional upon meeting
certain requirements (such as a requirement to submit a flight plan
or flight note, nominate a SARTIME, advise ATS of any changes to
the flight plan or flight note, and a requirement to continue to carry
a 121.5 beacon). As Flight Safety goes to press, this has not yet been
finalised - you should check the CASA website for details on whether
this short-term exemption has been approved and published.
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THE NEW RULES
Under Australian law, the carriage of portable devices – personal
locator beacons (PLBs) and emergency position indicating radio
beacons (EPIRBs) – is permitted in lieu of a fi xed ELT.
The minimum experience for the holder of a private pilot
licence to fl y solo in an aircraft registered on the Recreational
Aviation of Australia, Inc. (RA-Aus) register in the high
performance category is
(a) 50 hours dual on any category aircraft.
(b) 10 hours dual on RA aircraft.
(c) 5 hours dual on RA aircraft.
(d) sufficient training as deemed
d necessary by a CFI.
The pilot medical standard for private operations in RA-Aus
registered aircraft is
(a) equivalent initially to that for the issue of a private pilot’s
licence and thereafter a private motor vehicle driver’s
(b) equivalent to that for the issue of a private vehicle driver’s
(c) the same as a CASA class 2 medical.
(d) the same as a CASA PPL medical.
(a) request to cross an active runway as the holding point is
The validity period of an aerodrome forecast is from 0000 on
the 1st to 0600 on the 2nd. In the forecast this is now written
(b) request to cross an active runway as the runway is
(c) contact SMC
M immediately unless specified otherwise in
(d) contact SMC and request to cross an active runway as
On vacating the runway after landing at a GAAP aerodrome,
When approaching to land on an up-sloping runway there is a
tendency to perceive that you are
(a) stop engine.
(a) lower than you actually are, which may result in a steep
(c) engage rotor.
(b) lower than you actually are, which may result in an flat
(c) higher than you actually are, which may result in a steep
(d) higher than you actually are, which may result in a flat
With regard to helicopter ground operating signals, arms
crossed and extended downwards in front of body means
(d) start engine.
When slowing down in a circuit pattern in order to follo
preceding aircraft, flap may sometimes applied. This is
(a) create more drag.
W en an aircraft with full fuel tanks is parked on sloping
ground, loss of fuel from a tank vent
(b) increase the lift/drag ratio.
(a) is prevented by a check valve in the tank vent.
(d) improve forward visibility.
(c) raise the stall speed.
(b) is prevented by a check valve in the tank outlet line.
may occur even when the fuel is turned off.
(d) may occur when fuel transfers from the highest tank to the
lowest tank, but will be preventeed if the
h fuel is switched off.
10. The function of the Eustachian tube is to
(a) balance the manifold pressures when multiple carburettors
(b) drain water from the pitot static system.
d VHF transceiver may be used by a VFR aeroplane
provided it is
i licensed and unless a seaplane, the MTOW of the
aeroplane does not exceed
(c) equalise the pressure between the inner and middle ear.
(d) equalise the pressure in the middle ear with that on the
outside of the ear.
New generation mode ‘S’ SSR radar equipment is being
progressively installed at som
me locations and, with the tighter
tolerances required by the new equipment, uncommanded
code changes are being detected from some transponders.
During maintenance, these anomalies will be detected
(a) required because the AC busses must be interconnected
and therefore must be equally loaded.
q red because the AC busses are not interconnected.
(a) by thoroughly carrying out the procedures in AD/RAD/47.
(c) not required if the two AC busses are not interconnected.
(b) by thoroughly carrying out the test procedures in FAR 43
(c) by strict adherence to the test procedures in the
manufacturer’s maintenance manual.
In a twin engine aircraft with AC generators a load controller
(d) not required because
u the two AC busses are connected in
A mass balance on an elevator
(d) only after the equipment reaches a stable operating
(a) increases the stability of the control surface and opposes
the increasing of ‘g’.
The anomalies referred to in Q1 app
pear in the receiving
(b) increases the stability of the control surface and facilitates
the increasing of ‘g’.
(c) reduces the stability of the control surface and opposes the
increasing of ‘g’.
(a) random changes in the transmitte
t d code.
(b) always one code digit higher tha
h n selected.
(d) reduces the stability of the control surface and facilitates
the increasing of ‘g’.
(c) always one code digit lower than
(d) the leading digit being incorrect.
Referring to an electrical load analysis of
o a simple DC system,
using a 35 ampere-hour battery de-rated by 75%, and with an
emergency load of 4.5 A, the theoretical run time of the system
in case of a total generator failure is approximately
(a) thirst, and is best treated by immediately drinking a soft
(b) blue tinge to the fingernails, and is best treated by
immediately drinking a soft drink.
(a) 350 minutes
(c) drying of the nasal passages and a prickling sensation
around the eyes, and is best treated by drinking a soft drink.
(b) 460 minutes.
(c) 620 minutes.
(d) drying of the nasal passages and a prickling sensation
around the eyes, and is best treated by drinking water.
(d) 660 minutes.
MS22469-S94 refers to a
The first symptom/s of dehydration can be
Propellers with counterweights use oil pressure to
(a) flat head structural machine screw and the length is
measured under the head.
(a) decrease the blade angle and the force on the
counterweights assists this.
(b) flat head structural machine screw and the length is
measured from the flat head.
(b) decrease the blade angle and the force on the
counterweights opposes this.
(c) pan head machine screw and the length is measured under
(c) increase the blade angle and the force on the
counterweights assists this.
d pan head structural machine screw and the lengthy is
measured from the head.
(d) increase the blade angle and the force on the
counterweights opposes this.
In a turbine engine, ‘hot streaking’ refers to
(a) uneven distribution of cooling air entering the combustor.
(b) uneven distribution of power augmentation fluid in the
(c) uneven fuel distribution between fuel nozzles resulting in
uneven combustor temperatures.
(d) uneven fuel spray pattern from a fuel nozzle which
result in cutting through the
b tor cooling air la
creating a hot spot.
10. In the operation of a propeller, the centrifugal twisting moment
of the blade tries to move the blade angle to a
(a) finer pitch, as does the aerodynamic twisting moment.
(b) finer pitch, whereas the aerodynamic twisting moment tries
to coarsen the blade angle.
(c)) coarser pitch, as does the aerodynamic twisting moment.
(d) coarser pitch, whereas the aerodynamic twisting moment
tries to coarsen the blade angle.
ADE LAIDE (YPAD) RUNWAY 23 ILS or LOC. (Dated 20 Nov 08)
Yo are planning a fl ight to Adelaide (YPAD) in a Cessna 340
(operating as a category ‘B’ aircraft) and equipped with the
2 ILS/NAV receivers
2 ADF (1 R.M.I/ 1 Fixed Card)
1 Marker beacon receiverr
1 GNSS (TSO 129)
Your instrument rating is current on aall navigation aids. Your E.T.A for
YPAD is 0145Z. Part of the TAF on YPAD reads:
TAF YPAD 221830 2220/2308
19015KTS 6000 RA BKN015
BECMG 2302/2306 22020G35
4000 RA BKN006
The following questions relate to this fl ight and the Runway 23 ILS
Which of the following is correct concerning the validity
period of the TAF?
(a) All category ‘A’ and ‘B’ aircraft must use 1380’ and 4.4km.
(a) It is valid from 2200 to 1830 of the following day.
(b) Special alternate minima of 850’ and 4.0 km is only available
if the aircraft is Category 1 capable.
(b) It is valid on the 22nd from 2000Z to the 23rd at 0800Z
(c) It is valid from 2220Z until 2308Z
(c) Special alternate minima is only available if the Runwa
w y 23
ILS or LOC is to be fl own.
(d) For the TAF to be valid an E.T.A must be between 2030Z on
the 22nd and 0700Z on the 23rd.
(d) Special alternate minima can be used since your aircraft
has the required duplicated navigation equipment.
(e) Both b) and d) are correct.
Within the Adelaide Terminal Area, Approachh descends you
to 3000’ and assigns a radar vector of 090 towards Modbury
(MBY). You are cleared for a sector entry and one holding
Which of the following is correct concerning an alternate for
(a) No alternate required since visibility of 6000m and cloud at
1500’ is above alternate criteria.
(b) No alternate required because E.T.A 0145Z is before the
onset of the change to 4000m and cloud at 600’.
Select the correct statement concerning the alternate criteria
What sector entry would you fl y?
(a) Sector 1.
(c) Alternate is required since the E.T.A of 0145Z is within 30
minutes of the onset of the gradual change at 0200Z.
(b) Sector 2, intercepting a TR of 072 outbound.
(d) No alternate required since the gradual change (Becoming)
is not complete until 0600Z and your E.T.A is before this.
(d) Sector 3.
(c) Sector 2, intercepting a TR of 012 outbound.
On completion of the sector entry inbound you review the
What is the outbound limit of the pattern?
(a) 1 minute only.
(b) 16 DME only.
(c) 1 minute or 16 DME/ GNSS AD, whichever occurs fir st.
(d) 1 minute or 16 DME/ GNSS AD, whichever occurs later.
Turning inbound in the pattern and passing the heading of
245M the fi xed card ADF tuned to MBY reads 342R.
Disregarding ADF lag, where would you expect to see the LOC
needle on an instrument with the following scale?
MAPt using LOC only.
(b) Continue approach to LOC minima only utilising DME and// or
GNSS for profile.
(c) Continue approach to ILS landing minima utilising DME and/
or GNSS to cross check glideslope accuracy.
(d) Maintain 1310 and track to the MAPt utilising LOC only for
(a) Full scale to the left.
(b) 1/2 scale to the left.
(c) 1/2 scale to the right.
(d) Full scale to the rightt .
10. If the approach continues to landing minima, what will the
minima be, assuming a PEC of 50 and HIAL inoperative?
(a) DA of 320’/ 1.2km
(b) DA of 300’/ 1.5km
You are asked to report established..
When should the report be given?
(c) MDA of 320’/ 1.5km
(a) When on the localiser.
(e) DA of 320’/ 1.5km
(d) MDA of 820’/ 3.3km
(b) When on both LOC and glideslo
(c) When on both LOC and glideslope and over MBY.
(d) At the O.M.
You are cleared for the ILS Runway 23 for landing.
At what DME or GNSS AD do you expect to intercept the
(d) Cannot be determined from DME or GNSS.
At the OM position you are on glideslope and the altimeter
reads 1310. However, you have no OM light or audio.
What action must you take?
(a) Execute a missed approach and go around tracking to the
Organiser & More info
viation Safety Seminar
iation Safety Seminar
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Venue to be confirmed
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29 Mar 1 Apr
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31 Mar1 Apr
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Organised by A
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Have you got the latest copy
of the AOPA magazine?
Look out for the March issue of
For pilots and aircraft owners.
In this months issue:
>> Chipmunk Test
>> More on ASIC’s
>> Simulators – are they any use?
>> Travel stories
Ph: 02 9791 9099 Email: [email protected]
m.au Web: www.aopa.com.au
FLYING OPS ANSWERS
(d) there is no minimum hour requirement for high performance (80
KTAS + cruise) aircraft. RA-Aus ops manual 2.07 .2
(b) RA-Aus ops manual 2.07.5
(a) GEN 3.5 12.4.1; (b) was the previous format.
(c) on some types, fuel loss will occur only when the fuel is
(a) GEN 1.5 1.5.
(c) ENR 1.1. 34 and following table; the request to cross has been deleted.
(b) CAO 20.3.
IFR OPS ANSWERS
(e) AIP GEN 3.5- 25, Para 12.4.1 and AIP ENR 1.10- 2, Para 1.2.5
(c) AIP ENR 1.1- 93, Para 73.2.7
(d) AIP ENR 1.5- 31, Para 6.2
(b) AIP ENR 1.5- 23,24, Para 3.3.1, 3.3.3
(c) AIP ENR 1.5- 23, 24, Para 3.4.1
(d) HDG 245/ ADF MBY 342R, Thus TR is 227 to MBY, LOC is 222 so
ILS scale means full scale right.
(a) AIP ENR 1.6- 3, Para 3.12 Note
(b) Approach Plate- Distance Scale
(c) AIP ENR 1.5- 32, Para 7.2 C
(e) AIP ENR 1.5- 12, Para 1.18.2 and AIP ENR 1.5- 33, Para 8.1 a.
(c) AWB 34-013 warns of the problem.
(a) AWB 34-013.
(a) 35 x 0.75 ÷ 4.5.
(b) the convention for measuring the length varies with the type.
(d) thirst is not the fi rst symptom of dehydration.
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… essential aviation reading
INSIDE NEXT ISSUE
Our feature looks at the often neglected area of
UAVs — The growing issue of unmanned aerial
systems/(UAS) vehicles (UAVs) - part two of our
Icing... airborne and on the ground
And... more of the ever-popular ‘Close Calls’
actors for p
lots is a new resource
AS has designed
f r the GA and low-capacity regular public
i troductio to
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pra ical support for the
nin and asse
FR syllabus and
CAO 82.3 amendments.
The training package includes:
a comprehensive resour
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alcohol and other dru
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For more information (CFIs, and low
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THREAT MAN FAC ING SINGLE
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Scud Running: better to be down here wishing you were up there...
One of the most common causes
of fatalities in light aircraft is
VFR pilots continuing flight into
Flight at low altitude under cloud with
marginal visibility is often referred to as
scud running. Also known as get-there-itis
characteristic associated with this type of
behaviour and all too often, sadly, the flight
terminates in cumulus granitis.
It is frustrating to recognise how
avoidable accidents of this type are. Like
low flying and beat ups, they reflect poor
judgement or deficient decision making. By
their very nature, they often breach
consequences. This can be made more
difficult for insurers when combined with
dependants and executors seeking to
realise estates in the face of possible denial
of insurance coverage, due to apparent
breaches of policy terms and conditions.
Generally there is nothing new in the
way in which these accidents occur. The
scenarios we witnessed over the last 12
months don’t really differ from each other
or those over the past 25 years.
It is essential to maintain flight
discipline at all times and set your own
very high personal minimums. These
minimums are literally what you live and
die by when flying. They are the basis of go
or no-go decisions and most vital amongst
these decisions is if VFR flight is likely to
end up IMC. At the VFR minima of 1,000
feet AGL and 5,000 metres visibility, you
have 97 seconds to avoid an obstacle at
100 knots or 81 seconds at 120 knots!
That is not long particularly if you are not
current or are indecisive.
There have been several examples in
recent years involving private flights
returning from interstate trips where pilots
stayed on 2 or 3 days longer than intended
because of bad weather, until the old
get-there-itis played its foolish hand. The
irony of course, they all crashed with fatal
consequences due to continued flight into
the same bad weather which delayed
them. One experienced loss of control in
IMC minutes after take off to fly 1,000
miles from home. One hit ridge tops in IMC
an hour into an 8 hour flight. Another spun
in from low cloud 30 miles from home.
There are many more examples of
pilots who blasted off into forecast weather
without delay, assuming they could scud
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run if and when required and paid the
Clearly, decision making was flawed and
non-negotiable personal minimums were
not maintained. Tragically accidents including fatalities could easily be avoided by:
• Familiarise yourself with all
available services which make it
easier to update weather enroute,
e.g. AERIS, AWIS, Flightwatch.
• Assessing and interpreting the
forecast for departure, enroute,
destination, alternate and escape
routes, and overall weather picture.
• Ensuring that conditions are
suitable for the flight, taking into
proficiency and aircraft capabilities.
• Calling the ATC for assistance when
uncomfortable with the situation.
As a final thought, if you really have to
get there that badly, rather than exposing
yourself and passengers to unnecessary
risks, obtain an instrument
rating or even PIFR.