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FLIGHT SAFETY AUSTRALIA Vol 10 No 3 WIN $ 1,0 0 0 FOR YOUR STORY, p. 2 3 MAY – JUNE 2 0 0 6 DRUG & ALCOHOL TESTING GRAND CANYON TRAGEDY Legacy of a mid-air collision HERE COME THE JETSONS Very light jets set to takeoff CFIT IN THE SNOW Mt Hotham accident ROLLER COASTER RIDE: ADVICE FOR CABIN CREW ON AIR TURBULENCE what went wrong FLYING OPERATIONS EDITOR Mark Wolff CONTRIBUTING EDITORS What went wrong: James Ostinga & Steve Tizzard ATSB supplement: George Nadal email: atsbinfo@atsb.gov.au ASSOCIATE EDITOR Kimberley Bootes MARKETING & PRODUCTION Jo Sutton DESIGN & LAYOUT Delene White, Peter Markmann DESIGN ATSB SUPPLEMENT David Hope Into the void: Lost on the coast 16 CFIT in the snow: Mt Hotham accident 34 EDITORIAL ADVISORY PANEL Adam Anastasi, Eugene Holzapfel, John Klingberg, Sue Rice, David Yeomanns, Trevor Robinson, Steve Tizzard Chief executive officer, CASA Bruce Byron A/GENERAL MANAGER, AVIATION SAFETY PROMOTION, CASA David Pattie CORRESPONDENCE Address correspondence to: Flight Safety Australia GPO Box 2005 Canberra ACT 2601 ph: 131757 fax: 02 6217 1950 email: fsa@casa.gov.au Changed your address? Fill in the form in this issue, post (no stamp required) to: CLARC CASA address update Reply paid 2005 Canberra ACT 2601 Australia No way out: A meteorological maze 18 Whiteout: Extinguisher gone wrong 20 Collision: Legacy of Grand Canyon mid-air 37 For address change inquiries, call CASA on 1300 737 032. Distribution Bi-monthly to 90,000 aviation licence holders and cabin crew in Australia and Australian territories. Contributions Stories and photos are welcome. Please discuss your ideas with editorial staff before submission. Note that CASA cannot accept responsibility for unsolicited material. Warning: This educational publication does not replace ERSA, AIP, airworthiness regulatory documents manufacturers’ advice or NOTAMs. Operational information in Flight Safety Australia should only be used in conjunction with current operational documents. Information contained herein is subject to change. The views expressed in this journal are those of the authors, and do not necessarily represent the views of the Civil Aviation Safety Authority. Down fast: Warning on parachuting ops cabin crew RIGHT STUFF Roller coaster: Encounters with turbulence 44 Into the unknown: Scott Crossfield 42 Notice on advertising Advertising appearing in Flight Safety Australia does not imply endorsement by the Civil Aviation Safety Authority. Cover image courtesy: Air Safety Foundation Colour separations and printing by Offset Alpine. ©Copyright 2005, Civil Aviation Safety Authority, Australia. Copyright for the ATSB supplement rests with the ATSB. All requests for permission to reproduce articles should be directed to the editor (see correspondence details above). Registered printpost: 381667-00644. ISSN 1325-5002. 25 CASA CONTACTS cover story airworthiness Licensing & Registration Centre 1300 737 032 • Flight crew licences • Address updates • AME licences • Photo IDs • Medicals Service Centre 136 773 • AOCs & CoAs Switchboard 131 757 • General Inquiries CASA CENTRAL OFFICE Fix it now: It’s cheaper CASA Building Cnr Northbourne Ave & Barry Dr Canberra ACT 2600 GPO Box 2005 Canberra ACT 2601 48 CASA Service Centre PO Box 836 Fortitude Valley Qld 4006 Airline FIELD offices Brisbane 39 Navigator Place Hendra Brisbane QLD 4011 Canberra CASA Building Cnr Northbourne Avenue & Barry Drive Canberra ACT 2600 GPO Box 2005 Canberra ACT 2601 Melbourne Service difficulty reports: Selected listings 50 Drug and alcohol testing: The Australian government moves to introduce testing for safety sensitive personnel. 27 atsb SUPPLEMENT leading edge Level 11, 505 Little Collins St Melbourne VIC 3000 PO Box 558 Collins Street West Victoria 8007 Sydney Building 235 Cnr Qantas Dr & Robey St , Mascot 2020 PO Box 409 Mascot NSW 1460 General Aviation FIELD offices Adelaide 4 Kel Barclay Avenue Adelaide Airport SA 5950 PO Box 126 PBC Adelaide Airport SA 5950 Bankstown Building 628 Airport Avenue Bankstown Airport Brisbane 39 Navigator Place Hendra QLD 4011 Cairns Building 78, Mick Borzi Drive, Cairns International Airport, Cairns QLD PO Box 280N North Cairns Qld 4870 The Jetsons: Very light jets Canberra 53 Cnr Nomad Drive & Rayner Road Canberra Airport Pialligo ACT 2609 GPO Box 2005 Canberra 2601 regulars readback Letters to the editor Darwin 8 STATISTICS Australian and international incidents and accidents 10 flight notes Aviation safety news 13 ADs, AACs AWBs & SDRs Listings of airworthiness directives, advisory circulars, bulletins and service difficulty reports 50 safety check quiz 56 safety rules Regulatory change 64 short final Better approaches 66 Reservations House 2 Fenton Court Darwin Airport Marrara NT 0812 PO Box 41196 Casuarina NT 0811 AUSTRALIAN TRANSPORT SAFETY BUREAU NEWS • Final report on the Mount Hotham fatal accident • Collision with ground • Engine failure • Flight management system computer malfunction • Infringement of separation standards • Collision with ground • Loss of control • STAR non-compliance Moorabbin 19 Second Avenue Moorabbin Airport Mentone Vic 3194 PO Box 20 Moorabbin Vic 3189 Perth 130 Fauntleroy Ave Perth Airport WA 6104 GPO Box 1082 Cloverdale WA 6105 Tamworth Cnr Rentell St & Basil Brown Drive Tamworth Airport NSW 2340 PO Box 895 Tamworth NSW 2340 60 Townsville 1 Coral Sea Drive Townsville Airport QLD 4814 PO Box 7740 Garbutt Qld 4814 READBACK What about WAAS? In all of the informative articles on global navigation satellite systems (GNSS) that have been published in Flight Safety Australia there has been no definitive answer on the state of GPS augmentation in Australia. With resale outlets boasting their products are “WAAS enabled” I feel there is a lot of confusion that needs to be cleared up. Another area that needs examination is the likely outcome of enabling WAAS on your GPS unit and receiving correction data from a WAAS satellite serving the US. I know this can severely degrade the accuracy on some units. –Wayne Glasser, Sydney, NSW Australia is ahead of most of the world in implementing basic satellite-based navigation systems. This is in line with policies of the International Civil Aviation Organization (ICAO), and positions Australian aviation well for the future. Pilots can now take advantage of a range of GPS navigation approvals: enroute; non-precision approaches; as a substitute for DME; night VFR; and – since March of this year – stand alone IFR GPS operations using the latest generation TSO-146 receivers. But to make full use of the technology, augmentation systems are needed. ICAO has identified three types of wide area augmentation system (WAAS): aircraft-based augmentation systems (ABAS); satellitebased augmentation systems (SBAS); and ground-based augmentation systems (GBAS). The FAA now has a satellite-based wide area augmentation system (SBAS WAAS) in use that provides lateral and vertical approach guidance signals that can be received in Australia. However, because we are outside the US FAA WAAS “service area”, WAAS cannot be used here for new approaches with vertical guidance (APVs). The user can switch WAAS augmentation ON/OFF in most capable GPS receivers. For the new IFR TSO C145/6 receivers the accuracy needed will be guaranteed by the RAIM algorithms. This is not so with hand held receivers and users should beware of possible position errors when using GPS at all times, not only with WAAS enabled. In IFR receivers the WAAS signal can be enabled in the set-up menu, and will provide an accurate position output. Hand-held receivers picking up WAAS signals outside the service area will not give the required accuracy. More information is being sought on this from the manufacturers and the service provider. So what is the state of play for WAAS in Australia? Our air traffic services provider, Airservices Australia, is looking at the development of two forms of ground-based system (GBAS), the precision approach or GPS landing system (GLS), and the VHF transmitted ground-based regional augmentation system (GRAS). Details of these projects are available on the Airservices Australia website (www.airservicesaustralia.com). A cost-benefit study into options for augmentation systems is being considered by government aviation policy agencies. –Ian Mallett, chair, the Australian ATM strategic planning group (ASTRA) Tie-down knots I have been a pilot for only a few years, but I have been a yachtsman for over 30 years, and I have to say that the advice in your article, “Tie me down sport”, in the March-April issue of Flight Safety Australia can be improved on greatly. It is much better to use a bowline to initially attach the line to the aircraft Phn: 07 5485 3016 Fax: 07 5485 3017 Email: info@flycolumbia.com.au Web: www.flycolumbia.com.au The fastest certified piston engined aircraft in production ADVERTISMENT Photo courtesy of Rob Neil FLIGHT SAFETY AUSTRALIA MAY–JUNE 2006 Photo courtesy of Rob Neil READBACK and then a round turn and two (or more) half hitches to finish off and achieve the tension required. First, tie a bowline to the aircraft, loop the line under the ground wire (or through the ground tie down ring), back up to the aircraft and through the attachment point. Then loop the end of the line through the attachment again (this is the “round turn” part of the “round turn and two half hitches”). Pull on the rope to achieve light tension. Then finish off with the two half hitches. Light tension is ok when tying to a wire, but tension should not be applied between an aircraft and a solid fixture such as a ring, as this could result in structural damage to the aircraft. Tie the initial bowline so that its knot is about 10-20cm from the aircraft, so that it is simple to tie the half hitches around the bowline loop as well. If the line is the slippery nylon type, then add a few more half hitches. If the aircraft is going to be left for a long time, tie a figure 8 stopper knot in the end of the line to prevent the half hitches from slowly working loose. If the ground point is a wire, then put a “round turn” around the wire as well: this will grip the wire and reduce the chance of the rope sliding back and forth on the wire and chafing through the rope. The illustrations show the knots, and the two phases of tying down. If the tie down rope is too short to double up, then you can tie the round turn and two half hitches to the ground point, but really you should just get a longer tie down rope. And it would also be wise to buy your rope from a yacht supplies store rather than the hardware store, as you can then select a good quality rope built for exposure to water and sunlight. A bowline is always tied to something, and tied first, as it cannot be tied when the line is in tension A round turn and two half hitches are used when tying while holding tension Phase 1 Phase 2 Round turn & 2 half hitches –Allan Soars, Thornleigh, NSW send a Letter Ideal length for publication is 200 words. Longer letters may be edited. Specify if your letter is not for publication, or if you wish to have your name withheld. Send letters to Flight Safety Australia, PO Box 2005, Canberra ACT 2601 or email fsa@casa.gov.au Bowline Figure 8 stopping knot (should be tied up against half hitches round turn reduces horizontal sliding ADVERTISMENT MAY–JUNE 2006 FLIGHT SAFETY AUSTRALIA ACCIDENTS MAJOR INTERNATIONAL ACCIDENTS/INCIDENTS MARCH–APRIL DATE 02/03 Antonov AIRCRAFT LOCATION FATALITIES AIRCRAFT DAMAGE Nil 05/03 Cessna 208B Grand Caravan Lubanimanga, Congo Democratic Republic Arekuna, Venezuela Substantial Nil Written Off 09/03 Learjet 35A 17/03 Hawker Siddeley HS-748-286LFD 18/03 Boeing 737-6D6 La Paz-El Alto Airport, Bolivia Old Fangak, Sudan Sevilla Airport, Spain 6 Nil Nil Written Off Written Off Substantial 18/03 Beechcraft C.99 Near Butte, MT (USA) 2 Written Off 24/03 Cessna 208B Grand Caravan 28/03 Antonov 12BK Lamar Airport, Ecuador 5km from Payam Airport, Iran 5 Nil Written Off Written Off 28/03 Cessna 208B Grand Caravan Near Oak Glen, CA (USA) 2 Written Off 29/03 Ilyushin 62M Nil Written Off 31/03 Let 410UVP-E20 Moskva-Domodedovo Airport, Russia Near Saquarema, Brazil 19 Written Off 03/04 Lockheed C-5B Galaxy Dover AFB, DE (USA) Nil Written Off 10/04 Harbin Yunshuji Y-12-II Near Marsabit, Kenya 14 Written Off 14/04 Lockheed C-130H Hercules 16/04 Fokker F-27 Friendship 400M Kinshasa-D’Djili Airport, CDR Guayaramerin Airport, Bolivia Nil 1 Substantial Written Off 16/04 Cessna 208 Caravan I 23/04 Antonov 74TK-200 Haydom, Tanzania Kousseri, Cameroon Nil 6 Substantial Written Off 23/04 Antonov 2R Near Tersky, Russia 4 Written Off 24/04 Antonov 32B Lashkar Gah, Afghanistan 2 Written Off 27/04 Convair CV-580F 28/04 Cessna 208B Grand Caravan Amisi Airport, CDR Margarita Mountain, Uganda 8 3 Written Off Written Off DESCRIPTION The aircraft crashed 35 km from Tshikapa. Three passengers were seriously injured in the accident. The engine quit and a forced landing was carried out. The aircraft ran into a ditch and overturned. Shortly after takeoff the aircraft struck terrain and broke up. Aircraft overran the runway, causing the right hand main landing gear to fail. Landing mishap. The aircraft came to rest leaning to the right with the nose off the ground. Some 45 passengers were injured. The flight was last heard of around 14:48. Search crews found the wreckage of the plane on March 20. The aircraft lost height shortly after takeoff and collided with a building. Shortly after takeoff three of four engines failed and an emergency landing was carried out. The aircraft broke up and caught fire. Multiple birdstrike is thought to have been the cause of the engine problems. The aircraft had reached an altitude of about 8500 feet and the controller advised that they were heading into rising terrain. Nine seconds later radio contact was lost and the aircraft struck a ridge and crashed. The aircraft had a landing mishap and came to rest 400 m from the runway. The aircraft broke in three. Contact was lost and the flight appeared to have crashed between the cities of Saquarema and Rio Bonito. After takeoff the crew reported an emergency and attempted to return to Dover. On final approach the aircraft struck the ground tail-first. The tail separated and the nose section separated due to the impact. On approach the aircraft flew into the side of the cloud/shrouded foothills of Mount Marsabit. The left main landing gear either did not extend or collapsed on landing. The aircraft ran off the runway, causing substantial damage to the undercarriage and wings. An 80-year old woman died of a heart attack a few hours after the accident. The aircraft landed in severe weather, coming to rest in a sisal plantation. The aircraft crashed and broke up near a village and all six crew members were killed. An intoxicated pilot took four passengers on a flight, the aircraft banked sharply and crashed on approach. A truck crossed the runway when the aircraft landed. The Antonov swerved off the runway, and slid headlong into a nearby nomad settlement. No information on incident available. The wreckage of the aircraft was spotted on Margarita mountains. Notes: Compiled from information supplied by the Aviation Safety Network (see aviation-safety.net) 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 factual information refer to final reports of the relevant official aircraft accident investigation organisation. Information on injuries unavailable. Knowledge of the origin and maintenance history of aircraft parts is critical to aviation safety worldwide. A training and information forum on SUP safety measures that will provide critical information for air carriers, manufacturers, repairers, distributors and others handling aircraft parts. Featuring key experts from the Suspected Unapproved Parts (SUP) Program Office of the US Federal Aviation Administration (FAA) and the Civil Aviation Safety Authority. For further information and registration details go to www.casa.gov.au/sup2006 or contact Leanne Graham on 131757 or at sup2006@casa.gov.au. 10 FLIGHT SAFETY AUSTRALIA MAY–JUNE 2006 A joint initiative of the FAA and CASA Suspected Unapproved Parts Conference ADVERTISMENT Date: 21–23 August 2006 Venue: Hilton Hotel, Sydney ACCIDENTS AUSTRALIAN ACCIDENTS/INCIDENTS MARCH–APRIL DATE AIRCRAFT LOCATION INJURIES AIRCRAFT DAMAGE 05/03 Cessna U206E Hobart, Tas. Nil Substantial 10/03 Lancair 320 11/03 Robinson Helicopter R22 BETA Murray Bridge, SA 64km S JATAR, WA Nil Nil Substantial Destroyed 11/03 Piper PA-31 Navajo 2km E Murray Field, WA Nil Substantial 12/03 Glasair SH-2RG 13/03 S.O.C.A.T.A.-Groupe Aerospatiale TB-10 Tobago 18/03 Rutan Long-Ez 21/03 Cessna U206G 21/03 Cessna 337H Skymaster 22/03 Aerospatiale AS.350BA Squirrel Mildura, Vic. Parafield, SA Fatal Nil Destroyed Substantial Mackay, Qld 11km SE Kununurra, WA Exmouth, WA Maitland, NSW Nil Nil Nil Nil Substantial Substantial Substantial Destroyed 25/03 Cessna 210L Centurion Bankstown, NSW Minor Substantial 26/03 Cessna A188B/A1 Ag Truck 26/03 Cessna A152 Aerobat 55km S Narrandera, NSW Hobart, Tas. Fatal Nil Destroyed Substantial 29/03 Rotorway Executive 162F Mount Beauty, Vic. Fatal Destroyed 29/03 Robinson Helicopter R22 BETA Nebo, Qld Nil Substantial 31/03 Lancair 320 4km ENE Archerfield, Qld Fatal Destroyed 31/03 04/04 05/04 21/04 Hoxton Park, NSW 7km S St Albans, NSW Bankstown, NSW Southport, Qld Minor Serious Fatal Nil Substantial Substantial Destroyed Substantial 26/04 Cessna 337 Skymaster 27/04 Cessna U206G Exmouth, WA Mabuiag Island, Qld Nil Nil Substantial Substantial 30/04 Piper PA-28-235 Pathfinder Prime Seal Island, Tas. Nil Destroyed Searey Bell Helicopter 206B (III) Jetranger Lancair 360 Grumman American AA-5B Tiger DESCRIPTION The aircraft veered to the left and entered the grass, the nose landing gear collapsed and the right wingtip impacted the ground. The nose landing gear collapsed on landing. The helicopter partially lost engine power and the pilot attempted a forced landing, when the helicopter rolled onto the passenger’s side. During the descent, both engines failed. The pilot declared MAYDAY and carried out a forced landing. A homebuilt aircraft crashed. The two occupants were fatally injured. The aircraft was left of the centreline during landing. The solo pilot overcorrected the steering and left the runway, colliding with a ditch. The nosegear collapsed and separated from the aircraft during landing. During a water landing the amphibian Cessna C206 overturned and sank. The aircraft landed with the landing gear retracted. On a training flight the crew simulated a landing without hydraulics. The switches were not reset prior to takeoff, the crew lost control of the helicopter and it impacted the ground. During the initial climb the aircraft’s engine began to run roughly. The pilot decided to reject the takeoff and to land straight ahead on the remaining runway. The aircraft overran the runway and collided with a ditch. The aircraft impacted the ground and the pilot was fatally injured. The pilot decided to reject the takeoff and land straight ahead on the remaining runway. The aircraft overran the runway and collided with the perimeter fence, coming to rest inverted on the highway. The helicopter crashed into a paddock and was destroyed by the impact and the post impact fire. The helicopter experienced a loss of tail rotor authority after a tail rotor strike with a tree while mustering cattle and landed heavily. The aircraft impacted the ground. The pilot, who was the sole occupant, was fatally injured. During initial climb the left wing stalled and the aircraft impacted the ground. The helicopter collided with powerlines before impacting the ground. After takeoff, the aircraft turned right, descended and impacted the ground. During landing aircraft overran the runway and collided with a ditch and a fence. The aircraft landed without the landing gear selected down. During landing, the aircraft veered off the side of the runway and came to rest in a dam. Shortly after the takeoff, the aircraft encountered windshear and collided with the ground. Disclaimer: Information on accidents is the result of a cooperative effort between the AustralianTransport Safety Bureau (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 this data. 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. RB6 EXCLUSIVE B AT T E R Y WARRANTY AEROGUIDANCE CATEGORY B SYNTHETIC TRAINER EPIRB Why wait! You can upgrade to 406 MHz now for less than $500 Getting lost is easy. Being found is even easier thanks to KTi's new SatAlert RB6 406MHz EPIRB harnessing the very latest digital technology. Improving detection accuracy thereby reducing search and rescue times, the new 406MHz RB6 SatAlert EPIRB from KTi features an in-built strobe, longlife replaceable lithium battery and is COSPAS-SARSAT approved. The KTi RB6 SatAlert EPIRB is owner registered to further improve detection time and is designed and manufactured in AUSTRALIA. Price: Made in Australia Updated for the latest computer systems With the rising cost of operating aircraft, fuel – maintenance – airways charges etc, now more than ever it make sense to practice and hone instrument flying skills inexpensively on the ground. ADVERTISMENT The Aeroguidance Synthetic Trainer is CASA approved for ‘unsupervised’ use to meet two of the three hours IFR recency requirements. KTi has developed state-of-the-art IFR single and twin engine Synthetic Flight Trainer systems which provide essential skillbased accredited learning from the convenience of a home computer. The Aero Guidance delivers the ultimate in aviation realism and flight dynamics for pilots serious about maintaining instrument skill. Kinetic Technology International Pty Ltd 1 Kembla Street, Cheltenham East 3192 Victoria Australia be found with Phone: (03) 9585 3801 www.kti.com.au MAY–JUNE 2006 FLIGHT SAFETY AUSTRALIA 11 FLIGHT NOTES Award for top marks A 23 year-old Brisbane woman has been recognised as Australia’s highest performing female trainee professional pilot. Jacqueline Holmes has won a special award from the Civil Aviation Safety Authority and the Australian Women Pilots Association for outstanding academic achievement in professional aviation studies over the past year. Jacqueline, who is close to gaining her air transport pilots Warning on GNSS RNAV approaches Three fatal aircraft accidents over the past 18 months involving aircraft conducting GNSS RNAV approaches have prompted a highlevel warning on the use of unapproved procedures. The CEO of the Civil Aviation Safety Authority (CASA), Bruce Byron, has written to all licensed pilots to stress the need to follow published approach procedures. In two of the accidents, the pilots deviated from the published procedure. Other common factors were that the aircraft were operating in IMC conditions; high terrain was in the vicinity of the aerodrome; and the aircraft descended below the specified approach profile. Byron’s letter says deviating from published procedures not licence, is studying at Flight Training Australia at Archerfield in Brisbane. She hopes to get work as an instructor, and her dream is to fly airliners. CASA and the Australian Women Pilots Association chose Jacqueline as this year’s winner of the Sir Donald Anderson trophy because of her remarkable progress in aviation study and training during the year. She passed all three levels of pilot examinations in a little over 12 months with very high pass marks. only compromises the instrument approach safety margins, but can result in the GPS/GNSS unit being unable to achieve the accuracy required for the safe conduct of the approach. He urges pilots to resist external or self-imposed pressures to save time or money, to get passengers to their destination, or to “save face”. “Those who place commercial or other considerations above the safety of themselves and their passengers need to re-examine their priorities. Barring dire inflight emergencies, there can be no excuse for deviation from published instrument approach procedures,” he says. The letter warns that CASA will take strong action against pilots who deliberately deviate from published procedures, and will take similarly strong action Winner: Jacqueline Holmes, the 2006 recipient of the Sir Donald Anderson trophy. against aircraft operators who compel their pilots to deviate from the procedures. Further action on suspect crankshafts Lycoming Engines efforts to remove suspect crankshafts from active service continue, with the issue of revision A to Lycoming mandatory service bulletin (MSB) 569 on the subject of gradual phase-out of suspect crankshafts. Original issue of MSB 569 inadvertently omitted 404 crankshaft serial numbers. The latest revision makes that correction, keeping the total number of affected crankshafts unchanged. The US Federal Aviation Administration has a proposal on the table to mandate compli- ance with MSB569A. Notice of proposed rulemaking, FAA2006-24785, is available on the web link (http://dms.dot. gov/reports/fr.htm) for review and comment. After the closing date for comment, the FAA is likely to issue a final rule in the form of an airworthiness directive (AD). CASA will issue an equivalent Australian AD with similar applicability, requirements and compliance period, if the FAA issues one. Copies of the MSB and Lycoming cover letter can be downloaded free from Lycoming website (http://www.lycoming.textron.com/main.jsp). CASA recommends operators and maintainers to review MSB 569A to confirm if the proposed AD would affect their engine(s) and plan accordingly. advertisement MAY–JUNE 2006 FLIGHT SAFETY AUSTRALIA 13 FLIGHT NOTES Cabin pressure not responsible for DVT Stay away from whales Now that the whale watching season is in full swing, environmental authorities are concerned that some aircraft are coming too close to the mammals. Aircraft may disturb whales due to their speed, noise, shaddow or downdraft in the case of helicopters. Pilots should be aware that State regulations provide for allowable distances. In Commonwealth waters and in the Great Barrier Reef marine park, helicopters must keep 1,000m away from whales and aeroplanes British researchers reporting in the journal of the American Medical Association say that reduced cabin pressure is not responsible for deep vein thrombosis (DVT), and the likely cause is lack of movement. DVT involves formation of blood clots, often in veins in the legs. The condition can be life threatening if the clots reach the heart and lungs, where they can block blood flow. The researchers put 72 healthy volunteer adults in a chamber for eight-hour shifts in conditions that simulated a passenger jet flight, and compared results with those who spent eight hours in the chamber at normal oxygen and pressure levels. They found that changes to blood that indicate that clots may form occurred at the same rate in both conditions. The researchers concluded that there was no evidence that the low pressure, low oxygen environment of flight was activating the body’s blood clotting mechanism. The clotting changes were probably the result of sitting still for eight hours. In any case, the safety advice is the same when you are doing any form of long-haul travel: Stretch your legs, extend and flex the knees and ankles, and stand and walk if possible. must keep away by 1,000ft vertically and 300m horizontally. The exception is in the Whitsundays where helicopters must be separated from whales by an altitude of 2,000ft In Western Australia and Victoria aircraft must keep at least 300m away from whales. In South Australia the distance is 600m over a 1km radius for helicopters and 300m over a 300m radius for aeroplanes. The Northern Territory and Tasmania require a distance of 1,000m for helicopters and 300m for aeroplanes. In NSW the distances are 400m (helicopter) and 300m (fixed wing). The Commonwealth and States are discussing standardising allowable distances. advertisement 14 FLIGHT SAFETY AUSTRALIA MAY–JUNE 2006 Medical fees review The processing fee for private and student pilot medical exams is to be reviewed. Transport Minister Warren Truss announced the review in May when he released a Civil Aviation Safety Authority (CASA) discussion paper on overhauling the $130 fee for certifying class 2 health checks, introduced on January 1 as part of government’s push towards cost recovery. The $130 fee is in addition to the $80-$250 cost of the check up, and is supposed to cover the expense to CASA of issuing a certificate. CASA deals with 10,000 class 2 medicals every year. Mr Truss said the Government remained committed to cost recovery but believed every effort should be made to ensure the regulator set prices efficiently. FLIGHT NOTES Spate of jet tyre failures Tyre manufacturers and airport and government aviation safety specialists are concerned over a recent spate of blown aircraft tyres on passenger jets. While it is not unusual for aircraft tyres to deflate unexpectedly – the usual culprit is debris on the runway – there has been an unusual peak in the number of incidents reported during May. In the US, a regional jet aborted its takeoff from Albany International Airport after one of its main landing gear tyres blew, and another regional jet made an emergency landing at Washington national airport after a similar problem. Earlier, another jet suffered a main landing gear tyre failure while taking off from Washington National for Dallas. There were two other incidents in early May, one captured on CNN and other news networks. A regional jet taking off from Houston suffered double tyre failure on its main gear, leaving bare wheel exposed. At Chicago’s O’Hare International, another jet aircraft had just touched down on landing when it veered off the runway after one of the tyres failed. In Indonesia on May 5, a jet skidded off the tarmac at Jakarta Soekarno-Hatta International Airport after it suffered tyre failure while on takeoff. And in the Philippines on May 4, an Airbus A320 suffered dual tyre failure on landing at Zamboanga International Airport in Manila. Pilots brought the aircraft to a safe stop in the middle of the runway.Safety authorities are investigating. Accreditation for airport managers The International Civil Aviation Organization (ICAO) and Airports Council International (ACI) signed an agreement in May to develop and deliver a joint training program on airport management. The courses will cover airport operations, financial management, safety management systems, airport certification and security. The development of the training package could lead to an ICAO program of professional accreditation for airport managers. w w w WEBWATCH FLY A CESSNA? If you are a Cessna owner or simply fly a Cessna regularly you should check out the Cessna Pilots Association of Australia website (www.cessnapilotsassociationofaustralia.org.au). It provides links to experienced LAMEs and pilots who can provide you with invaluable technical advice. The site lists all the activities of the association, which include systems and procedures courses and pilot proficiency and engineers training. SURVEY ON RUDDER USE IN UPSETS The safety analysis team at the International of Air Transport Association (IATA) is calling on all regular public transport (RPT) pilots to fill out a confidential online survey on rudder use in yaw/roll upsets. The survey is on the IATA website (http://www. iata.org/ruddersurvey). Analysis of the information will allow IATA and industry experts to assess the use of rudder in transport airplanes and the use of flight controls during yaw/roll upsets based on actual pilot experience and training. For the purposes of the survey IATA is defining an upset as an aeroplane motion that the pilot believed required immediate corrective action. NEW SITE ON AIR TRAFFIC MANAGEMENT The latest developments in aviation communications, navigation, surveillance and air traffic management (CNS/ATM) technologies are now available on a website produced by the Australian strategic air traf- fic management group (ASTRA), a whole-of-industry planning body that brings together key representatives from government and industry. The site (www.astra.aero) features an explanation of the Australian air traffic management (ATM) strategic plan. It also includes information on user-preferred trajectories, ADS-B implementation and developments in global navigation satellite systems (GNSS). You can submit questions about future developments online. BRAIN TEASERS Put your aviation knowledge to the test with the interactive quizzes on the popular Avweb site (www. avweb.com/brain/brain). Although the operational information is USbased, there’s a lot to learn, from sharpening your cross-country navigation skills, to how to handle illusions and what to do to step up to twin-engine operations. DID IT AGAIN The daily aero-tips by Thomas Turner on aero-news on the web often deliver the goods. Turner’s recent sermon on personal electronic devices tells about what happened when he left his mobile on in the back of his aircraft. When he tried to fly an ILS approach, the centred localiser needle didn’t quite line up with the runway; and he heard consistent beeping noises through the headset. Find out more on the aero-news website (www.aero-news.net/news/ featurestories.cfm?ContentBloc kID= d3e3bdd8-4896-4a5a-a93bd1833ee73c68&Dynamic=1). advertisement MAY–JUNE 2006 FLIGHT SAFETY AUSTRALIA 15 WHAT WENT WRONG Courtesy Gary Shephard INTO THE VOID M any commercial pilots can point to a single experience that changed their whole approach to flying. For me, that experience came when I had 250 hours in my logbook and I am grateful the lessons I learnt did not come at the cost of three lives. I was scheduled to fly from He rvey Bay to Rockhampton in a four-seat Robinson R44. The Rockhampton agricultural show was underway and the aim of the trip was to establish a temporary joy-flight service for the duration of the show, a practice that had proved profitable for the company in the past. My boss was at the show and he had mentioned that he was keen for me to get there – and start flying – as soon as possible. Two colleagues were joining me for the flight. While they were both ground crew, one of them also held a commercial helicopter pilot’s licence. In fact, he had con16 FLIGHT SAFETY AUSTRALIA MAY–JUNE 2006 siderably more flight time than me though he hadn’t flown for ages due to a long illness. Now recovered, it was agreed that this flight could be used to give him much needed co-pilot time. (I didn’t realise it at the time, but he had flown only three hours in the past two years.) By the time we departed, low cloud and fog extended along the coast and inland for 20nm. While the local weather looked poor, I was somewhat comforted by reports that the weather at our destination was near perfect; light winds and CAVOK. I took off and climbed to 500ft, just below the cloud base. Visibility was about 5,000m. Once the aircraft was established on track – 5nm inland LOST ON THE COAST Juanita Franzi A junior helicopter pilot is forced to make an unplanned landing in a hostile environment. Name withheld by request. Wrong way: a decision to continue to track along the coast led to more low cloud and fog. WHAT WENT WRONG and parallel the coast – I handed over to the second pilot. Visibility, which had been around 5,000m at takeoff, now seemed to be deteriorating, making VFR navigation increasingly difficult. I asked the other pilot to track inland to avoid the worst of the weather. While we had plenty of fuel, the diversion would add a further half-an-hour to our flight time and possibly raise the ire of the owner, but I figured it was the safest course. I allowed his decision to stand. I didn’t realise it at the time, but from that point on my role as pilotin-command was compromised. Compromised: The second pilot disagreed with my decision, arguing that it would be better to track to the coast. Being less experienced and not wanting to tread on anyone’s toes, I allowed his decision to stand. I didn’t realise it at the time, but from that point on my role as pilot-in-command was compromised. We soon arrived over the coast, 300ft above a straight piece of shoreline. According to my calculations, we should have been near a series of inlets. There were none, and I foolishly reasoned that the WAC chart had to be incorrect. We were flying into wind and were now 200ft above the ground, Visibility was appalling. Worse, with vegetation butting up against the shoreline, there was nowhere to land. I was still considering our options when I suddenly spotted a sand bar about 10m from the beach, 50m long and 20m wide. I told the pilot to land, but he refused. He argued that the machine could be damaged if we were on the ground when the tide came in. I repeated the instruction to land, with an assurance that I would take the blame if the skids got wet. Again he refused. We continued along the coast, getting progressively lower and slower to stay clear of the falling cloud base. As the conditions worsened my colleague acknowledged the seriousness of our predicament and agreed to turn back to the sand bar. My eyes were bulging trying to maintain sight of the ground. Then it was gone. For five or six seconds we peered blindly into the muck, desperately hoping for a glimpse of the mangrove swamps just below us. Control: Then I saw the ocean: we were pitched forward 20 degrees, banking right at 45, and descending rapidly. “We’re too low!” I shouted. He flared sharply and put the collective in his armpit. “Low RPM!” was the next shout as the rotor speed decayed rapidly with the flare then dropped to the low 90s with the load placed on it. He recovered RPM and, obviously shaken, started to land the helicopter in a mangrove swamp. I opened my door and was watching salt water rise up the skids getting closer to the air filter. “What are you doing? We can’t land here.” He pulled the machine out of the swamp then followed the coast till we found the nearby sandbar we’d passed earlier. ANALYSIS: THE FIVE Ps I wonder how many pilots would admit to being in a situation like this one? At least one of the two pilots involved in this incident has learnt an important lesson, and by sharing the story he has given other pilots the opportunity to benefit from his experience. Not all VFR-into-IMC situations end so well. A useful tool for all pilots to remember is the acronym PPPPP – the five Ps – which stand for, “Prior planning prevents poor performance”. Although this was supposed to be a VFR flight, it’s unclear whether the pilot prepared a flight plan, obtained a weather forecast or briefed his passengers before departure. At the very least, an area forecast would have given the pilot an indication of the likely weather conditions enroute. Armed with that information, he could have planned accordingly or, if required, postponed the flight. And by including the co-pilot and even the chief pilot in the flight planning process, any possible differences of opinion could have been resolved on the ground well before takeoff. There can only be one captain in an aircraft. Without an appropriate understanding of the roles of the pilots on board, an adverse authority gradient can lead, as it did in this case, to confusion and misunderstanding. This is something the airlines have long known, and under the banner of After landing, the second pilot relinquished any further control of the aircraft for the remainder of the trip. Then a break in the clouds exposed some blue sky revealing our location in a natural bay, and I was able to ascertain our exact position. Wanting to take advantage of the break we climbed aboard again and set off across the bay. We called the chief pilot and explained the situation to him. He called the boss and told him there would be no more flying today. We completed the journey and two successful days of joy flight operations without incident. $1,000 Best entry crew resource management (CRM) airlines have honed their systems and procedures to ensure that crews clearly understand their roles and responsibilities and are adept at working as a team to achieve the best possible safety outcomes. It would seem this flight departed with both pilots unsure of their roles. A detailed briefing before flight – covering at the very least who is in command, how tasks will be shared, and who will do what in the event of an emergency – would have averted many of the problems that these pilots encountered. Even if the second pilot’s skills had been put to use helping with navigation and decision-making the outcome would have been markedly better. Then there is the matter of “presson-it is”. The decision by one of the pilots to press on into deteriorating weather – presumably to save time and to avoid delays –jeopardised the safety of the flight. It also resulted in them arriving at their destination later than they would have if the pilot had delayed departure, diverted, or put down at an early opportunity in accordance with the requests of his colleague. This story is worth remembering if you are ever tempted to break the rules. Fortunately, this poor performance did not end in tragedy. Prior planning should prevent a repeat performance. – Mal Walker, helicopter pilot and CASA flying operations inspector. MAY–JUNE 2006 FLIGHT SAFETY AUSTRALIA 17 WHAT WENT WRONG NO WAY OUT A VFR pilot presses on into bad weather and is caught in a “meteorological maze”. Name withheld by request. Courtesy Howard J Curtis S ANALYSIS: GA’s BIGGEST KILLER T his pilot’s account bears all the characteristics of what has undoubtedly been the biggest single killer of Australian VFR pilots and their passengers since we began flying–unintentional IMC operations. Quite a number of experienced pilots will admit to having survived a similar misadventure, mostly early in their flying careers. They have learned the hard way, that unless you are absolutely certain that you can reach your destination – or a safe alternative – the golden rule is never to proceed unless you are completely confident that there remains the option to turn back or divert. The first mistake is usually a decision to continue flight into deteriorating weather. The further you “press on”, the more you expose yourself to multiple hazards. It is notable that two pilots who were passengers observed the situation developing, and believed it was of sufficient concern to justify very assertive 18 FLIGHT SAFETY AUSTRALIA MAY–JUNE 2006 intervention. Unfortunately, their concerns were ignored and the flight proceeded into increasing danger. It is notable that two pilots who were passengers observed the situation developing, and believed it was of sufficient concern to justify very assertive intervention. The prime risk of flight in marginal conditions is sudden and unintended loss of external visibility and the consequent disorientation, something that can result in tragedy very quickly. And the risk is highest in low-level, scud-running situations like the one described in this story because pilots are commonly disoriented even before they lose visibility, possibly in a low level turn, flustered by the sudden emergency, and without enough data to make a quick and confident transition to instrument flight if they are so rated. ydney was bathed in early morning sunshine when the four-seat Maule took off from Bankstown Airport. I was one of two glider pilots on board the aircraft, heading down to the Riverina to bring a glider back to Sydney on aero-tow. Our pilot was an experienced glider-tug pilot and he had brought a friend along with him (also a pilot) to assist with navigation and no doubt keep him company on the slow flight home. The weather was fine, the engine was running smoothly, and all indications were that this would be just another pleasant bluesky flight. That is, until we passed Yass. The scattered clouds that had been visible on the horizon for most of the flight were growing in front of our eyes, and starting to form a solid bank of cloud. By the time we reached Lake Burrinjuck, my fellow glider pilot and I voiced our concerns about carrying on, telling the pilot we Even if you are instrument flight qualified and equipped, and certain the surrounding terrain will allow you to climb in cloud to a safe altitude, you can still find yourself in IMC below the lowest safe altitude. If precautionary search and landing is not possible, establish the aircraft in a steady climb, ensure it is trimmed correctly, and advice ATC. The reasons why pilots find themselves in unintentional IMC are often more complex than simply “press-on-it is”. Diversion training is a useful way of “weather-proofing” yourself, but cannot match the actual experience, when the guiding hand of an instructor is not present. Too often a training diversion is merely going back to the start point or to another airfield. Frequently, little thought is given about which direction might result in better weather: holding, diverting to a potentially good precautionary search area that you have previously spotted, or back tracking to a known feature that you can follow to a safe area. WHAT WENT WRONG Handling of passengers can be a problem for low time pilots, and handling frightened passengers and bad weather at the same time can be even more demanding. In this case, the pilot would have been prudent to listen to his passengers concerns. Another factor that can cause problems is the fact that often a low time plot will flying a faster aeroplane those used during training, and can be slow to realise a situation is getting out of hand. Flying too high is a temptation when the weather is bad, especialy if you have not been shown the technique in real weather. Fifty feet to a couple of hundred feet lower may reveal a clear horizon ahead. However, you must be sure that terrain will not present a danger, and must quickly change your plans if it is still gloomy. If you are not confident that you are able to handle this kind of situation, it might be time to have a friendly chat and perhaps even an advanced training flight with your instructor. current conditions. Our copilot’s only contribution to resolving the problem was to become quite agitated and start mumbling how stupid it was to be in this situation. As we made a steep turn to the left we could see that the cloud had started to close in behind us. Alarmingly, the cylinder of clear air that we were in seemed to be getting smaller by the second. We began to make our way in the vague direction of Canberra but it was like being in a big meteorological maze; every direction we took seemed to end in a wall of low cloud. Both of us in the back had serious fears for our safety and strongly suggested that we should find a suitable paddock, land the aircraft – which was fitted with “balloon tyres for retrieving gliders from out-landings – and wait until the weather cleared. All I wanted to do was stand safely on the ground again – it didn’t matter where. After what seemed like hours of weaving our way through the weather and terrain, we stumbled on Lake George. I still have vivid memories of the tops of trees passing uncomfortably close to the underside of the aircraft as we came over the high ground to the west of the lake. At least we now knew where we were. The pilot decided at that point to “hedgehop” along the (dry) lake and low ground to Goulburn. Just to add a bit of spice to our predicament, the drizzle we had been encountering developed into quite heavy rainsqualls that further reduced our visibility. Luckily the two of us in the back seat had a reasonable knowledge of the area, and with the cloud base now marginally higher, we were able to head in the general direction of Goulburn. With collective sighs of relief, we finally landed at Goulburn airport. We had somehow managed, more by good fortune than good judgement, to avoid every power line, tall tree, high feature and cloud covered rock between Gundagai, Lake Burrinjuck, Lake George and Goulburn (and, I’m presuming, a few places in between). Even now, many years later, it gives me the shivers when I think of all the things that could have gone wrong. Lady Luck certainly looked after us that day. $ 500 Highly commended VFR CRITERIA Juanita Franzi would prefer to turn back to Sydney and try another day. Although both of us were experienced glider pilots, the thought of getting caught in bad weather on aero-tow, having to release in an area not of our choosing, and then trying to find a suitable area to land in was not something we looked forward to. Unfortunately the response we received was not the one we wanted to hear. The pilot was sure the weather ahead was, “not as bad as it looked”. About 15 minutes later, approaching Gundagai, it became very obvious that the weather ahead was every bit as bad as it looked. The cloud was thick with a low base, and there was no way we were going to get any closer to our destination on our present course. Only then did our pilot agree to turn back, complaining loudly that the weather forecast he obtained prior to take off had let him down. As we made a steep turn to the left we could see that the cloud had started to close in behind us. Alarmingly, the cylinder of clear air that we were in seemed to be getting smaller by the second. The pilot then decided to try and get under the cloud base and divert to Canberra, as we had no hope of getting back to Sydney in the In the clear: The VFR criteria for distance from cloud and visibility are designed to keep you out of trouble. You need to plan ahead so that you remain within limits. MAY–JUNE 2006 FLIGHT SAFETY AUSTRALIA 19 WHAT WENT WRONG T WHITEOUT here’s an old saying about war that has been adapted by some to aviation: “Flying is 99 per cent boredom punctuated by 1 per cent sheer terror”. My moment of sheer terror happened when I was flying for a local parachute club. It was a perfect day for flying and I was climbing towards a run-in height of 12,000ft. With a few hundred feet to go, my attention was focused on keeping the climb rate of the fully loaded Cessna 182 as high as possible. Suddenly there was a loud “whoosh” and the instrument panel rapidly disappeared in a cloud of white smoke. I swore loudly then closed the throttle, thinking some engine component must have blown through the firewall. That explanation didn’t quite add up, though, as the “smoke” was cool and lacked a strong odour. Not what you’d expect from a hot engine failure. It soon emerged that a rear passenger had inadvertently bumped the trigger of the fire extinguisher mounted below my seat. The extinguisher had emitted a short burst of dry white powder straight A cockpit fire extinguisher is inadvertently activated in flight. Name withheld by request. Istockphoto Juanita Franzi ACCIDENTAL ACTIVATION 20 FLIGHT SAFETY AUSTRALIA MAY–JUNE 2006 Spray: A rear passenger accidently triggered the fire extinguisher mounted below the pilot’s seat. The extinguisher shot out a burst of dry white powder which covered the instrument panel and windscreen. WHAT WENT WRONG Suddenly there was a loud “whoosh” and the instrument panel rapidly disappeared in a cloud of white smoke. “blind” flight as I had lost sight of the horizon and just about everything inside the cockpit as well! Fortunately, I had plenty of altitude and therefore some time to sort things out. I needed it too – extinguisher powder is highly electrostatic and it took ages to clean enough of the stuff away before I could contemplate a safe landing. Back on the ground and still covered in the stuff, I was left to consider how much worse things could have been if the extinguisher had fired at a lower altitude, say Location & mounting of fire extinguishers A irworthiness directive (AD) general 65, amendment 4, sets out the requirements for carriage of handheld fire extinguishers. The AD applies to all aircraft except private and aerial work aeroplanes with maximum takeoff weight not exceeding 5,700kg; rotorcraft with maximum takeoff weight below 2,750kg; and gliders, powered sailplanes and power-assisted sailplanes. Even though these requirements do not apply to the aerial work the Cessna 182 was doing in this story, they nevertheless represent good practice. They include: One extinguisher shall be readily available in the pilot compartment to a crew member. Dry powder or water based extinguishers are not to be located in the pilot compartment or any compartment common to the pilot compartment. after takeoff? As it turned out, apart from possible medical consequences of inhaling fire extinguisher powder, no harm appeared to be done. We later found that the safety handle had worked its way up into the cocked position, away from its normal safety stop against the extinguisher’s body. This allowed the push trigger on the top of the handle mechanism to become live. The reason the safety handle moved was possibly due to the position and movement of my headset bag that was stowed under the seat. (In those days I would wedge the bag under the seat to make sure it didn’t follow the parachutists when the in-flight door opened.) This incident certainly caught me unprepared, as I had never considered the consequences of activating a fire extinguisher (intentionally or otherwise) in a confined cabin. If faced with a real fire, I now ask myself if it would be wise to unload a dry powder extinguisher into the confines of a small cockpit. $ 500 Highly commended Water based extinguishers are not to be located in cabins of aircraft which do not carry cabin attendant. Each extinguisher shall be so located and installed as to be readily accessible and its availability clearly evident to persons who may be required to use it. For aircraft in which pilots and passengers occupy the same compartment, one extinguisher, readily available to a flight crew member, shall be sufficient if the compartment seats 9 passengers or less. If the compartment seats more than 9 passengers, another extinguisher readily available to passengers shall be installed. Extinguishers shall be so located in an environment and mounted in an attitude which complies with the manufacturer’s recommendations. Extinguishers shall not be mounted in positions which may lead to accidental discharge or restrict access to other equipment. Note: A compartment means an area separated from other areas within the aircraft by door, passage or staircase. ANALYSIS: THE WRONG EXTINGUISHER H ow many of you are now asking yourself, “What type of fire extinguisher do I have in my aircraft?” If you purchased your extinguisher at the local hardware store then odds are you also have a dry powder fire extinguisher. This pilot found out the hard way that dry powder fire extinguishers are the wrong type to be installed in a cockpit. Fortunately the incident occurred in a phase of flight where there was sufficient time available to clean up the mess and make a safe landing. Had the incident occurred during takeoff, approach or at night, this story may not have had such a happy ending. The author’s story illustrates how dry powder extinguishant works – it completely coats material and absorbs flammable fluids, removing the oxygen the fire needs to continue. The powder can be damaging to electronics if it find its way into avionics equipment. Halon (BCF & BTM) is widely considered the best general-purpose extinguishant for use in aircraft. It is electrically non-conductive and is considered a “clean agent” because it leaves no residue when it evaporates. On the downside, it is a particularly nasty greenhouse gas. In Australia, the possession of Halon is prohibited unless the chemical is in a fire extinguisher mounted in an aircraft. More environmentally friendly agents are being developed to replace Halon in cockpit fire extinguishers, but for the time being Halon is still considered the safest option. There is one exception to the prohibition on dry powder extinguishant in the cockpit and that is where the aircraft is a balloon. In the highly ventilated environment of a balloon open basket, a dry powder fire extinguisher is the preferred type to be carried. The author raises an interesting question about the medical effects of fire extinguishers. All pilots should know that the emissions pro- Juanita Franzi into the instrument panel. It was only a short puff, but the effect was dramatic. “Blind” flight: Extinguisher powder sticks to everything. In this case, the things it liked most were my glasses, the windscreen, the windows and the instruments. With these items completely obscured, my pleasant VFR sortie had turned into a Analysis continued over page MAY–JUNE 2006 FLIGHT SAFETY AUSTRALIA 21 WHAT WENT WRONG duced by any fire extinguisher will be less harmful than the fumes produced by burning aircraft materials or, worse still, the injuries that can be inflicted by an unchecked fire. Fire fighting: A fire grows at an exponential rate, so time is a critical factor. You should access the site of the fire by any safe means available and extinguish it as quickly as possible. Make sure you are familiar with, and follow, the procedures listed in the aircraft flight manual. Generally, try to cut off any source that may be fuelling the fire. If you are dealing with an electrical fire, turn off the master switches. You only have a small amount of extinguishant onboard, so use it wisely. Fight the base and front of the fire and then work back and upwards. When the fire is out, ventilate the aircraft to remove the fumes. Then, no matter how small the fire appeared to be, or how quickly you put it out, aim to land as soon as practical. If the fire was electrical, consider landing with the electrics switched off. Many small aircraft, especially those with a fixed undercarriage, are quite capable of landing without electrical equipment in VMC. If you require some electrical equipment, turn off all the switches and circuit breakers you can, turn the master switch back on and progressively return power to those electrical circuits that are essential for landing. Fight the base and front of the fire and then work back and upwards. When the fire is out, ventilate the aircraft to remove the fumes. Fire extinguishers are mandatory equipment in a large proportion of aircraft. AD/General/65, AD/Balloon/13 and CAO 95.4.1 cover the aircraft types and kinds of operation where fire extinguishers are required. Where a fire extinguisher is not required, CASA recommends at least one fire extinguisher is installed within reach of the pilot. advertisement Fax: (03) 9580 4629 Email: support@avcats.com.au 22 FLIGHT SAFETY AUSTRALIA MAY–JUNE 2006 The conditions imposed by these airworthiness directives are a good guide to the type of extinguisher you should have installed. Additionally, CASA airworthiness bulletin AWB 26-2 (www. casa.gov.au/airworth/awb/26/002.pdf) provides recommendations, precautions and information on the installation and use of handheld fire extinguishers. Check your aeroplane or helicopter. If you have dry-powder fire extinguisher in the cockpit, take it out. You could use it to mount it on your kitchen or garage. Then go and buy an appropriate fire extinguisher. At the very least it may one day help you to avoid a sudden whiteout in the cockpit. New national rules on the possession and import of Halon have recently been issued by the Federal Department of Environment and Heritage to replace a range of State regulations. Full details of these will be covered in the next issue of Flight Safety Australia. Mark Bathie is a CASA airworthiness engineer specialising in crashworthiness. RIGHT STUFF INTO THE UNKOWN Courtesy NASA Mid-air launch: D-558-2 launch from B-29 mothership. Legendary test pilot, Scott Crossfield, had the real “right stuff”. research aircraft. In April he was found dead in the wreckage of his Cessna 210A by search and rescue crews in the mountains northwest of Atlanta, Georgia, after radio and radar contact was lost the previous day. He had been on a day IFR flight from Alabama to Virginia. He was 84. Yeager was involved with the USAF team that was working on the X-1A, an aircraft designed to surpass Mach 2 in level flight. However, their plans were stymied when Crossfield beat them to the record. Investigation: The cause of the crash is under investigation by the US National Transportation Safety Board (NTSB), which released a preliminary report in May. The report says that a review of radar and meteorological data indicates that Crossfield’s Cessna entered a level 6 thunderstorm shortly before it crashed. ATC tapes showed that controllers did not issue any weather advisories or SIGMETs to the pilot. At 1109:28 (local time) Crossfield radioed ATC to ask for a deviation to the south due to weather. The request was approved. At 1110:02, radar contact was lost. Altitude at the time was 5,500ft. According to the report, debris from the aircraft was found in two areas 1nm apart, with the main wreckage in a crater 4ft deep. “The wreckage distribution was consistent with a low-altitude in-flight breakup,” the report said. Limited damage to the tree canopy also showed the plane plunged nearly straight down. No mechanical or other problems with the aircraft were found. Corbis/Australian picture library MACH 2: THE ROCKET-POWERED D-558-2 Courtesy NASA I n his 1985 autobiography, Chuck Yaeger talked about his experience as a test pilot in the 1950s: “I never [knew] when I might [have been] taking my last ride … The bullet shaped X-1 research rocket airplane had zoomed me into the history books by cracking through the sound barrier. “That first Mach 1 ride launched the era of supersonic flight. I always had butterflies being dropped from the belly of the B29 mother ship [on the] sound barrier mission … I was scared, knowing that many of my colleagues thought I was doomed to be blasted into pieces by an invisible brick wall in the sky.” Yaeger is the most well known of the US military test pilots made famous by Tom Wolfe’s book, “The right stuff”, which celebrated the “heroic” days of test flying in the 1950s and 1960s. In Wolfe’s account of the early years of the space age, Crossfield and Yeager are portrayed as the type of men with, “the ability to go up in a hurtling piece of machinery and put [their] hides on the line and then have the moxie, the reflexes, the experience, the coolness, to pull it back in the last yawning moment – and then to go up again the next day, and the next day, and every next day”. Scott Crossfield was briefly the fastest man alive when he became the first person to fly at Mach 2 in 1953. He later helped design and fly the X-15 rocket-powered Scott Crossfield talks to media after his first flight to Mach 2 in the Douglas D 558-2 (left). An above view of the D-558-2 (right). MAY-JUNE 2006 FLIGHT SAFETY AUSTRALIA 25 RIGHT STUFF Following the tragic accident, key aviation figures paid tribute to Crossfield’s contribution to aviation. The chairman of the aeronautics division at the Smithsonian’s National Air and Space Museum in Washington, Peter Jakab, said, “He was one of the greatest test pilots in the heroic days of test flying in the 1950s and 1960s at places like Edwards Air Force Base. But [he] wasn’t just a great pilot; he really was an enormous contributor to aerospace in many ways during the second half of the 20th century as a technical adviser and policy adviser”. Administrator of the National Aeronau- twice the speed of sound. He achieved the milestone in a Douglas D-558-2 Skyrocket which was carried up to 32,000ft by a B29 Superfortress and “launched”. After climbing to 72,000ft, Crossfield accelerated down to 62,000ft where he broke Mach 2. The D-558-2 Skyrocket and the X-15 are on display at the National Air and Space Museum in Washington. Crossfield downplayed his aviation milestone, which came six years after US Air Force test pilot Yeager broke the sound barrier in 1947. Mach 2 “wasn’t a very big deal,” Crossfield said in a later media interview. “It was made more of by the media than we Just in time to be proclaimed the fastest man alive for the 50th anniversary of flight on December 12, 1953, Yeager flew an X-1A to a record speed of more than Mach 2.4. Crossfield later worked for North American Aviation as a pilot and design consultant for the revolutionary X-15 rocket-powered aircraft. In 1960, he flew at Mach 2.97 in an X-15 launched from a B-52 bomber. There were some close calls. During an X-15 flight in 1959, one of the engines exploded. The emergency landing broke the aircraft’s back just behind the cockpit, but Crossfield escaped injury. Test pilot: After a career as a World War II US Navy flight instructor, Crossfield joined the High Speed Flight Research Station as a research pilot in 1950. Moment of glory: Scott Crossfield in the cockpit of the Douglas D-558-2 just after his recording breaking Mach 2 flight on November 23, 1953. Celebrated work: Crossfield addressing a1988 aviation symposium. tics and Space Administration (NASA), Michael Griffin, said in a statement that Crossfield “was a true pioneer whose daring X-15 flights helped pave the way for the space shuttle”. The director of the Johnson Space Center, Mike Coats, said “Scott Crossfield was a pioneer and a legend in the world of test flight and space flight. The astronaut corps and all of NASA are deeply saddened by his death, but his legacy will be with us through the centuries”. Crossfield took his first solo flight in 1938. He studied engineering at the University of Washington before joining the Navy in 1942. After a career as a World War II Navy flight instructor, he joined the High Speed Flight Research Station in California (a predecessor of NASA) as a research pilot in 1950. Fastest: On November 20, 1953 “Scotty” Crossfield became the first person to fly at did. I’d been flying around Mach 1.9, 1.96, 1.97. We were running into all the typical problems that go with those speeds in airplanes that aren’t designed (to go that fast). We were way over designed [for] speed on that airplane.” Others played it up as a battle between US Navy and US Air Force test pilots to become the fastest pilot. The battle to become the fastest person on earth intensified during the latter half of 1953. Yeager was involved with the USAF team that was working on the X-1A, an aircraft designed to surpass Mach 2 in level flight. However, their plans were stymied when Crossfield beat them to the record. After they were bested, Yeager set out to beat Crossfield’s record. Yeager wrote at the time: “The television networks had scheduled special programs about Crossfield and his Mach 2 flight. ... Our plan was to smash Scotty’s record on December 12.” On June 8, 1959, Crossfield became the first to fly the aircraft on an unpowered glide from 37,550ft. He flew the X-15 aircraft a total of 14 times. He continued working for North American until 1967, overseeing testing and quality assurance on the Hound Dog missile, Paraglider, Apollo Command and Service Module and the Saturn V rocket’s second stage. From 1977 until his retirement in 1993, he was a technical consultant to the House of Representatives Committee on Science and Technology, advising its members on matters relating to civil aviation. “I am an aeronautical engineer, an aerodynamicist and a designer,” he told Aviation Week & Space Technology. “My flying was only primarily because I felt that it was essential to designing and building better airplanes for pilots to fly.” Now that’s the real right stuff.. Courtesy NASA A LIFE OF ACHIEVEMENT 26 FLIGHT SAFETY AUSTRALIA MAY–JUNE 2006 COVER STORY TESTING ALCOHOL The Australian Government announced in May that the aviation sector will be required to introduce mandatory drug and alcohol testing for safety-sensitive personnel. David Newman examines the decision. Transport Safety Bureau (ATSB) will have its powers expanded to enable testing to occur after accidents and incidents. The review of the safety benefits of introducing a drug and alcohol testing program was announced in March 2004 immediately following release of the final ATSB report into a fatal accident on Hamilton Island in which all six on board lost their lives. The accident occurred on September 26, 2002. A Piper PA-32-300 Cherokee 6 light aircraft crashed shortly after take-off on a charter flight from Hamilton Island to Lindeman Island. Witnesses told investigators that the aircraft seemed to have had a rough, intermittently running engine after becoming airborne. The aircraft made a right turn, descended and hit the ground in a nose-low, right-wing low attitude. The aircraft was then consumed by a severe post-crash fire. The investigation by the ATSB found no evidence to suggest what may have caused the reported engine problems. Postmortem toxicological examination of the pilot’s blood revealed a blood alcohol concentration of 0.081 per cent , the presence of an inactive metabolite of cannabis, and an analgesic preparation consistent with a therapeutic dosage. The ATSB accident report noted that “there was insufficient evidence to definitively link the pilot’s prior intake of alcohol and/or cannabis with the occurrence. However, the adverse effects on pilot performance of post-alcohol impairment, recent cannabis use and fatigue could not be discounted as contributory factors to the occurrence. In particular, the possibility that the pilot experienced some Istockphoto DRUG & F light crew, cabin crew, ground refuellers, licensed aircraft maintenance engineers, baggage handlers, security screeners, air traffic controllers and other personnel with airside access at airports are among a wide range of safety-sensitive roles expected to become subject to drug and alcohol testing in 2007 following a decision to introduce a testing regime by the Federal Minister for Transport and Regional Services, Warren Truss. The move follows a report by the Australian Government Department of Transport and Regional Services (DOTARS) and the Civil Aviation Safety Authority (CASA) that reviewed the safety benefits of introducing drug and alcohol testing. Civil aviation safety regulations prohibit flight crew from being under the influence of drugs or alcohol, but testing is not required by law. A broad approach to testing in various forms is likely to be adopted. Testing could involve screening applicants prior to them taking on safety-sensitive roles, random on-the-job testing and monitoring the effectiveness of rehabilitation as an employee prepares to return to work. Drug and alcohol testing in its various forms is in place in the United States and Europe, and has been shown to reduce aviation safety risks arising from drug and alcohol use. Civil aviation safety regulations will be developed to enable an industry testing program to be introduced. This program will be implemented and paid for by industry, with a reporting requirement to CASA, similar to a testing regime that has existed in the United States for many years. The Australian Now it’s aviations turn: Alcohol testing has been in place for road users for many years. Now safety sensitive personnel in aviation are likely to be subject to a broad approach to testing for drugs and alcohol. MAY–JUNE 2006 FLIGHT SAFETY AUSTRALIA 27 COVER STORY degree of spatial disorientation during the turn as a combined result of the manoeuvre, associated head movements and alcoholinduced balance dysfunction could not be discounted.” An examination of various international aviation accident and incident databases, together with other research, revealed a number of dangerous events between 1999–2005, in which drugs and/or alcohol were present. Testing in its various forms has played a crucial role in bringing these instances to light, as well as screening persons testing positive to inappropriate alcohol or drug use from taking on safety-sensitive roles. Testing has also been an important tool in managing the return to duty of persons who have undertaken treatment for inappropriate substance use and sought to return to work. As work begins on implementing a comprehensive approach to testing in an Australian context, a consultative approach involving government and industry is being pursued. The Standards Consultative Committee (SCC), various industry organisations and businesses are engaged with CASA and DOTARS in progressing this latest safety initiative. Recommendations: The report by DOTARS and CASA, “Safety Benefits of Introducing Drug and Alcohol Testing for SafetySensitive Personnel in the Aviation Industry”, made the following key recommendations: • Drug and alcohol testing be introduced 28 FLIGHT SAFETY AUSTRALIA MAY-JUNE 2006 for safetysensitive personnel in the Australian aviation industry. • DOTARS and CASA to commence development of an appropriate regulatory framework under the Civil Aviation Act 1988 and associated civil aviation safety regulations. • Industry to be encouraged to participate in the regulatory development process, including by way of participation in the SCC, the aviation regulatory standards and services industry consultative body. An examination of various international aviation accident and incident databases, together with other research, revealed a number of dangerous events between 1999 –2005, in which drugs and/or alcohol were present. • As a separate testing initiative for noblame safety investigations by the ATSB, the Transport Safety Investigation Act 2003 be amended to allow for medical examinations and alcohol and drug testing to occur following an accident or incident. • The Minister for Transport and Regional Services to ask the Attorney General to examine extending existing police powers to test motorists for alcohol and drug use to include similar testing of pilots, and to seek his support in raising this matter with his States and Territories. • Safety sensitive personnel to be clearly defined. It is suggested that this definition should include flight crew, cabin crew (flight attendants), flight instructors, aircraft dispatchers, aircraft maintenance and repair personnel, aviation security personnel including screeners, air traffic controllers, baggage handlers, ground refuellers and other personnel with airside access including contractors. • Testing should be introduced under the Civil Aviation Act 1988 and associated civil aviation safety regulations and be administered by the industry, according to specified standards and with regular reporting to CASA on tests undertaken and results obtained. • The organisations required to conduct drug and alcohol testing as a minimum should include air transport operators, air traffic control facilities, aviation maintenance and repair businesses, airports, flying training providers and contractors performing safetysensitive functions for the above operators. • Maximum permissible limit or limits should be established for alcohol use, noting in particular current UK and US standards a blood alcohol content (BAC) of either 0.02 per cent or 0.04 per cent respectively. The lower rate of 0.02 per cent is encouraged from a safety perspective. • Zero tolerance testing should apply to five illicit drug groups – cocaine, marijuana, opiates, amphetamines and phencyclidine. • Safety-sensitive personnel should be required to bring to the attention of their employer their use of prescribed or overthecounter drugs that may affect the performance of their duties. • CASA should ensure that drug and alcohol testing become a required component of operator safety management systems. • Testing should be implemented in various forms, to maximise its benefits to aviation safety. Types of testing to be implemented should include preemployment, random, reasonable suspicion, postincident/accident, return to duty and followup. • Pre-employment testing should be required in all cases prior to recruitment or transfer to safety-sensitive positions. • CASA’s regulatory response should require at least a minimum random testing rate of five per cent of safety sensitive personnel (that is, that five per cent of persons in safety-sensitive roles will in the course of a calendar year be tested at least once). • Prohibited conduct for alcohol should include an alcohol concentration at a level to be determined (0.02 per cent BAC is suggested) or greater; use of alcohol while on duty; use of alcohol prior to performance (eight hours for flight crew and cabin crew, a lesser figure may be appropriate for other safety-sensitive personnel); use of alcohol within eight hours after an accident; and refusal to submit to an alcohol test. • Prohibited conduct for drugs should include a positive drug test result; use of drugs while on duty; and refusal to submit to a drug test (including test results demonstrating adulteration and substitution). • The consequences of positive test results should include immediate removal from safety sensitive roles and referral to a substance abuse professional and the possibility of withdrawal of CASAissued certification. • Industry should be encouraged to implement testing as part of a broader response to drug and alcohol use in safety-sensitive roles – including better employee education, encouraging staff to selfidentify substance abuse problems and employee assistance programs offering the opportunity of rehabilitation and return to duty. • Operators should be responsible for all aspects of the testing programs, including associated costs. An examination of the major effects of alcohol and the illicit drugs that will be covered by the drug and alcohol testing program reveals the extent of impairment that they can cause. Other illicit drugs can also impair performance, as can legal prescription drugs and over-the-counter medications. ALCOHOL Alcohol abuse causes significant public health and social problems, and a large proportion of hospital admissions. It has a number of widespread effects on the body, and impairs almost all forms of cognitive function, such as information processing, decision-making, attention and reasoning. Problems include it’s effects as a central nervous system depressant. These effects are related to the dose taken. Alcohol can lead to an increase in risk-taking behaviour and inappropriate decision-making. It causes problems with memory, attention, vigilance, speech, perception and reasoning skills. Istockphoto COVER STORY Alcohol impairment: Studies have shown that even low doses affect pilot performance. The performance of any demanding psychomotor task, such as driving a car or flying an aircraft, is significantly impaired by the effects of alcohol. Visual function can be impaired, and the innerear balance organs can also be adversely affected. The long-term effects of alcohol abuse can also be very significant. Chronic liver disease and brain damage can result, and general social functioning is impaired. In general terms, international research indicates that some seven to 10 per cent of fatal general aviation accidents are alcohol-related. Alcohol increases fatigue, increases the risk of spatial disorientation and hypoxia, and reduces tolerance to G forces. This latter point arises from the dehydrating effects of alcohol, which can lead to an increased risk of G-induced loss of consciousness in aerobatic pilots. Post-alcohol impairment (PAI) is defined as performance impairment after alcohol is no longer detectable (a blood alcohol concentration of zero). However, the symptoms of PAI can impair performance. These symptoms include fatigue, lethargy and gastrointestinal upset. Visual and vestibular effects can persist for up to 48 hours. As such, PAI can lead to impaired performance especially in high workload, demanding situations, such as emergencies. Many studies have documented the deterioration of flying skills with alcohol, both in the acute intoxication stage and the post-alcohol impairment stage. In one study, pilots with a blood alcohol concentration of 0.02 per cent demonstrated much worse landing performance in a flight simulator than when their BAC was zero. A pilot’s ability to detect angular motion (as in a turn) has been found to be reduced by a BAC of 0.04 per cent. Significantly, 14 hours after achieving a BAC of 0.1 per cent, a group of pilots performed much worse on a flight simulator task than before. Importantly, pilots are often unaware of their own performance impairment. It is important to remember that even low doses of alcohol can impair pilot performance. The residual effects of alcohol may seriously impair their performance, especially in high workload, demanding situations such as an inflight emergency. COCAINE Cocaine is an extremely addictive drug. Its effects have a rapid onset, and can appear almost immediately after just one dose. The effects are short-lived, lasting from a few minutes to a couple of hours. The duration of cocaine’s early euphoric effects depends upon how it is taken – smoking generally produces a more intense, shorter-duration effect than snorting. Small doses of cocaine cause feelings of euphoria, heightened energy, increased talkativeness, and raised alertness. Heightened sensations of sight, sound and touch are also reported. While some users report that physical and mental tasks are more quickly carried out with cocaine, other users have reported quite the opposite effect. Europhic effects impair judgement and decision making. Cocaine can cause a number of effects within the body, including dilated pupils, increased heart rate and blood pressure, and even an increase in body temperature. Large amounts of cocaine (several hundred milligrams or more) can produce bizarre, unpredictable, and someMAY-JUNE 2006 FLIGHT SAFETY AUSTRALIA 29 COVER STORY times violent behaviour. Other effects include tremors, dizziness, restlessness, irritability, anxiety and paranoia (including paranoid psychosis, with auditory hallucinations). The cardiovascular effects of cocaine tend to account for the majority of complications related to its use. These adverse effects include heart rhythm disturbances, increased blood pressure, heart attacks, chest pain and respiratory failure. Strokes, seizures, convulsions and coma have also been reported, as well, as gastrointestinal effects such as abdominal pain and nausea. OPIATES Opiates include drugs such as morphine, codeine and heroin. Morphine is often used before or after surgery to help control severe pain. Codeine is used for milder pain, and is found in medications such as Panadeine, Panadeine forte and Codral cold tablets. Some of these medications are also used to relieve severe diarrhoea (Lomotil, for example, which is diphenoxylate) or severe coughs (codeine). Opiates work by selectively attaching to specific receptors in the central nervous system and gastrointestinal tract, with the result that a person’s perceptions of pain and pleasure are altered. This accounts for the initial feelings of euphoria that opiates can create. However, they can also produce drowsiness, constipation, and can reduce the stimulus for breathing. In general terms, narcotic substances produce sedation, slowed reflexes, raspy speech, sluggish movements, slowed breathing, cold skin, and possible vomiting. With ongoing use or abuse of narcotics, the user will develop a tolerance to the effects, requiring more of the drug to produce the same effect. Long-term use also can lead to physical dependence. If the drug is then stopped, withdrawal symptoms appear. These can include restlessness, muscle and bone pain, insomnia, diarrhoea, nausea and vomiting, cold flushes and chills, and uncontrollable leg twitching. These effects may be seen within 4 to 6 hours of the last dose, and generally reach a peak 2 to 3 days later. Derived from morphine, heroin usually appears as a white or brown powder. 30 FLIGHT SAFETY AUSTRALIA MAY-JUNE 2006 Poor performance: Tests of the effects of marijuana on flying skills show a jump in errors. The pilots were unaware of the mistakes they were making. Heroin users generally experience effects immediately after injection. These effects include euphoria, relief of any withdrawal symptoms and relief from pain. Any physical effects will become evident after 15-30 minutes, and are more usually noticeable in new users. These effects include sedation, sleepiness, poor coordination, slow breathing and depressed reflexes. The depression of the central nervous system caused by heroin clouds mental function. Reasoning ability and alertness are significantly impaired. A narcotic overdose is often life-threatening. It results in slow and shallow breathing, cold and clammy skin, convulsions, coma, and without prompt medical attention, death. MARIJUANA Marijuana use is widespread. In recent years the potency of marijuana has increased due to the development of more sophisticated cultivation techniques. The modern form of marijuana can contain 15 times the level of active ingredient found in marijuana used in the 1960s. There are a large number of acute effects of marijuana. It can produce a sense of relaxation and euphoria. However, in some users there are severe anxiety attacks, panic reactions, paranoia and in some cases psychosis and hallucinations. Marijuana can also distort sensory perceptions, such as colour, taste and smells, as well as time. Heightened emotions and increases in pain thresholds have also been reported. Marijuana also increases heart rate, adversely affects blood pressure, and can also increase a sense of hunger. Normal eye movements can also be adversely affected. Psychomotor effects include reduced strength, impaired balance, poor coordination and unsteadiness. Memory and attention are also adversely affected. Complex tasks such as driving or flying are particularly sensitive to its performance impairing effects. There is consistent evidence that the adverse cognitive, behavioural and physical effects of marijuana may still be present 24 hours after the last dose. Chronic cannabis use is associated with a number of adverse health effects. COVER STORY Recent research conducted in Australia suggests that regular marijuana smokers are developing severe respiratory diseases such as emphysema on average 25 years earlier than tobacco smokers. The tar in marijuana smoke contains higher concentrations of cancer-causing substances than tobacco. They then smoked a single marijuana cigarette, and were re-tested in the simulator 24 hours later. The results were disturbing. A number of studies have examined the effects of marijuana on pilot performance and shown that its use results in deteoration of flying skills. The number of minor and major errors increase, but the pilot is often unaware of any performance problem. The more difficult the task, the more likely performance will be impaired. In one study, 10 pilots who were also marijuana users underwent eight hours training in a flight simulator on a landing task. They then smoked a single marijuana cigarette, and were re-tested in the simulator 24 hours later. The results were disturbing. The pilots demonstrated more difficulty lining up with the runway, and there were a greater number and size of control deflections. The lateral deviation on approach was twice that seen pre-cannabis. There was a greater distance from the centre of runway on landing, with one pilot missing the runway completely. (hyperthermia), resulting in liver, kidney, and cardiovascular system failure (including heart attack). Ecstasy can be addictive for some users. Almost 60 percent of people who use ecstasy report withdrawal symptoms, including fatigue, loss of appetite, depressed feelings and trouble concentrating. Chronic users of MDMA perform more poorly than nonusers on certain types of cognitive or memory tasks. Users of MDMA face many of the same risks as users of other stimulants such as cocaine and amphetamines. These include increases in heart rate and blood pressure – a special risk for people with circulatory problems or heart disease – and other symptoms such as muscle tension, involuntary teeth clenching, nausea, blurred vision, faintness, and chills or sweating. Research in animals links MDMA exposure to long-term damage to brain cells that are involved in mood, thinking, and judgment. AMPHETAMINES Amphetamines are psychostimulant drugs. There are several types of illegal amphetamines, including “speed” (amphetamine, dexamphetamine), “meth” (methamphetamine, methylamphetamine), “ice” or “crystal meth” (crys- tal methamphetamine hydrochloride, purified methylamphetamine). Amphetamines come in a number of different forms, including tablets, powder, liquid, crystals or capsules. They can be injected, snorted, smoked or swallowed. Amphetamines stimulate the brain and produce changes such as adrenaline release, increased heart rate and blood pressure, a burst of energy and increased alertness. The user becomes restless, excited, talkative, with a dry mouth, increased sweating and dilated pupils. The effects of amphetamines depend on the strength of the dose, the blend of chemicals, the physiology of the user and their state of mind at the time of taking the drug. In high doses, amphetamines can cause nervous anxiety and irritability. Amphetamine psychosis can also occur. This includes symptoms such as hallucinations, paranoia, delirium, panic and impulsive behaviour. In some people, this state of mind can lead to hostility and aggression. Adverse physical symptoms include heart palpitations, headaches, dizziness, blurred vision, tremor and loss of coordination. The consequences of overdose include collapse, seizure, heart failure or death. Tolerance to and dependence on amphetamines can also occur. Withdrawal ECSTASY Ecstasy is the common name for 3,4Met hylened iox y met ha mpheta mi ne (MDMA). The drug is colourless, tasteless, and odourless, and is taken for its effect on increasing stamina and producing a relaxed, euphoric state. The euphoric state clouds judgement and impairs decision making. Ecstasy’s effects on the brain can include depression, anxiety, paranoia and severe neurological problems when used over a long period of time. Also, confusion, depression, sleep problems, drug craving, and severe anxiety can occur during and sometimes days or weeks after taking MDMA. In high doses, MDMA can lead to a sharp increase in body temperature Legal and illicit drugs: Interactions between alcohol and cocaine, and opiates and some medications can be life threatening. Many combinations of drugs can produce severe complications. MAY-JUNE 2006 FLIGHT SAFETY AUSTRALIA 31 COVER STORY symptoms can include tiredness, irritability, extreme hunger and depression. PCP This term refers to the combined effects of drugs. Some combinations of drugs produce much more severe complications or physical effects than is the case when the drugs are taken by themselves. One drug may counteract the other, or may significantly amplify the effects of the other drug. Such drug interactions can be life-threatening. There is a potentially dangerous interaction between cocaine and alcohol. When taken together, the body converts them to a substance known as cocaethylene. This substance lasts longer in the brain and is more poisonous than either cocaine or alcohol alone. The majority of drug-related deaths involving two-drug combinations are a result of individuals taking both cocaine and alcohol together. Opiates can also interact adversely with a range of other medications. When prescribed, opiates should be used with other medications only under the supervision of medical staff. Opiates should not be used with substances such as alcohol, antihistamines (such as are used for hay fever and other allergies), barbiturates, or benzodiazepines (such as valium). The adverse interaction of opiates with these medications can lead to life-threatening respiratory effects. Istockphoto Phencyclidine or PCP (from the chemical name Phenyl Cyclohexyl Piperidine), acts like a hallucinogen, a stimulant, and in other respects it is similar to a depressant. It is known as “angel dust.” Among its side effects are delirium, visual disturbances and hallucinations and, occasionally, violence. Some evidence of long-term memory disorders and psychological disturbances resembling schizophrenia has also been linked to PCP. Many PCP users ingest their drugs by smoking. Use of PCP results in a combination of the effects produced by depressants, stimulants, and hallucinogens. These include disorientation, memory loss, attention problems, slurred speech, muscle rigidity, sensory distortions and agitation (associated with excitement and auditory hallucinations). Other effects include a raised pain threshold, loss of a sense of personal identity, heat stress and profuse sweating. PCP users may suddenly turn violent. Tolerance to the drug can develop. When smoked or injected, PCP’s effects generally last 4-6 hours or more. COCKTAIL EFFECTS Prescription problems: Side effects and so-called cocktail effects can be extensive. Check with your DAME. PRESCRIPTION DRUGS 32 FLIGHT SAFETY AUSTRALIA MAY–JUNE 2006 There is a huge range of legally available medications (both prescription and overthe-counter), many of which are perfectly safe for pilots and other safety-sensitive personnel to take under the supervision of medical staff, such as a designated aviation medical examiner. However, from a safety viewpoint, there are some important questions to consider: • What is the condition being treated? • Is there an associated risk of incapacitation or impairment of performance? • What are the side-effects of the medication? • Does the medication behave differently at altitude? The side-effects of medications can be extensive. Typical examples include impairment of cognitive functions (memory, attention, decision-making), sedation, altered arousal/alertness (even hyperactivity), altered mood, impairment of vision, poor hearing and balance, allergic reactions, skin rash and gastrointestinal upset. Some medications can make the effects of hypoxia worse, or occur at a lower altitude than normal. The combination of most medications with alcohol can be unpredictable, and could have a negative impact on performance. That is why any drug prescribed by a medical professional must be taken according to the directions given. There are side-effects to these drugs which can occur in some people and can cause significant ill-health. Of course, the reason that the drugs are being taken can, in many cases, be sufficient to remove a safety-sensitive individual from their employment temporarily until they are well again. For example, antibiotics can cause a skin rash, or gastrointestinal illness (such as nausea, vomiting and diarrhoea). Antidiarrhoea medications can cause drowsiness, problems with vision and even dehydration. Complex anti-diarrhoeal medications (such as Imodium and Lomotil) contain antispasmodic agents, to help control the bowel spasms, and are generally considered not compatible with the safe performance of aviation-related duties. Antihypertensive drugs (used to control high blood pressure) can have several possible side-effects, depending on the particular drug being used. These side-effects can include tiredness, lethargy, and dizziness. Some can even cause problems with the immune system. Antidepressants can adversely interfere with normal thought processes, coordination, concentration and alertness. Weight control drugs can increase blood pressure, interfere with fine motor coordination, and produce tremors and even irritability. Some medications can make the effects of hypoxia worse, or occur at a lower altitude than normal. The combination of most medications with alcohol can be unpredictable, and could have a negative impact on performance. Due to the round-the-clock nature of modern aviation operations, many safetysensitive personnel use sleeping agents. CASA provides clear guidance on the use of these medications. Medical certificate holders should not fly or control for at least 12 hours after using Temazepam, or at least 8 hours after using Zolpidem, due to potential issues with alertness. The safety regulator stresses that these drugs must not be combined with alcohol. Due to its potential side-effects affecting the central nervous system, the regulator advises that Triazolam (another type of sleeping agent) is not compatible with flying or controlling duties. The use of Melatonin is not supported. OVER-THE-COUNTER MEDICATIONS Over-the-counter drugs are the sorts of apparently harmless medications that you can get directly from a pharmacist or even a supermarket without the need for a prescription. They include simple pain killers such as aspirin and Panadol, to cold and flu treatments, cough elixirs and antihistamines. As with all medications, there is always the potential for a side-effect to develop, particularly when other medications are also taken. Cold and flu medications can contain agents such as pseudoephedrine, which can cause adverse problems such as elevated blood pressure and increased heart rate. Some of these medications also contain codeine, which as we have seen earlier can have many undesirable effects. These include euphoria, drowsiness, slowed breathing and possible respiratory arrest, nausea, confusion, constipation, sedation, unconsciousness and coma. There is also the potential for tolerance and addiction to develop with prolonged use. Some cough elixirs and suppressants contain significant amounts of alcohol. This can cause sedation and problems with alertness. Aspirin is a very common and simple analgesic agent, for the relief of minor pain. However, it can cause gastrointestinal upset and bleeding, especially in combination with alcohol. Aspirin also interferes with the blood clotting process, making any bleeding more severe than it might otherwise be. Paracetamol is a well-used and generally safe drug, but can cause liver damage when taken in large doses (well beyond the recommended dosage). Hay fever medications (such as the antihistamines) can cause drowsiness, even some of the newer non-sedating versions. Anti-inflammatory medications, such as the non-steroidal class of drugs (Nurofen, Voltaren) are generally safe, but also have some side-effects. These can include gastrointestinal irritation. The use of alcohol with these medications is to be avoided. What about vitamins, minerals and dietary supplements? In Australia, the quality and safety of vitamins have been assessed by the Therapeutic Goods Administration. However, pilots and air traffic controllers should not exceed the recommended daily allowances for these substances. The manufacture and preparation of herbal medicines are not always subject to the same strict regulations that apply to more conventional medications and drugs, in terms of quality, potency, safety or efficacy. Some of these herbal preparations may also contain agents that may interact with other medications. Some herbal preparations can cause side-effects such as hallucinations, disorientation, sedation, drowsiness, slowed reaction times, liver damage, heart rate Istockphoto COVER STORY Harmless? Over the counter drugs can have sideeffects when taken with other medications. and rhythm disturbances, and even heart attack. According to the medical guidelines applied by CASA, routine use of herbal preparations is viewed as being incompatible with flying or controlling duties. The so-called “cocktail effect” is also a serious potential factor with over-thecounter medications. The combination of various over-the-counter medications with each other, or with prescribed or illicit drugs, or especially with alcohol, can lead to unpredictable and significant adverse effects. In addition, there are also dangers that arise from the interaction between the medication effects and the aviation environment (in terms of altitude and hypoxia, pressurisation, cold, fatigue and shiftwork). It is important here to stress that whenever there is any doubt about the wisdom of taking medication, you should consult your doctor. Self-medication can be dangerous. Consult your designated aviation medical examiner (DAME). The introduction of a mandatory drug and alcohol testing program has the potential to reduce the possibility that a drug or alcohol affected individual will be performing a safety critical task while their performance is impaired. Draft regulations for public comment are expected to be released by CASA late this year or early in 2007. David Newman is an aviation medicine consultant and Managing Director of Flight Medicine Systems Pty Ltd. MAY-JUNE 2006 FLIGHT SAFETY AUSTRALIA 33 FLYING OPERATIONS Courtesy ATSB Impact: Part of the Chieftain’s wreckage following its controlled flight into terrain (CFIT). CFIT IN THE SNOW Poor decision making and appalling conditions contributed to the tragic crash of a charter flight near Mt Hotham, according to the final investigation report into the accident. W hy did he do it? Why would an experienced commercial pilot change his mind and fly into extreme weather in an attempt to land his two passengers at Mt Hotham despite warnings that the weather at the ski resort was so bad that he would be unable to land? It’s a question even an extensive 10-month investigation by the Australian Transport Safety Bureau (ATSB) cannot answer fully. But the final investigation report, released publicly in May, does provide some clues to the factors that contributed to the fatal accident at Mt Hotham in the early evening of July 8, 2005. The charter pilot was flying from Essendon to Mt Hotham to rejoin family members. On board the Piper PA31-350 Chieftain were two wealthy ski enthusiasts who were looking at investing in the area. Was it a simple case of “press-on-itis”, in which the pressures to complete the flight overcome the pilot’s judgement of risk? With 1,268 hours on the Chieftain – and 4,770 hours total flight time – the pilot had recently renewed his instrument rating, including his GNSS RNAV endorsement. He knew the area well, having flown into Mt Hotham 204 times over the past six years, chalking up 51 flights into the area in 2005. He was competent and experienced. And yet 34 FLIGHT SAFETY AUSTRALIA MAY–JUNE 2006 one decision on the afternoon of July 8, 2005 would eventually lead to the loss of the aircraft and all on board. The charter pilot’s first decision was the right one. While taxiing at Essendon around 1630 eastern standard time (EST) he changed the planned destination from Mt Hotham to Wangaratta. He told ATC that Mt Hotham was “all socked in”. Weather forecasts predicted icing conditions in the area, and the aircraft was not equipped with anti-icing gear. Earlier in the day a Dash 8 and a Cessna Citation had tried to land at Mt Hotham, but were unable to establish visual reference at the approach minima. Both flights had diverted to alternate aerodromes. It was another fatal controlled flight into terrain (CFIT), the direct cause of some 30 per cent of fatal general aviation accidents in Australia according to an ATSB analysis. Fateful decision: About 15 minutes after departure the pilot changed his mind; he would proceed to Mt Hotham after all. He called air traffic control and advised them of his fateful decision. He then got flightwatch to relay the flight’s estimated arrival time (1719 EST) to Mt Hotham aerodrome. The news worried the aerodrome manager, an accredited meteorological observer. The aerodrome manager did not like the look of the conditions. He told the flightwatch operator that the weather was so bad the aircraft would not be able to land. Automatic recordings of these transmissions show that the pilot’s response was that he would go ahead with the landing, as “... our customer is keen to have a look at it”. ATSB investigation interviews with air traffic controllers after the accident shed more light on the pilot’s relationship with his customer. A senior air traffic controller reported a conversation with the Chieftain pilot that revealed he was enthusiastic about a proposed development at Mt Hotham and the potential benefit for his business. The pilot reportedly spoke of being asked by the developer if weather was an operational problem at Mt Hotham. According to the controller, the pilot had assured the developer that in ten years of operating into the area, weather had never prevented him from making a landing. At 1714 EST, the pilot told control that he was overhead Mt Hotham and requested a change of flight category from VFR to IFR in order to land on runway 29 using a straightin GPS approach (GNSS RNAV) via the initial approach fix HOTEA. Ten minutes later he contacted the Mt Hotham aerodrome manager by radio to get the runway lights switched on. The manager tried to radio back that they were turned on, but got no reply. It took days to find the wreckage. While the aircraft was fitted with an emergency locator transmitter (ELT) no signals were received by search and rescue teams. Hazardous weather over the next two days meant that most of the search was restricted to small parties on foot and on horseback. Mid-morning on the third day a search and rescue helicopter finally found the wreckage near the top of a tree covered ridge 5km south of the aerodrome, and about 200ft below the aerodrome’s elevation. Accident investigators arriving at the site found the Chieftain had cut a swathe through trees on the slope of the ridge and was broken into several large sections. They also found the reason there was no FLYING OPERATIONS emergency transmission from the ELT: the intense heat from the post-impact fire had caused the ELT to fail. Damage to the engines and propellers was consistent with both engines delivering power at the time of impact. The landing gear was extended, and the wing flaps fully retracted. It was another fatal controlled flight into terrain (CFIT), the direct cause of some 30 per cent of fatal general aviation accidents in Australia according to an ATSB analysis. CFIT occurs when an airworthy aircraft, under the control of the flight crew, is flown unintentionally into terrain, obstacles or water. CFIT mostly occurs during the approach and landing The ATSB investigators interviewed a range of people to try to understand why the pilot made the decision to divert to Mt Hotham. The final report devotes a section to the pilot’s operational decision making, part of which attempts to answer this problem. The report says the pilot “… may have become overconfident as a result of previously successful landings. He may also have felt some pressure to attempt the approach as a consequence of his claims regarding his operations at Mt Hotham. Successful completion of the flight could have been seen to confirm to the resort developers his credentials for reliable aircraft services to the resort.” The report also concluded that there may also have been family pressures, with the pilot feeling a strong desire to rejoin his family at Mt Hotham. “Press-on-itis” was partially to blame, but this was not the only factor. Approach problem: Investigators checking radar data and other information found that although the told air traffic control he would conduct the RWY 29 RNAV GNSS instrument approach, he did not follow the published procedure. He did not overfly any of the initial approach fixes, but conducted a “home made” approach by tracking adjacent to the Great Alpine Road, apparently to follow it to the Mt Hotham aerodrome. In the process he diverged further left of the published RNAV GNSS inbound track. The Chieftain had cut a swathe through trees on the slope of the ridge and was broken into several large sections When the pilot advised control that he was going to conduct an instrument approach he was already 700ft below the initial approach altitude. He did not overfly any of the initial approach fixes. Radar data recorded the aircraft turning towards the aerodrome when passing abeam the intermediate fix HOTEI, at 7,200 ft (see diagram). Interviews with Mt Hotham staff established that the pilot had frequently spoken of an unpublished arrival method he used in poor weather. He would fly down a valley to the south-east of Mt Hotham aerodrome, locate the Great Alpine Road and follow it back to the aerodrome. The pro- cedure was not reflected in the company’s operations manual. The charter operation’s chief pilot – also the pilot’s wife – told investigators that she believes that the pilot was able to remain in visual contact with the ground and that he elected to remain visual and that he in fact tracked around the high feature in a clockwise direction, and attempted to follow the roadway to YHOT. However, the weather at Mt Hotham aerodrome at the time of the accident did not meet the minimum requirements for the conduct of flight under VFR. The conditions in the area were also significantly worse than the IFR approach minima. The published IFR approach minima to the RWY 29 RNAV GNSS approach were: a minimum descent altitude of 4,970ft and visibility of not less than 4.2km, but meteorological data recorded at the Mt Hotham aerodrome automatic weather station showed that during the period 1659 to 1759 visibility was 300m. Witnesses near Mt Hotham told investigators that at the time of the accident there had been fog, mist, low cloud, drizzle, light rain and sleet. The report says that pilot’s alternative approach procedure for adverse weather arrivals into Mt Hotham depended upon his ability to accurately judge the extent and severity of weather conditions. However, the ATSB’s report noted, “in utilising his alternative approach procedure, the pilot negated the inbuilt safety margins of the published instrument approach. Without adequate AIRCRAFT FLIGHT PATH Mt Mt Hotham Hotham Aerodrome Aerodrome Mt Battery Wangaratta AD REF Mt Hotham Aerodrome HOTEM Wreckage Essendon Airport Melbourne Cobungra HOTEF Gr ea tA lpi ne R o ad Mt Livingstone HOTEI The wrong approach: The pilot changed his mind and diverted to Mt Hotham while on the way to Wangaratta (above). He used a “home-made” approach to Mt Hotham. Radar data showed that the aircraft appeared to be tracking adjacent to the Great Alpine Road on the last segment of the flight, diverging further left of the published GNSS RNAV inbound track (left). MAY–JUNE 2006 FLIGHT SAFETY AUSTRALIA 35 FLYING OPERATIONS safety margins, the pilot was entirely dependent upon his situational awareness and recognition of his own limitations.” Visual illusion: Although the ATSB found no evidence that airframe icing affected the flight, it may have been a factor. What is certain is that safety margins were further eroded by the weather the pilot encountered. Snow and snow covered terrain in low light can induce visual illusions. The report notes that the conditions at the time of the accident could cause illusions associated with a phenomenon called “flat light”. Flat light can impair a pilot’s ability to perceive depth, distance, altitude or topographical features. It can completely obscure the features of the terrain, making it difficult to distinguish closure rates. In these conditions a pilot may become spatially disoriented, unable to maintain visual reference with the ground, and unaware of actual altitude. Investigators believe that it was likely that the pilot’s depth-of-field and contrast vision were impaired. They noted in the final report that the aircraft was moving towards heavily snow covered and steeply rising terrain, in conditions of continuing snowfall. “Any existing visual cues may have created visual illusions as to whether the aircraft was climbing, descending or flying level. The pilot’s request that the runway lights be switched on is consistent with the low visibility conditions due to weather and light that prevailed at the time of the accident,” the report said. The pilot had been the subject of several incident reports that had been submitted by air traffic control to the ATSB and the Civil Aviation Safety Authority. In the three year period from 2001 until 2004, he was reported for failing to maintain lowest safe altitude at night, violations of controlled airspace and a failure to comply with air traffic control instructions. The pilot was aware that he was under CASA scrutiny, but told a Flying Operations Inspector that he could not understand CASA’s concerns as he had never had an accident. Findings: The ATSB report found: • There were no indications prior to, or during the flight, of problems with any aircraft systems that may have contributed to the circumstances of the occurrence. • The pilot continued flight into forecast and known icing conditions in an aircraft not approved for flight in icing conditions. • The global navigation satellite constellation was operating normally. • The pilot did not comply with the requirements of the published instrument approach procedure. • The pilot was known, by his chief pilot and others, to adopt non-standard approach procedures to establish his aircraft clear of cloud when adverse weather conditions existed at Mt Hotham. • The pilot may have been experiencing self-imposed and external pressures to attempt a landing at Mt Hotham. • Terrain features would have been difficult to identify due to a heavy layer of snow, Getty Images FLAT LIGHT PHENOMENON F lat light, also known as sector or partial white-out, is an optical illusion caused by the diffused lighting that occurs under a cloudy sky, particularly when the ground is snow covered. While not as severe as white-out, when the aircraft may be engulfed in a uniformly white glow, the condition causes pilots to lose their depth-offield and contrast vision. Flat light conditions inhibit visual cues, impairing a pilot’s ability to perceive depth, distance, altitude or topographical features. Flat light can 36 FLIGHT SAFETY AUSTRALIA MAY–JUNE 2006 completely obscure the features of the terrain, creating an inability for the pilot to distinguish closure rates. Reflected light can give a pilot the illusion of ascending or descending when actually in level flight. In these conditions a pilot may become spatially disoriented, unable to maintain visual reference with the ground, and unaware of actual altitude. – ATSB transport safety investigation final report, “Collision with Terrain, Mt Hotham, Victoria, 8 July 2005, VH-OAO, Piper Aircraft Corporation PA31-350 Navajo Chieftain. poor visibility, low cloud, continuing heavy snowfall, drizzle, sleet and approaching with the requirements of the published instrument approach procedure and flew the aircraft at an altitude that did not ensure terrain clearance. • The aircraft accident was consistent with controlled flight into terrain.The report recommends that the Civil Aviation Safety Authority review the requirements for terrain awareness warning systems for Australian registered turbine-powered aircraft below 5,700kg and turbine powered helicopters against international standards. CASA is examining the recommendation. end of daylight. • The pilot’s attitude, operational and compliance practices had been of concern to some Airservices’ staff. • The operator’s operational and compliance history was recorded by CASA as being of concern, and as a result CASA staff continued to monitor the operator. However, formal surveillance of the operator in the preceding two years had not identified any significant operational issues. In conclusion the ATSB listed four significant factors that contributed to the accident. These were: • The weather conditions at the time of the occurrence were extreme. • The extreme weather conditions were conducive to visual illusions associated with a flat light phenomenon. • The pilot did not comply with the requirements of flight under either the instrument flight rules (IFR) or the visual flight rules (VFR). • The pilot did not comply with the requirements of flight under either the instrument flight rules (IFR) or the visual flight rules (VFR). • The pilot did not comply with the requirements of the published instrument approach procedure and flew the aircraft at an altitude that did not ensure terrain clearance. • The aircraft accident was consistent with controlled flight into terrain. The report recommends that the Civil Aviation Safety Authority review the requirements for terrain awareness warning systems for Australian registered turbine-powered aircraft below 5,700kg and turbine powered helicopters against international standards. CASA is examining the recommendation. For ATSB summary of the accident report, see page 60 FLYING OPERATIONS Juanita Franzi GRAND CANYON COLLISION Point of impact: The relative positions of the two aircraft as the collision occurred. The DC-7’s port outer wing was demolished, as its number 1 propelled slashed off the Super Constellation’s rear fuselage. It’s 50 years since a DC-7 and a Super Constellation collided mid-air over the Grand Canyon. Macarthur Job reviews the accident and its legacy. M orning cloud lay over Los Angeles as a TWA Lockheed Super Constellation boarded 63 passengers for New York via Kansas City on the last day of June, 1956. Not far away on the airport, a United Air Lines DC-7 was also about to depart for Chicago with 58 passengers. Showers were expected in the Grand Canyon area, with some thunderstorms. Further inland to the east, the cloud tops were at about 15,000 ft, with good visibility above them. The Super Constellation’s first leg would be in controlled airspace to Daggett, 101nm north-east of Los Angeles. The second and third legs would then be flown outside controlled airspace, cruising at 19,000 ft. Initial reporting points would be Daggett itself, Lake Mohave, and the Painted Desert “line of position”, 20nm beyond the eastern end of the Grand Canyon. The Lockheed lifted off at 9.01am Twenty minutes later, on TWA’s company frequency, the crew reported approaching Daggett and asked the TWA operator to request ATC for a change in altitude to 21,000ft. This was refused – 21,000ft was not available “because of traffic”. They then requested a clearance for “1,000 ft on top” (1,000 ft above cloud level). The Los Angeles controller, after ensuring that the Super Constellation was by that time at least 1000ft above cloud level, cleared it as requested. The controller added, “Advise TWA 2 traffic is United 718, estimating Needles at 0957”. The operator transmitted the amended clearance and traffic information to the Super Constellation, adding that the United aircraft was at 21,000 ft. At 9.59am the Lockheed flight crew reported that they estimated the aircraft would arrive over the Painted Desert line at 10.31am. Because of the cloud level, the “1,000 on top” clearance effectively put the aircraft at an actual altitude of 21,000 ft. At 9.58am, the DC-7 crew reported over The Needles at 21,000ft, amending their estimate for the Painted Desert line to 10.31am – precisely the same time as the Super Constellation was expected to reach the line. Conflicting traffic: The DC-7, taking off three minutes after the Super Constellation, remained in controlled airspace as far as Palm Springs, 106nm due east of Los Angeles, continuing then outside controlled airspace as previously cleared, at 21,000ft. At 9.17am the DC-7 reported on United Air Lines’s company frequency that it was over Palm Springs at 18,000ft, still climbing, estimating The Needles on the ColoMAY–JUNE 2006 FLIGHT SAFETY AUSTRALIA 37 FLYING OPERATIONS rado River on the hour, and the Painted Desert line at 10.34am. At 9.58am, the DC-7 crew reported over The Needles at 21,000ft, amending their estimate for the Painted Desert line to 10.31am – precisely the same time as the Super Constellation was expected to reach the line. At 10.31am, United Air Lines’s radio operators heard a brief, garbled transmission they were unable to comprehend. No Painted Desert position report subsequently came from the DC-7. It raised the operators’ concern – particularly as they could not contact the DC-7. Equally puzzled were TWA’s radio operators – the Super Constellation had not reported as expected at the Painted Desert line and was failing to respond to calls. As disquiet intensified, the civil aviation authorities were forced to issue a missing aircraft alert, and search and rescue action began, directed from an Air Force Base in California. The area where both aircraft had seemingly vanished was a desolate expanse of mountains, deep canyons and parched desert, its terrain ranging from 12,000ft peaks to the Grand Canyon itself. Throughout that afternoon, searching aircraft could find no trace of the overdue airliners. Rising smoke: At Grand Canyon Village on the southern side of the Grand Canyon a general aviation operator, hearing late in the afternoon that two airliners were missing, recalled seeing smoke rising from the canyon during an earlier sightseeing flight. Resolving to investigate, the pilot flew back to the area. Descending into the canyon over the smoke, the pilot was awed to sight the triple tail of a Super Constellation perched on a rocky shelf on the canyon wall, several hundred ft above the Colorado River. Fragmented wreckage lay nearby. More than a kilometre to the north there was smoke from another fire. Next morning an Air Force helicopter made a hazardous landing on the ledge crash site of the Super Constellation, establishing that all 63 people aboard had perished. The DC-7 wreckage was stewn on the near-vertical canyon wall less than two kilometres away. A US Army transport unit helicopter with a medical officer on board managed a difficult and dangerous landing near the DC-7 crash site, but found that none of the 58 passengers and crew had survived. 38 FLIGHT SAFETY AUSTRALIA MAY–JUNE 2006 Civil Aeronautics Board investigators, flown in by the helicopters, found that the Super Constellation had crashed upside down on the side of the Grand Canyon, more than a kilometre south of the junction of the Colorado and Little Colorado Rivers. Its short wreckage trail showed it had done so at a steep angle, an intense fire following. There was no doubt that the two aircraft had collided – several pieces of the DC-7’s port outer wing lay among the Lockheed’s wreckage. The main wreckage of the DC-7, nearly two kilometres to the north-east, was on istration, was found amongst the Super Constellation wreckage. Embedded in the DC-7’s wing skin, was a piece of headlining from the Lockheed’s rear cabin. Flight planning and ATC procedures: Long-range airline flights were permitted outside controlled airspace, provided numerous reporting points defined the route. United Air Lines’ policy allowed such flights on either IFR or VFR flight plans, but did not allow them outside controlled airspace in IMC. TWA policy permitted such flights in IMC outside controlled airspace, but only on an IFR flight plan the same side of the canyon. Investigators concluded that impact had occurred with the DC-7 in a nose-down, wing-down attitude. Again an intense fire had followed. The investigation provided evidence of the aircraft’s relationship to each other at the moment of collision. Pieces of the port outer wing of the DC-7 bore evidence of the collision. The biggest piece, found between the two crash sites, was deformed on its leading edge, with dents, tears and scratches covering much of its lower surface. The DC-7’s wing tip deformation contained black rubber smears from the Lockheed’s deicer boot, and red paint smudges from its painted structure. A section of the underside of the wing, bearing part of the DC-7’s painted reg- with an assigned altitude. When operating “1,000 on top”, TWA aircraft were to adhere to visual flight rules. Controllers told investigators that, because TWA’s Lockheed was soon to pass from the Los Angeles ATC area to that of Salt Lake City, it was necessary to coordinate its request for an altitude change. At the time, both flights were IFR traffic, operating in controlled airspace. The Director of ATC explained that when the Lockheed requested 21,000ft, it had not reached Daggett, nor had the DC-7 reached Needles. But in projecting their tracks eastward, although neither aircraft would be cruising continuously in controlled airspace, both would cross more corridors of controlled airspace FLYING OPERATIONS before they reached the Painted Desert line of position. For this reason, ATC was required to keep them separated. This separation was for instrument flights in controlled airspace only, and the corridors were the last such areas the aircraft would traverse for some distance. ATC maintained progress on IFR aircraft in uncontrolled airspace only to enable their safe spacing into the next control area. Flights in uncontrolled airspace, the Director explained, whether VFR or IFR, were bound neither by clearance nor flight plan. No responsibility tion manual stipulating: “During the time an IFR flight is operating in VFR weather conditions, it is the direct responsibility of the pilot to avoid other aircraft, since VFR flights may be operating in the same area without the knowledge of ATC.” Investigators found that at 9.58am the DC-7 reported it was over The Needles at 21,000 ft, and amended its Painted Desert estimate to 10.31. This position report was passed to Albuquerque ATC at 10.01am and at the same time an attempt was made to pass it to Salt Lake ATC, but there was a delay on the interphone line. A minute 1000ft ft 00 16 Getty Images COLORA DO for separation of aircraft in these areas was accepted. So when the TWA aircraft amended its flight plan to 1,000ft on top, no information about this was passed to the United DC-7. None was required, even though the flights were still in controlled airspace. The ATC Director explained that the TWA Super Constellation’s clearance required it to maintain 1,000ft on top only while within a control area. Once out of controlled airspace, although operating on an IFR flight plan, it was in effect a VFR flight. In the US at the time, aircraft separation in VFR weather depended solely on flight crews, regardless of flight plan or clearance. US Regulations at the time placed this responsibility on pilots, the flight informa- RIVER Impact sight: The Grand Canyon (left). Above: The wall against which the stricken DC-7 impacted. The crash site is circled. Swiss mountaineers, flown in for the task, had to climb from the Colorado River to reach the strewn wreckage (broken line). later at 9.59am, the Lockheed reported to its company operator that it had passed over Lake Mohave at 9.55am, was 1,000 on top at 21,000 ft, estimating the Painted Desert line of position at 10.31am. This report was passed to Salt Lake ATC. The sector controller who received it was the one who had previously denied the Lockheed’s request for 21,000 ft. A few minutes later at 10.13am, when the landline to Salt Lake ATC cleared, the same controller received the DC-7’s 9.58am report that it too, was estimating the Painted Desert line of position at 10.31am. Both the ATC Director and the Salt Lake controller were asked by investigators why traffic information was not transmitted to the two aircraft when the controller knew both were at the same altitude, with both estimating the Painted Desert line of position at the same time, with their tracks were converging. The controller explained that he had no knowledge of the track either aircraft was following. Both were by this time in uncontrolled airspace and specific tracks were not required. Because the Painted Desert line of position was nearly 175nm long, the two aircrafts’ estimates did not mean they would converge there, but merely that both would cross the line at that time. The controller was not required to pass on advisory information in uncontrolled airspace and it was only a discretionary requirement in control areas. Such an advisory service was not possible as normal practice, and would have needed additional ATC facilities and personnel. Pilots flying in the area of the accident confirmed the forecast weather. The lower cloud coverage began well east of Las Vegas, increasing eastwards, becoming nearly overcast 20-25nm west of the Grand Canyon. In the Grand Canyon area there were towering cumulus clouds rising to about 25,000ft. Even so, aircraft had no difficulty maintaining visual flight above the top of the general overcast, which was at about 15,000ft. Analysis: The time of the collision was determined from the garbled transmission United Air Lines radio operators heard on the company frequency at 10.31am. The recording was subjected to spectrographic analysis, which found the transmission contained two voices, both under great emotional stress. The principal speaker transmitted, “Salt Lake, ah, 718... we are going in!” During the momentary pause after “718”, a second voice yelled a word that could have been “look”, “pull” or “come”, followed by the words “up...up”. The transmission began seven seconds before 10.31am. The initial impact occurred above a position just west of the Super Constellation wreckage, with the DC-7 moving from right to left relative to the Super Constellation at angle of about 25°. Slowly overtaking it at the same time, the DC-7’s port aileron bumped the leading edge of the Lockheed’s centre fin. A moment later, the underside of the DC-7’s port wing struck the upper rear fuselage of the Super Constellation. As the two stricken aircraft MAY–JUNE 2006 FLIGHT SAFETY AUSTRALIA 39 FLYING OPERATIONS SEE AND BE SEEN How to avoid a mid-air collision. A s air traffic has increased, so has the importance of seeing if you are to avoid the possibility of a mid-air collision. Yet you usually see only what your mind lets you see. If your mind is on other things, you might not see approaching traffic – until it is too late. One disadvantage your eyes encounter in flying is the time they require for accommodation. They automatically adjust (accommodate) when you look from near to far objects and vice versa. But changing your focus from an instrument panel to an aircraft a kilometre or so away, can take two seconds or more – a slow process when as much as 10 seconds can be needed to see and avoid another aircraft on a collision course. A related problem can develop above haze or cloud layer, when there is no distinct horizon. With little or nothing for your eyes to focus on, although you are looking out, you do not consciously see anything – even conflicting traffic, should it enter your field of vision. And when something becomes visible to only one eye, perhaps hidden from the other by a windscreen pillar, the blurred image you receive may not impinge on your mind. Another difficulty is your eyes’ narrow field of vision. Although they accept light from an arc of nearly 200°, their focus is limited to about 10-15°. This narrow field is the only area in which the eyes clear- 40 FLIGHT SAFETY AUSTRALIA MAY–JUNE 2006 able cloud situation, this could have been reduced to as little as 12 seconds. Without cloud, it should have been possible for the Super Constellation’s captain to have seen the DC-7 for about 40 seconds, but in the most unfavourable cloud situation, this could also have have been as little as 12 seconds. Findings: The investigation report listed the factors that could have led to the accident. They were: • Intervening clouds reducing time for visual separation. • Limitations of cockpit visibility. • Preoccupation with cockpit duties. • Preoccupation with other matters, such as attempting to provide passengers with a more scenic view of the Grand Canyon. • Physiological limits to human vision, reducing the time available to see and avoid the other aircraft. • Insufficient enroute traffic advisory information because of inadequate facilities and lack of ATC personnel. The accident triggered further development of the air traffic system. Today, major public transport aircraft in the US and elsewhere cruise under IFR regardless of weather conditions, in airspace under positive control at all times, and are equipped with last-defence collision avoidance systems such as TCAS. “See and be seen” is no longer relied upon as the primary means of collision avoidance. ly identify objects. Though you sense movement with your peripheral vision, what we see “out of the corner of your eye” is of little help. A further complication in identifying conflicting traffic is that early on, an aircraft on a collision course appears to have no relative motion. It remains seemingly stationary, without appearing to hard to see – and continuous scanning difficult. Scanning: When even light training aircraft on reciprocal headings can have closing speeds over 200kt, seeing and being seen in time to take avoiding action is a challenge. A big part of the answer is effective scanning. In cruising flight, you need to scan an area 60° to either Scanning techniques 5 4 3 2 1 6 1 7 8 9 2 3 4 5 6 7 8 9 10 ATSB/CASA continued to pass laterally, the port wingtip of the DC-7 hit the leading edge of the Constellation’s port fin, while the DC-7’s No 1 propeller cut into the Lockheed’s rear fuselage. Although the accident apparently occurred in visual conditions, collision studies showed that the limitations of cockpit vision, apparent size and shape of the conflicting traffic, colour and contrast, as well as distance and cloud, not to mention fatigue – could all affect a pilot’s ability to sight an aircraft on a converging course. From the captain’s seat of the DC-7, with no clouds intervening, the Super Constellation should have been in view for between 50 and 120 seconds. But in the most unfavour- Example 1: The centre-to-side pattern involves moving the eyes methodically from the centre of the visual field to the far left. The eyes then return to the centre and move right. This is followed by a brief scan of the instrument panel before the process is repeated. Example 2: The side-to-side pattern involves moving the eyes methodically from the far left of the visual field to the far right, pausing very briefly in each block of the viewing area to focus. This is followed by a brief scan of the instrument panel before the process is repeated. grow in size. Then suddenly, as it gets really close, it balloons frighteningly to fill our whole windscreen. This means that marks on the windscreen could obscure it until it is much too close. The environment can also limit effective vision. On cloudy or hazy days, you may be legally VFR, but at the minimum distance from cloud, conflicting traffic may be hard to detect. Glare, over a brightly lit cloud layer, or while flying directly into the sun, also makes traffic side, not forgetting what can be seen from side windows. Scanning 10° up and down horizontally is also a good idea and allows you to spot any aircraft below and climbing, or above and descending. Scans that have proved themselves are based on the theory that traffic can be detected only through a series of eye fixations at different points, each becoming a field of focus. By fixating every 10 to 15°, it should be possible to detect FLYING OPERATIONS COLLISION Tragic tracks: Flight planned tracks of the Super Constellation and the DC-7 eastwards from Los Angles. The two aircraft took off within three minutes of each other and their intended tracks intersected near the Painted Desert line of position. Inset: The Grand Canyon area showing approximate position of the in-flight collision near the junction of the Colorado and Little Colorado rivers. any contrasting or moving object in each visual block. Across the total scan area, this involves 9-12 blocks, each requiring one to two seconds for accommodation. One method is to start at the far left of the windscreen and make a methodical sweep to the right, pausing each time to focus. The other is to start in the centre, moving progressively to the left, then CHECKLIST Keep windscreen and windows clean and clear of obstructions. Have charts folded in proper sequence. Use strobe lights or the rotating beacon constantly. Navigate VFR by passing slightly to one side of radio aids. Pass over airports at a safe altitude, say, above 3,000ft AGL. Use recommended radio procedures – listen out for reports. Conflicting traffic that seems to be moving is not on a collision course. But if it appears stationary, get out of its way quickly. Compensate for blind spots (a critical mid-air situation is a fast low wing aeroplane overtaking and descending on to a high wing during final approach). Scan constantly. Keep looking – and watching out for traffic. swinging quickly back to the centre and repeating the performance to the right. While your head is moving, vision blurs, so unless a series of fixations is made, there is little likelihood of detecting all targets in the scan area. Concentrate on critical areas. In the circuit, check right and left before turns. On descent and climbout, make gentle turns to ensure no one is in the way. On final do not fixate on the aiming point. Look beyond and below this point for other traffic. What ATC can see: In class G airspace air traffic controllers might observe the risk of a mid-air collision. However, VFR aircraft may not have had their altitudes verified with ATC and therefore cannot expect collision avoidance advice. If you have a transponder and you are not within radar coverage, controllers cannot see you, and your transponder will not flash in response to radar interrogation. However, the light flashing is not a guarantee that the transponder is being interrogated by ATC radar, it could be marine, military or other radar sources. If you have a transponder it must be switched on and selected for mode C if this mode is available. If you do not have transponder you are not allowed to fly in any class of controlled airspace (A, C, D and E). An exemption applies to aircraft operating in class E that are unable to power a transponder. At many aerodromes without a control tower or where the control tower is not operating there can be mix of IFR and VFR operations. VFR pilots operating at these aerodromes need to take special care to maintain a listening watch on the radio, announce their arrival and departure in accordance with standard calls, and ensure that their transponders are operating. Larger regional airline aircraft are fitted with traffic alert and collision avoidance systems (TCAS) which scan for operating transponders and need mode C altitude data to resolve potential collisions. If your transponder is not switched on with mode C, TCAS equipment cannot detect you. AUSTRALIAN MIDAIR COLLISIONS 1961-2003 Number of collisions Location of Collision Circuit area Near circuit area En-route Deliberately close Total 1961-1980 11 2 1 2 16 1981-1990 4 1 1 3[4]* 9[10] 1991-2003 9 2 0 1 12 Total 24 5 2 6 37[38] * Figures in brackets is the total if the balloon collision near Alice Springs in 1989 is included Study results: The Australian Transport Safety Bureau (ATSB) has analysed 37 midair collisions that occurred in Australia between 1961 and 2003, involving powered registered aircraft. They have accounted for 0.4 per cent of accidents involving registered powered aircraft and 2.7 per cent (45 fatalities) of all fatal accidents over the period. All of the collisions involved general or sports aviation aircraft, with no collisions involving regular public transport aircraft. MAY–JUNE 2006 FLIGHT SAFETY AUSTRALIA 41 FLYING OPERATIONS Istockphoto POINTS With the growing number of parachuting operations, pilots need to take care to avoid conflict, writes Greg Cox. I t’s about the fastest a human can move Pitfalls: At one airfield an inbound reguwithout direct aid from a machine. Of lar public transport (RPT) flight arrived course, you generally need an aircraft partway through a parachuting drop. to get you up there, but from a drop height Although there is a requirement for of 14,000ft a parachutist can reach a ter- parachute operations to cease when RPT minal velocity of 200km/hr. They usually flights are due, this one had arrived early. open their parachute canopies between Once on the ground, the crew of the RPT 4,000ft and 2,000ft AGL after which they discussed the conflict with the parachutdescend at about 1,000ft/min. ists. Part of the problem was the flight The sport is partly about the experience of crew’s radio procedures. They switched moving at great speed. It’s also fast growing to the CTAF to make their inbound call with over 70 parachuting clubs now active and immediately switched back to the around the country. There are around 3,000 company frequency – without waiting regular members of the Australian Para- for any response from other traffic that chute Federation (APF) who jump either may have been in the area. Hundreds haveaslost theirorlives as a result of flights can also socially, competitively, instructors at Conflicts with private pressurisation problems. McGhie explains the skydiving displays around the country. John occur. At a fly-in being held at a small With over 70,000 people now trying regional aerodrome, a skydiving basics of how the pressure system works and what display to the sport for the first time each year, there was scheduled and publicised as part of doa when there isthrough a problem. are lot of bodies falling the air the day’s activities. Following the drop a at high speeds! Alongside this growth in very stressed pilot approached the paraactivity comes a risk that conflict might chutists and expressed his anger that he occur between parachuting and other hadn’t been aware of their presence, and operations. It’s happened before. Fortu- had come dangerously close to them. nately, in Australia so far there have been The parachutists explained that the no accidents as a result. pilot of the jump aircraft had made a series of radio calls on the local frequency to announce the jumps. That didn’t go down well with the inbound pilot – he didn’t have a radio. In this case, the pilot should have taken some steps to find out what the situation at the fly-in was likely to be when he arrived. NOTAMs are no longer issued unless parachuting operations involve over 100 descents a day or more than one aircraft. The parachute symbol is used on enroute and area charts (ERC-low and AC), VNCs and VTCs to show the location of regular parachuting operations that are notified to authorities by the APF. ERSA will also note aerodromes where parachuting operations are common. However, operations that have only recently been set up, or are conducted on an infrequent basis, may not be rep- PARACHUTING THROUGH CLOUD D uring a drop, parachutists are normally required to remain clear of cloud and in sight of the drop target throughout the descent. There is no minimum distance from cloud required. So if there is cloud and you are approaching or near a parachute drop zone, make sure you listen out for radio announcements of any intended parachuting drop. Operators can apply to CASA to carry 42 FLIGHT SAFETY AUSTRALIA MAY–JUNE 2006 out drops through cloud. In this case they must be clear of cloud for the last 1,000ft before their planned canopy opening height (at least 2,000ft AGL, higher for some tandem, training or specialised jumps). Approval for parachuting through cloud has been granted to operators using drop zones near: • Nagambie, Victoria. • Wilton, NSW. P • • • • Wollongong, NSW. Canberra, ACT. Cairns, Queensland. Toogoolawah, Queensland. Details are at www.casa.gov.au/rules/ miscinst/index.htm – all are marked by chart symbols and some of them also have a danger area established. Jumping through cloud may be approved at other parachuting locations in the future. Courtesy Greg Fox FLYING OPERATIONS resented by a symbol on charts and may not rate a mention in ERSA. There are also display sites where parachutists jump that may not be identified on aeronautical charts and are only notified by real-time radio broadcast. NOTAMs are no longer issued for casual jumps unless parachuting operations involve over 100 descents a day or more than one aircraft. Generally this will only occur at large parachuting events. While parachuting has long been considered a VMC operation, it is now possible to legally parachute through cloud in certain circumstances (see box). The operation requires the operator to follow agreed procedures to maintain safety. Risk reduction: To reduce the risk of conflict with parachuting operations, pilots need to understand the procedures used, and take a few simple precautions. In CTAF areas the jump pilot will normally broadcast the intention to drop a parachutist, on the CTAF, at least two minutes before the drop. In CTAF-R environments pilots of parachute aircraft will broad- PARACHUTE OPS SYMBOL Watch out: When you see this symbol on a chart it means that parachute drops occur in this area. Take precautions by either avoiding the area or taking care to listen out on the appropriate frequency. Parachute drops can occur up to 14,000ft. cast their intentions four minutes prior to dropping. The parachutists will drop upwind of their target, with this distance dictated by the strength of the wind. Generally they drop around one mile upwind of the target; however, this can be up to three miles upwind depending on the height of the drop. Parachute operations in controlled airspace need to request a “drop clearance” from ATC at least five minutes before the drop, and receive the clearance before dropping. Preparation helps. Check your charts and exercise caution when operating near areas marked with the parachute symbol. Use your radio on the appropriate frequency if you are flying near areas where parachute operations occur and request details of any activity. Listen out, know where you are, and be prepared to adjust your track if necessary to allow for parachutists. Beware if you are flying into or out from an airfield where parachuting is in progress as the potential for conflict peaks as everyone converges on the same area – avoid the area upwind of the target. THE JOB OF JUMP PILOT P arachute pilots are required to hold at least a private pilots licence (PPL) with 200 hours total time. One hundred of these hours are to be as pilot-in-command with 10 hours on type. Many are commercial pilots. Although there is no formal endorsement for parachute flying, jump pilots are trained by either the APF club se- The pilot of the jump aircraft will be listening and watching out for conflicting traffic and the jumpmaster (who is responsible for ensuring the parachutists exit over the correct spot) does the same, with a visual scan of the airspace below before the jump. The jump pilot will also broadcast advice on where the parachutists left the aircraft, and can usually advise when all parachutists are on the ground. At airfields where parachuting is a regular occurrence, there is usually an operating procedure agreed between users of the airfield to ensure that everyone is aware of safety procedures. Greg Cox is training manager for the Australian Parachute Federation. The Australian Parachute Federation controls skydiving and parachuting at nearly all civilian operations in Australia. With the approval of the CASA it sets the standards of operation, conducts competitions, issues licences and instructor ratings, conducts exams and publishes a magazine and newsletter to keep its members informed of current events and safety standards. Visit the APF website (www.apf.asn.au). nior pilot, the club chief (parachute) instructor and sometimes both. This training covers aspects of flight specific to parachuting; efficient climb and descent profiles, flight with the door off or open and, of course, flying along with all your passengers jumping outside! Parachute pilots are not required to make a jump themselves, although many do. MAY–JUNE 2006 FLIGHT SAFETY AUSTRALIA 43 C R O E A L S L T O ER RIDE R CABIN CREW R egular public transport flights would encounter light to medium air turbulence almost daily. Occasionally, aircraft experience severe air turbulence that quickly change altitude by as much as 1,000ft in altitude, and make food service and walking impossible, as unsecured objects are tossed about. Turbulence is air movement that normally cannot be seen and often occurs unexpectedly. It can be created by many different conditions, including atmospheric pressure, jet streams, air around mountains, cold or warm weather fronts or thunderstorms. Turbulence can even occur when the sky appears to be clear (clear air turbulence or CAT). While turbulence is normal and happens often, it can be dangerous. Its roller coaster ride can cause passengers and cabin crew who are not wearing their seat belts to be thrown about without warning. Fear of flying can be increased by the experience of turbulence, as the following passenger report to a popular website illustrates: “I flew a little while ago to Melbourne from Europe. I am very petrified of flying now, mainly because of the severity of the turbulence. I know that there is nothing really a pilot can do about it. But, the pilot announced there would be a little bit of turbulence, not the stuff that would cause the aircraft to feel like it is descending 1,000ft! Also, at the time there was no fasten seat belt sign on. “Okay, I understand there is something called human error, but why would such a case happen? This, as might be expected, was over the Bay of Bengal where there are many clouds that cause turbulence. Though September 11th has not changed my view on fly44 FLIGHT SAFETY AUSTRALIA MAY-JUNE 2006 Istockphoto How to minimise the risks of injury from inflight turbulence. By Sue Rice and US Federal Aviation Administration specialists. ing that [experience] certainly did.” The nervousness is understandable because turbulence is thought to be the leading cause of non-fatal injuries to airline passengers and cabin crew. The US Federal Aviation Administration estimates that each year around 58 people in the US are injured by turbulence while not wearing their seat belts. From 1980 through to June 2004, US air carriers had 198 turbulence accidents, resulting in 266 serious injuries and three fatalities. Two of the three fatalities involved passengers who were not wearing their seat belts while the seat belt sign was illuminated. According to the FAA, around two-thirds of turbulence-related accidents occur at or above 30,000ft. Flight attendant injuries occur at a … high rate compared to others because flight attendants spend more time in the passenger cabin unseated and, therefore, unbelted. Injury data: The US data strongly suggest that an effective measure during a turbulence encounter is to have passengers and flight attendants seated with seatbelts fastened. From 1980-2003, only four people received serious injuries during turbulence who were seated with seatbelts fastened (excludes cases of other people falling onto and injuring properly secured occupants). Flight attendant injuries occur at a disproportionately high rate compared to other crewmembers and other cabin occupants because flight attendants spend more time in the passenger cabin unseated and, therefore, unbelted. In Australia over the five years (2001-2005) 56 turbulence incidents were reported to the Australian Transport Safety Bureau (ATSB). Many more go unreported. Several of the incidents are worth recounting because they illustrate how even light or moderate turbulence can cause injury: • During a B737 flight from Adelaide to Perth the aircraft encountered moderate to severe clear air turbulence. Two flight attendants working in the rear galley received minor injuries when they were thrown to the floor. • A B767 during cruise the aircraft encountered light turbulence that resulted in a flight attendant in the rear galley falling backwards onto a fold-down bench and injuring her back. • As the Dash 8 approached its destination aerodrome it encountered an area of moderate turbulence which resulted in both flight attendants being thrown to the floor. • A B747 encountered unexpected turbulence which caused it to deviate 700ft above its cleared level. After returning to level flight it was discovered that an unrestrained cabin crew member had been badly bruised Effective training should include: effective use of the passenger address system (PA) and other methods of communicating with passengers; the location of handholds throughout the aeroplane (or equipment that could be used as a handhold); and how to secure a service cart or an entire galley in minimum time. Communication: Communication and coordination among crewmembers is a critical component of an effective response to turbulence or a threat of turbulence. Ef- CABIN CREW fective team performance can be promoted through: • Use of standard phraseology so that meaning and intent are never in doubt. • Use of standard operating procedures (SOPs) so that all crewmembers know what to expect and what to do during a turbulence encounter. • Effective preflight briefings on the potential for turbulence encounters during each sector. • Keeping the flight deck informed of the conditions in the cabin. • Information flight crew receive from preflight weather briefings and from other pilots about forecasts of turbulence ought to be passed on to the cabin crew. Because the chief defence against injury from turbulence – apart from avoiding the phenomenon – is to promote seatbelt use and compliance with the fasten seatbelt sign, use of the seatbelt sign should be backed up with an announcement over the PA. Flightcrew should promptly and clearly communicate turbulence advisories including specific directions to flight attendants and to passengers. Those advisories can include directions to be seated with seatbelts fastened, and to secure cabin service equipment, as conditions may require. Flight attendants should effectively communicate directions to passengers to be seated with seatbelts fastened. The environment in the cabin may be very different from the environment in the flight deck during turbulence. Flight attendants should feel free to request that the flightcrew illuminate the fasten seatbelt sign whenever it is appropriate to do so in their judgment. Conversely, when the fasten seatbelt sign remains illuminated for prolonged periods of time for reasons other than protection from a turbulence encounter, its effectiveness can diminish for passengers and flight attendants. Air carriers should develop and implement practices to encourage the use of an approved child restraint system (CRS) to secure an infant or a small child. Parents and guardians should be encouraged to ensure that children under the age of two, travelling in their own seats have their harness secured at all times, and particularly when the fasten seatbelt sign is illuminated. Sue Rice is a CASA cabin safety specialist. Istockphoto CASA photo library DESIGN SAFEGUARDS Communication is key: Communication and coordination among crewmembers is a critical part of an effective response to turbulence or a threat of turbulence. . Flghtcrew should promptly and clearly communicate turbulence advisories to flight attendants and to passengers. 2 3 4 1 Causes of turbulence 1. Thermals - Heat from the sun makes warm air masses rise and cold ones sink. 2. Jet streams - Fast, high-altitude air currents shift, disturbing the air nearby. 3. Mountains - Air passes over mountains and causes turbulence as it flows above the air on the other side. 4. Near the ground a passing plane or helicopter sets up small, chaotic air currents, or Microbursts - A storm or a passing aircraft stirs up a strong downdraft close to the ground When an aircraft encounters unanticipated turbulence there may not be time for preparation by crewm embers or passengers. In this situation, measures most likely to prevent or mitigate injuries caused by turbulence involve aircraft design. Effective aircraft design features promote the following: Interior restraints and overhead bin doors can prevent equipment failures during turbulence. Cabin structures with hard or angular surfaces, corners, or protrusions can be minimised. Emergency handholds can be readily identifiable and usable in the cabin, galley and lavatories (such as handles, bars, or interior wall cut outs) by flight attendants and passengers who are not seated with seatbelts fastened. Handrails and/or handgrips can be installed under the overhead compartments in the cabin. Horizontal and vertical “grab bars” can be installed on the counters and stowage compartments in galleys. In configurations where seats are distributed with a large pitch and the seat backs can be reclined to an almost flat position, air carriers can install supplemental handholds beside the seats or install partitions around the seats to provide a handhold if the seat is fully reclined. Handholds can be installed outside the lavatories on the bulkhead walls for use by passengers who may be standing outside the lavatory at the onset of a turbulence encounter. MAY–JUNE 2006 FLIGHT SAFETY AUSTRALIA 45 CABIN CREW TURBULENCE GUIDANCE for pilots and cabin crew STANDARD TERMINOLOGY Duration Occasional. Less than 1/3 of the time. Intermittent. 1/3 to 2/3 of the time. Continuous. More than 2/3 of the time. Note: Duration may be based on time between two locations or over a single location. All locations should be readily identifiable. Intensity Light chop. Slight, rapid and rhythmic bumpiness without major changes in altitude or attitude. Light turbulence. Slight, erratic changes in altitude and/or attitude. Occupants may feel a slight strain against seatbelts. Unsecured objects may be displaced slightly. Food service may be conducted and little to no difficulty is encountered in walking. Moderate chop. Rapid bumps without appreciable changes in aircraft altitude or attitude. Moderate. Changes in altitude and/or attitude occur but the aircraft remains in positive control. It usually causes variations in indicated airspeed. Occupants feel definite strain against seatbelts. Unsecured objects are dislodged. Food service and walking are difficult. Severe. Large, abrupt changes in altitude and/or attitude. Large variations in indicated airspeed. Aircraft may be momentarily out of control. Occupants are forced violently against seatbelts. Unsecured objects are tossed about. Food service and walking are impossible. Extreme. Aircraft is violently tossed about and is practically impossible to control. May cause structural damage. Types Thunderstorm turbulence. Turbulence associated with thunderstorms or cumulonimbus clouds. A cumulonimbus cloud with hanging protuberances is usually indicative of severe turbulence. Clear air turbulence. Turbulence above 15,000ft not normally associated with cumuliform cloudiness. Windshear turbulence even when in cirrus clouds. Mountain wave turbulence. Turbulence as a result of air being blown over a mountain range or a sharp bluff causing a series of updrafts and downdrafts. 46 FLIGHT SAFETY AUSTRALIA MAY–JUNE 2006 EFFECTIVE PROCEDURES Suggested standard operating procedures. Information about flight conditions Inform ATC of turbulence at check in with new controller. Inform ATC when unforecast turbulence is encountered enroute. Inform company so that following flights will be aware of the flight conditions or be planned on another route. Inform/query other aircraft operating in the area on a common frequency. Query ATC about “the rides” when you check in with a new controller/sector. When advised of turbulent conditions Prior to departure, seek alternate routing to avoid the affected areas or delay departure until conditions improve. Change enroute altitudes or routes. Slow to the manufacturer’s recommended turbulence penetration speed. Prior to descent, seek alternate routing to avoid the affected areas or, if severity dictates, hold or divert to alternate. Avoid any convective activity (CBs) enroute by at least 20nm. General procedures If turbulence is expected before the flight departs, the preflight briefing to the lead flight attendant must include turbulence considerations. The briefing should include: What the captain wants the cabin crew to do when turbulence is expected. Intensity of turbulence expected. Methodology for communicating to the cabin the onset or worsening of turbulence (cabin interphone or PA). Phraseology for the cabin crew to communicate the severity of turbulence. Expected duration and how an “allclear” will be communicated. Use a positive signal of when cabin crew may commence their duties after takeoff and when they should be seated and secured prior to landing. If flight into turbulence is unavoidable: Passengers should be informed of routine turbulence via the PA system. Do not rely on the seatbelt sign alone. Cabin crew should be informed of routine turbulence via the interphone. If the cabin crew experiences uncomfortable turbulence without notice from the flight crew, they should take their seats and inform the flight crew. All service items must be properly stowed and secured when not in use. Injury avoidance Expected turbulence. If advance notice exists enabling the captain to brief the cabin crew either prior to the flight or in-flight via the interphone, flight crew should: Brief the cabin crew on the expected turbulence level and its duration. Clearly articulate expectations from the cabin crew and request confirmation of completed actions. Instruct the cabin crew to immediately and plainly report any deviations from the expected turbulence level. Develop a method to inform the cabin crew of the completion of the turbulence event. Little warning. In a situation when sufficient warning exists to seat the passengers and for the cabin crew to perform their duties: Captain turns on seatbelt sign and makes a public address announcement: “Flight attendants stow your service items and take your seats. Passengers please remain seated until this area of turbulence has passed and I have cleared you to move about the cabin”. Cabin crew stow all applicable service items, perform cabin compliance check, and secure themselves in their jump seats. Lead flight attendant informs captain of the completion of these items. When conditions improve, captain uses the public address system to advise the cabin crew that they may resume their duties and whether or not the passengers may move about the cabin. Imminent turbulence or turbulence occurring. If there is sudden, unexpected or imminent turbulence requiring immediate action to protect cabin crew and passengers: Captain turns on seatbelt sign and makes a public address announcement: “Flight attendants and passengers be seated immediately. Passengers please remain seated until this area of turbulence has passed and I have cleared you to move about the cabin.” Cabin crew take first available seat and secure themselves. No compliance checks are performed and items are secured only if they present no delay in securing a person in a seat. When conditions improve, captain makes public address announcement advising the cabin crew that they may resume their duties and whether or not the passengers may move about the cabin. Adapted from US Federal Aviation Administration advisory material. AIRWORTHINESS ADVICE FOR GA AIRCRAFT OWNERS CASA photo library FIX IT NOW If something isn’t quite right with your aircraft, don’t just live with it – fix it. Deferred maintenance often ends up being more expensive, and can compromise your safety, writes Mike Busch. A s a LAME, I sometimes have trouble understanding what makes aircraft owners do some of the things they do. Particularly amazing to me are some of the mechanical problems that aircraft owners elect to live with rather than fix. Nearly four decades as an aircraft owner has taught me that it’s usually cheaper to fix a problem sooner rather than later – sometimes a great deal cheaper. Not to mention that continuing to fly with a known mechanical deficiency can sometimes be hazardous to your health. Apparently some aircraft owners don’t share my fix-itnow philosophy. Check out this report that I recently received from an aircraft owner: “Shortly after I bought my aeroplane last year, I noticed a drip coming from under the aircraft which pooled just to the left of the nosewheel. The drip occurred with a frequency of one drip probably every five seconds while the aircraft sat static with the fuel selector on either the left or right tank. Obviously one of the very important shutdown tasks for me was to turn the fuel selector off in order to stop the leak. I never established whether the fuel leaked while the engine is running. “After not flying for the past month, I 48 FLIGHT SAFETY AUSTRALIA MAY–JUNE 2006 went out to my aircraft last week. It was leaking fuel despite the selector being in the off position. There was a big pool of avgas beneath the airplane, and the fuel gauges indicated that I had lost almost all the fuel in my tanks. “Not understanding why the fuel now leaked regardless of fuel selector setting, I started the aircraft, taxied it around to warm-up the engine and then left it at the maintenance hanger. This owner’s decided to do nothing about the starter adapter slippage until it gets so bad that he cannot tolerate it. This is truly a foolish attitude because every time a TCM starter adapter slips, it “makes metal” inside the engine. “I am being told by the very competent maintenance supervisor that originally it was simply a fuel selector gone bad. However, they are now telling me that given that the aircraft now leaks in any position, it’s also a bad engine-driven fuel pump. Usually I’d say let’s fix the selector and see if that resolves the problem altogether but I am concerned about the fuel pump going out at some critical time. Please advise.” Here we have an owner who knowingly flew his airplane for a year with a known, significant fuel leak in the engine compartment. He only brought it to the attention of his mechanic when he could no longer stop the leak when the aircraft was parked by turning off the fuel selector. Now he’s asking whether it would be OK to fix the fuel selector and continue flying with the fuel leak in the engine compartment unaddressed. Good grief! I cannot imagine operating my lawnmower with a known fuel leak, much less my aircraft. What is this owner thinking? Exhaust Leak? While still scratching my head over that one, I heard from the owner of a Cessna 340 that made me start scratching my head again: “I don’t push the engines hard, running at 65 per cent power or lower most of the time. However, despite a published service ceiling of 27,000ft, the engines really don’t perform well over 15,000ft. I routinely fly over that altitude, but the cylinder-head temperatures get a little high, and the engines burn more oil. AIRWORTHINESS chafed line. If ignored, it can cause a fire, loss of the aircraft, and perhaps even loss of life. So don’t just dismiss what you think might be a minor problem; it might soon grow to a major one. Fix it now – or at least discuss it with your maintainer before making a fix-or-defer decision. It’s usually the smart and prudent thing to do, and it might just wind up saving you a lot of money. Mike Busch is an aviation maintenance engineer and columnist for AvWeb. Reproduced with permission. Courtesy AvWeb he was suffering from the classic symptoms of a TCM starter adapter that is severely worn and slipping. What is worrying is that the owner’s description makes it obvious that he’s been aware of this slippage problem for a long time, yet did nothing about it. Even after the slippage got so severe that he nearly found himself stranded, his first thought was to “monitor it” and only bring it to the attention of his maintenance organisation “if it acted up again”. This owner’s decided to do nothing about the starter adapter slippage until it gets so bad that he cannot tolerate it. This is truly a foolish attitude because every time a TCM starter adapter slips, it “makes metal” inside the engine. If the owner is really lucky, most of that metal will be caught by the oil filter and won’t circulate through the engine, contaminate the bearings and plug up the small passages in the hydraulic valve lifters. If he’s not so lucky, he could easily find himself buying an expensive engine overhaul. Yet this owner is hardly alone. Countless owners of TCM-powered aircraft have slipping starter adapters, but elect to live with the problem rather than fix it. Not smart. Fix or defer? I could go on and on with similar examples, but by now I’m sure you’ve got the idea. Any time you become aware of something on your aircraft that isn’t quite right, the smart thing to do is to bring it to the attention of your mechanic pronto. If the mechanic agrees that the problem is one you can prudently defer fixing until the next scheduled maintenance cycle, fine. But it’s often the case that the fix-or-defer decision is a “pay me a little now or pay me a lot later” proposition. An exhaust leak at an exhaust-riser flange might be solved with a simple gasket if addressed early. If left unaddressed until the cylinder exhaust flange has been severely eroded, the jug will probably have to come off for expensive rework or replacement. A slipping TCM starter adapter if caught early can usually be fixed for several hundred dollars or so by installing an undersize spring. If allowed to continue slipping until the shaftgear is worn beyond limits, you’re looking at thousands of dollars to repair – or if you get unlucky, a new engine. A fuel leak caught early can often be fixed by tightening a B-nut or replacing a Catch leaks early: An exhaust leak at the cylinder exhaust port, if caught early, can often be fixed with a cheap gasket. If you let it go, you’re probably looking at a costly cylinder rework job, or in extreme cases (as shown here) a whole new cylinder. Courtesy AvWeb “Sometimes I have trouble with the wastegates functioning properly at altitude, too, and I get some bootstrapping of manifold pressures needle separation, which is unpleasant at best (because the engines get out of synch), and is dangerous at worst (because the bootstrapping could be due to an exhaust manifold leak). So as a practical matter, I only climb over 21,000ft if it is absolutely necessary.” It is perplexing that this owner can be sufficiently knowledgeable to recognise that his aircraft has a turbocharging problem that prevents it from operating properly at altitude, and even understands that the problem could well be due to an exhaust leak, yet continues to fly the aircraft with that known deficiency. Doesn’t he know about airworthiness directives that require repetitive inspection of his exhaust system every 50 hours, and pressure testing at every annual inspection? What is this owner thinking? Starter adapter slipping: The beat goes on. Here’s a post I saw recently on a popular internet aviation forum: “On my departure from a regional aerodrome one Sunday afternoon, I turned the key to start the engine (a TCM IO-520) and I could hear the starter motor, but the prop wouldn’t turn. It did actually turn slightly, but then just sat there. “I have noticed frequently in the past that the prop turns a little and then stops and then a second or two later it continues. Once the prop starts turning, the engine usually fires on the first turn and starts right up. “On my previous airplane, my maintainer told me to turn the prop until I hear the click and it would help to start. So I turned everything off, got out of the aircraft and turned the prop by hand until I heard it click. I turned it again until I heard it click a second time just for good measure. I then got back in the plane and it fired right up like normal. “When I stopped for fuel at an airstrip on the way home, the engine started right up with out having to do the prop trick. “I figured I would monitor it and if it acted up again to call in my maintenance organisation for a surgical procedure, but after thinking about it this morning I thought I would come to the forum here and see what others have to say.” Replies to this owner’s post explain that Starter slipping? If you try to start a TCM engine and the starter motor turns but the prop doesn’t, you can bet that the starter adapter is slipping (top). This indicates that the spring and shaftgear (lower left and right) are worn. If you catch the problem early, it can be repaired for a few hundred dollars by installing an undersize spring. If you let it go, you may wind up buying a new shaftgear for thousands of dollars, or perhaps even a new engine for tens of thousands. MAY–JUNE 2006 FLIGHT SAFETY AUSTRALIA 49 AIRWORTHINESS SERVICE DIFFICULTy REPORTS To report urgent defects call 131757 fax 02 6217 1920 or contact your local CASA Airworthiness Inspector (Freepost) Service Difficulty Reports, Reply Paid 2005, CASA, Canberra, ACT 2601 (Online) www.casa.gov.au/airworth/sdr Selected reports received march-april 06 AIRCRAFT ABOVE 5700 KG Airbus A320232 AC Power distribution system – screw missing 510002664 SEC 1 circuit breaker screw missing. CB not terminated to main bus bar TSN: 30 hours/9 cycles Airbus A330303 Pitot system contaminated 510002615 Captain’s pitot line contaminated giving low airspeed indications. (5 similar occurrences) BAC 14620011 Fuselage Frame Cracked 510002634 Fuselage frame 41 cracked on inner flange. Found during NDT inspection iaw SB53-182. Crack length 6.35mm (0.250in). (8 similar occurrences) Boeing 7272J4 Fuel wiring faulty 510002647 No2 fuel tank shutoff valve failed to close allowing fuel to spill via the fuel vent system. Investigation found a faulty wiring splice located in the wing leading edge. TSO: 1,001 hours Boeing 737476 Landing gear retract/ extension system – cable separated 510002692 Landing gear would not retract. Investigation found the ground spoiler interlock valve cable detached from the lower rodend adapter allowing the cable to run free and prevent operation of the main landing gear safety sensors. (1 similar occurrence) Boeing 73776N Control column binding – bearing race rotating 510002594 Control wheel binding in both directions. Suspect bearing/housing. Investigation found the lower bearing outer race rotating in the ELL fitting PNo 15-14521-6. P/No: BACB10AU21 (2 similar occurrences) Boeing 7377BX Leading edge devices – slat damaged 510002716 No5 leading edge slat damaged and outboard sensor target contacting the sensor. Investigation found the outboard roller misaligned causing the bolt and washer to rub on the cam plate and shear allowing the bolt to migrate and the target to contact the sensor. Boeing 7377Q8 Wing, centre box fume barrier damaged 510002686 Secondary fuel vapour barrier damaged in eight areas. Areas affected were TP3-R, TP9-R, TPR6-R, TP3-L, TP6-L, TP9-L, SF3-R, SF3-L. Found during inspection iaw AD/B737/245. (4 similar occurrences) Boeing 7378FE Drag control system – cable failed 510002561 Ground spoiler interlock cable failed. Suspect caused by cable rodend bearings seizing due to moisture. P/No: 580250403 (8 similar occurrences) 50 Boeing 7378FE Horizontal stabiliser attach bolt damaged 510002596 Horizontal stabiliser attachment bolts and pins contained fretting damage on shafts. Found during inspection iaw AD/B737/224. (3 similar occurrences) Boeing 747 Power lever – control rod FOD 510002570 No1 engine power control lever FOD. Investigation found a roll of teflon tape jammed between the control rod and the LH engine cowl restricting throttle movement. FOD. Personnel/ maintenance error. Aircraft is foreign registered. Boeing 7474H6 Fuselage skin panel damaged 510002549 Scribe damage evident at fuselage skin panel LH and RH sides located between Stn 1660 and Stn 1680. (5 similar occurrences) Bombardier DHC8202 Air Data Computer – CCA out of limits 510002714 Digital Air Data Computer (DADC) Circuit Card Assembly (CCA) out of tolerance. Found during inspection iaw AD/Rad/43 Amdt6. P/No: 7021904975 (1 similar occurrence) Embraer EMB120 Propeller feathering system solenoid valve failed 510002650 RH engine feathering system solenoid valve failed. P/No: 7902132. TSN: 20,652 hours/22,887 cycles. TSO: 7,328 hours/6,287 cycles Fokker F28MK0100 Aileron tab control washer worn 510002693 LH and RH aileron tab actuator bracket thrust washers worn. Found during inspection iaw AD/F100/61. Fokker F28MK0100 Vertical stabiliser damaged 510002732 Following removal of the LH VOR antenna, pre-existing damage to the LH side of the vertical stabiliser was found. Suspect caused when the antenna mounting plate was removed. Damage was bounded fore and aft by the 32% and 50% spars, and vertically by rib 3.5 and rib 3.4. Learjet 45 Emergency locator beacon - module faulty 510002513 ELT activated during taxi. Switch exercised and ELT light went out. ELT then reactivated during flight. Investigation found a failed PA module and signs of water ingress on the pins of the switch lever assembly connector. P/No: 406PA. TSN: 4,264 hours/7,527 cycles AIRCRAFT BELOW 5700 KG Beech 200 Crew Shoulder harness inertia reel faulty 510002651 Pilot and Copilot shoulder harness inertia reels were pre mod items. Found during inspection iaw Pacific Scientific Alert Service Bulletin SB-A25-1124A. P/No: 110745201. (2 similar occurrences) Beech 200 Elevator jammed 510002727 FLIGHT SAFETY AUSTRALIA MAY–JUNE 2006 Elevator jammed. Elevator servo changed and bridle cable rerigged. Beech 200 Landing gear selector - selector valve failed 510002554 Landing gear selector valve failed in the “up” position. P/No: 10138800517SNO120A. TSO: 9,319 hours Beech 76 Landing gear position and warning system - striker corroded 510002582 Main landing gear down limit switch strikers contained intergrannular corrosion on the tips allowing the switch actuator to bypass the down limit stop. P/No: 16936002539 Beech B200C Fuselage frame doubler cracked 510002698 Fuselage frame doubler located at the lower aft corner of emergency exit cracked in radius. Crack length approximately 9.525 (0.375in). Crack stops at rivet. TSN: 16,991 hours/18,555 cycles Beech B200C Wing attach bolt cracked 510002546 LH lower forward wing attachment bolt cracked. Found during NDT inspection iaw AD/Beech200/38 Amdt4. P/No: 817841644. TSN: 117 months. TSO: 58 months. (2 similar occurrences) Beech C23 Landing gear brake system - pipe corroded 510002667 RH brake failed. Investigation found the hydraulic pipe corroded. Corrosion was caused by contact with an old style steel wire reinforced hose resting on the aluminium pipe. P/No: 16958000187. TSN: 4,801 hours Cessna 402A Aileron control system - cable twisted 510002601 RH aileron control cables twisted twice around each other in area located between WS 89.5 and WS 133.5. P/No: 5000082737 Cessna 404 Aileron control system - cable frayed 510002742 Aileron cable frayed at fairlead. P/No: 58151032 Cessna 402A Main landing gear trunnion pivot loose 510002602 LH and RH main landing gear trunnion forward pivot forgings loose due to unserviceable rivets and screws. LH main landing gear upper torque link pin not retained by rollpin and lockwire. Squat switch rigged to allow undercarriage retraction while on the ground. P/No: 08227201819. TSN: 6,752 hours Cessna 402A Emergency exit incorrectly fitted 510002597 Emergency exit incorrectly fitted. Investigation found the pins disengaged but lockwired in a manner that kept tension on the release cables. Further investigation revealed emergency exit retainers to be made from stainless steel and the exit glued in place with silastic. Removal of the exit proved extremely difficult the tabs had to be bent with pliers and the silastic cut by inserting an aluminium strip between exit and surrounding bulkhead. AD/GEN 37 last carried out on 10/11/03. Personnel/maintenance error. P/No: 50111302. TSN: 6,752 hours Cessna 402A Engine exhaust system worn and leaking 510002600 LH engine exhaust system worn and leaking. Inspection found PNo 9910295-13, PNo 9910295-14, PNo 9910301-4, PNo 9910301-31, PNo 9910301-33 and PNo 5355108-4 bulged and leaking from several holes due to chaffing damage at engine mount bulkhead and extremely thin material on left and right stacks. Area surrounding leaks had very thick build up of exhaust gas indicating that the leaks had been present for sometime. AD/C400/43A8 last carried out on 30/05/05. (1 similar occurrence) Cessna 402C Hydraulic reservoir, main - sight glass split 510002624 Hydraulic reservoir sight gauge split at both the bottom and top ends leading to loss of hydraulic fluid. Landing gear emergency down system failed to operate. Investigation found the emergency extend bottle valve was stuck half way preventing operation. P/No: 51170712. TSN: 50 hours. TSO: 50 hours Cessna 441 Wing spar delaminated 510002657 Wing rear spar delaminated. Found during Ultra-Sonic inspection iaw AD/Cessna400/103 Amdt 2. Delamination had progressed from the results of the last NDI carried out on 29th August 2005. P/No: 572216525 (3 similar occurrences) Pilatus PC12 Flight compartment window cracked 510002699 Copilot’s side window cracked through screw holes in mounting lugs. P/No: 9598110112. TSN: 9,580 hours/9,980 cycles/120 months Pilatus PC12 Prop de-ice harness wires broken 510002533 Propeller de-ice harness wires (3off) broken at 180 degree bend. P/No: 3E23604. (23 similar occurrences) Piper PA28236 Aircraft fuel distribution system – hose worn 510002618 Main fuel line chafed by LH nosewheel steering stop. (2 similar occurrences) Piper PA34220T Fuel boost pump brush worn 510002574 LH electric fuel boost pump brushes worn prematurely. Investigation found brush springs of different lengths. Commutator shows signs of arcing. P/No: 9A1577. TSN: 84 hours. (2 similar occurrences) Piper PA34200T Main landing gear trunnion cracked 510002607 RH main landing gear trunnion cracked in door rod attachment lug. Cracks originate from a sharp corner AIRWORTHINESS where the lug moulds into the trunnion housing. P/No: 39486015. TSN: 3,173 hours. (3 similar occurrences) Swearingen SA227AC Fire detection system – wire separated 510002590 LH engine rear lower fire detector wire separated from detector and shorting on engine firewall. False fire warning resulted in LH engine fire bottle being discharged. Swearingen SA227AC Hydraulic pump O-ring failed 510002745 Total loss of hydraulic fluid. Investigation found the RH hydraulic pump pressure fitting “O” ring seal failed. Both pumps replaced due to running dry. TSO: 41 hours/37 cycles/1 month Swearingen SA227AC Trailing edge flap control system – hose leaking 510002589 RH flap actuator “up” hose leaking from area where the swaged end fitting attaches to the hose. P/No: SS1000F000M110Y Swearingen SA227C Engine bleed air system gasket leaking 510002713 LH engine bleed air system gasket leaking. Hot air activated an adjacent fire detector probe causing an engine shutdown and fire bottle operation. Swearingen SA227DC Extinguishing indicating system faulty 510002639 LH engine fire extinguisher bottle “empty” warning. Visual inspection of the bottle gauge indicated “full”. Indicating system checked with no fault found. No further indications occurred and the aircraft returned to service. Swearingen SA227DC Trailing edge flap actuator cracked 510002566 RH trailing edge flap actuator cracked around base and leaking hydraulic fluid. P/No: 2736053003. TSO: 4,201 hours/2,864 cycles (3 similar occurrences) Kawasaki BK117B2 Rotorcraft servo system - trim unit binding 510002633 Lateral cyclic force trim motor faulty, causing cyclic control restriction. P/No: L209CCM3 Robinson R22BETA Main rotor blade debonded 510002728 Main rotor blade root debonded from blade skin. Found during inspection iaw AD/R22/36. P/No: A0164. TSN: 393 hours. TSO: 393 hours (3 similar occurrences) ROTORCRAFT Allison 250C20B Turbine governor bearing disintegrated 510002506 Power turbine governor drive bearing failed. TSO: 1,157 Hours Garrett TPE3318402S Engine fuel distribution – solenoid leaking 510002654 Engine Primary Only solenoid valve leaking. Found during post installation engine run. Valve is outside of the serial number range indicated in SB TPE331-73-0268. P/No: 69254513BC (1 similar occurrence) Garrett TPE3318402S Engine oil pump failed 510002515 Engine oil system rear turbine scavenge pump driveshaft jammed in housing and stripped the driveshaft teeth preventing oil from being scavenged back to the gearbox. Oil pressure build-up then unseated rear turbine oil seal and dumped oil into the exhaust. P/No: 86504611. TSO: 3,592 hours/3,312 cycles (6 similar occurrences) GE CF680C2 Turbine engine stalled 510002560 LH engine stalled during taxi. Troubleshooting could find no defects evident. Investigation could find no definite cause for the stall but it was suggested that it may have been caused by deployment of the thrust reversers at slow speed. P/No: CF680C2B6 (2 similar occurrences) GE CF680C2 MEC faulty 510002628 LH engine Main Engine Control (MEC) Bell 206B Turbine governor bearing disintegrated 510002506 Power turbine governor drive bearing failed. TSO: 1,157 hours Eurocopter AS332L Main rotor gearbox pump low pressure 510002677 Main transmission gearbox oil pump low pressure. P/No: 7034600. TSN: 9,987 hours. TSO: 2,294 hours Eurocopter AS350B3 Rotorcraft servo cracked 510002580 Forward main rotor servo cracked. Found during inspection iaw AD/Ecuriel/117. Crack was within limits but servo was replaced with a serviceable item. P/No: SC5084. TSN: 1,097 hours (2 similar occurrences) Eurocopter AS350B3 Swashplate bolt incorrect part 510002550 Incorrect bolts fitted to swashplate, pitch links and upper servo. Correct bolts are structural high shear bolts PNo 350A37-1210-20 and should have the part number stamped into the bolt head. Suspect incorrect bolts are non structural type bolts. Personnel/ maintenance error. Incorrect part. TSN: 400 hours. TSO: 400 hours. (3 similar occurrences) Eurocopter AS365N Tail rotor blade delaminated 510002578 Tail rotor blade delaminated. Found during inspection iaw AD/Dauphin/ 27A6.P/No: 365A12002004. TSN: 171 hours. TSO: 171 hours (4 similar occurrences) PISTON ENGINES Continental IO520C Engine crankcase cracked 510002739 RH crankcase half cracked at forward bearing journal. Crack was found without the use of dye penetrant. Crankcase had just been crack detected by an NDI company and returned as “Serviceable”. P/No: 6525381. TSO: 2,125 hours (5 similar occurrences) Lycoming IO540E1B5 Engine power section - valve lifter pitted 510002665 LH engine oil contaminated. Inspection found four valve lifters PNo 72877 severely pitted and two camshaft lobes PNo LW19340 worn. P/No: 72877. TSO: 659 hours Lycoming IO360A1G6 Engine rear section gasket damaged 510002623 RH engine accessory housing oil filter converter plate gasket extruded beyond the plate causing total loss of engine oil leading to inflight shutdown of RH engine. P/No: LW13388. TSN: 1,308 hours. TSO: 14 hours Lycoming O540F1B5 Engine cylinder section valve guide faulty 510002740 Exhaust valve guide suspect faulty. Exhaust valve stuck in valve guide and pushrod bent. TURBINE ENGINES AIRWORTHINESS faulty. Engine failed to shut down when cutoff lever moved to “cutoff” position. P/No: 8061865. TSN: 28,607 Hours. TSO: 9,371 Hours (3 similar occurrences) Lycoming LTS101750B1 Turbine engine air inlet linkage damaged 510002726 Engine flow fence actuating linkages P/No 4-061-008-XX had worn a recess in the air inlet slot. One of the two linkages had fractured preventing retraction of the flow fence. P/No: 4061008XX PWA JT8D15 Engine air inlet guide vane cracked 510002557 No1 engine fan case inlet guide vane located at approximately 2 o’clock position cracked on previous weld repair. Crack length 114.3mm (4.5in). Engine was undergoing an alignment inspection following removal from foreign registered aircraft for fitment to Australian registered aircraft. Further investigation which included an NDT check found no crack existed. P/No: 500353601 PWA PW120A Engine oil system seal damaged 510002577 No2 engine oil system breather carbon seal damaged resulting in increased oil consumption. P/No: 3037223 PWA PW150A Engine reduction gear – bolt fouled 510002635 RH engine reduction gearbox chip detector indication. Investigation found a small bolt fouled in the chip detector assembly. Further investigation could find no other fault. P/No: 1234. TSN: 294 hours/363 cycles. TSO: 295 hours/363 cycles Rolls Royce TAY65015 Compressor bleed control switch faulty 510002593 No1 engine bleed air switch faulty. Investigation found the plunger sticking due to contamination. P/No: 402EN1RN303 PROPELLER Hartzell HCF2YR1 Propeller governor flyweight incorrect part 510002625 Incorrect part number flyweights fitted to governor. PNo 196406 fitted. Correct PNo 196405. Personnel/maintenance error. Incorrect part. P/No: 196406. TSN: 5,083 hours. TSO: 1,310 hours Hartzell HCM2YR2 Propeller blade section nut loose 510002700 Propeller dome piston loose on pitch change shaft. Investigation found the nut PNo B-3807 was loose on the pitch change shaft allowing the piston to move. Subsequent movement of the piston allowed oil to leak to the air side of the dome. P/No: B3807 Airworthiness Directives MAY 11, 2006 PART 39-105 - LIGHTER THAN AIR There are no amendments to Part 39105 - Lighter than Air this issue PART 39-105 - ROTORCRAFT Bell Helicopter Textron 427 Series Helicopters AD/BELL 427/3 - Kaflex Drive Shaft AD/BELL 427/4 - Hydraulic Solenoid Tee Fitting Eurocopter AS 350 (Ecureuil) Series Helicopters AD/ECUREUIL/118 - Upper and Lower Fins of Stabilisers Kawasaki BK 117 Series Helicopters AD/JBK 117/6 Amdt 4 - Main Rotor Blade AD/JBK 117/10 Amdt 3 - Tail Boom Vertical Fin Spar Robinson R22 Series Helicopters AD/R22/31 Amdt 11 - Main Rotor Blades - CANCELLED Robinson R44 Series Helicopters AD/R44/18 Amdt 1 - Main Rotor Blades PART 39-105 - BELOW 5,700KG Airparts (NZ) Ltd. FU 24 Series Aeroplanes AD/FU24/53 Amdt 2 - Flap Control Torque Tube - Inspection Cessna 208 Series Aeroplanes AD/CESSNA 208/19 - Flight and Ground Icing Operations Eagle X-TS Series Aeroplanes AD/X-TS/5 Amdt 2 - Flap Hinge Support Bracket Pacific Aerospace Corporation Cresco Series Aeroplanes AD/CRESCO/7 - Engine Mount Structure - CANCELLED PART 39-105 - ABOVE 5,700KG Airbus Industrie A319, A320 and A321 Series Aeroplanes AD/A320/172 Amdt 1 - Main Landing Gear Support Rib 5 Airbus Industrie A330 Series Aeroplanes AD/A330/9 Amdt 3 - Nose Landing Gear AD/A330/43 Amdt 1 - Cockpit Instrument Panel AMD Falcon 50 and 900 Series Aeroplanes AD/AMD 50/34 - Ice and Rain Protection - Outboard Leading Edge Slats Boeing 737 Series Aeroplanes AD/B737/40 Amdt 3 - Structural Modification and Inspection Program Boeing 747 Series Aeroplanes AD/B747/46 Amdt 6 - Forward Fuselage Pressure Shell AD/B747/324 - Upper Deck Area Fuselage Frames - CANCELLED AD/B747/340 - Fuselage Main Frame Boeing 767 Series Aeroplanes AD/B767/29 Amdt 5 - Configuration, Maintenance & Procedures Standard for Extended Range Operation - CANCELLED AD/B767/220 - Fuel Crossfeed Valve Bombardier (Boeing Canada/De Havilland) DHC-8 Series Aeroplanes AD/DHC-8/119 - Main Landing Gear Up-Lock Assembly British Aerospace BAe 125 Series Aeroplanes AD/HS 125/141 - Fan Venturi Motor Clearance - CANCELLED AD/HS 125/178 - Air Conditioning - Fan Venturi Motor British Aerospace BAe 146 Series Aeroplanes AD/BAe 146/119 - Hydraulic System - Accumulators with Suspect Defect PART 39-105 - ABOVE 5,700 KG Cessna 550 (Citation II) Series Aeroplanes AD/CESSNA 550/25 - Engine Fire MAY–JUNE 2006 FLIGHT SAFETY AUSTRALIA 51 AIRWORTHINESS Bottle Wiring Cessna 560 (Citation V) Series Aeroplanes AD/CESSNA 560/7 - Engine and Auxiliary Power Unit Fire Bottle Wiring Cessna 750 (Citation X) Series Aeroplanes AD/CESSNA 750/3 - Auxiliary Power Unit Fire Bottle Wiring Dassault Aviation Falcon 2000 Series Aeroplanes AD/F2000/10 - Ice and Rain Protection - Outboard Leading Edge Slats AD/F2000/11 - Flap Jackscrew AD/F2000/12 - Hydraulic Shut-off Valve AD/F2000/13 - Engine Spherical Bearing Dornier 328 Series Aeroplanes AD/DO 328/57 - Uncommanded Flap Retraction AD/DO 328/58 - Control Cables Embraer EMB-120 (Brasilia) Series Aeroplanes AD/EMB-120/44 - Cargo Configuration Fokker F100 (F28 Mk 100) Series Aeroplanes AD/F100/78 - NLG Door Uplock Bracket Assembly Gulfstream (Grumman) G1159 and G-IV Series Aeroplanes AD/G1159/45 - Cockpit Flight Panel Displays Kelowna Flightcraft (General Dynamics/Convair) Series Aeroplanes AD/CONVAIR/2 - Elevator and Rudder Hinge Pins and Bushings AD/CONVAIR/3 - Supplemental Corrosion Inspection Program AD/CONVAIR/4 - Supplemental Inspection Program AD/CONVAIR/5 - Nose Landing Gear Axle AD/CONVAIR/6 - Elevator Outer Torque Tube Assembly AD/CONVAIR/7 - Cockpit and Cabin Windows AD/CONVAIR/8 - NLG Drag Strut Upper Left Hand Segments AD/CONVAIR/9 - Wing Front Spar Lower Caps AD/CONVAIR/10 - Main Landing Gear Cylinders AD/CONVAIR/11 - Main Windshield Lower Longeron Splice Channel AD/CONVAIR/12 - Main Landing Gear Piston/Axle Assemblies AD/CONVAIR/13 - Main Landing Gear Trunnion Fittings AD/CONVAIR/14 - Main Landing Gear Beam Webs AD/CONVAIR/15 - Nose Landing Gear Aluminium Uplock Quadrant Lug AD/CONVAIR/16 - Wing Front Spar Lower Rail AD/CONVAIR/17 - Pilot and Co-Pilot Direct Vision Window Frame Casting AD/CONVAIR/18 - Nose Landing Gear Retract Fork AD/CONVAIR/19 - NLG Actuating Cylinder Rod End Eyebolt AD/CONVAIR/20 - MLG Torque Arm Apex Bolt AD/CONVAIR/21 - FAA Non-Repetitive ADs AD/A109/8 Amdt 2 - Tail Rotor Blades Bell Helicopter Textron Canada (BHTC) 222 Series Helicopters AD/BELL 222/35 - Fuel Valve Switch Bell Helicopter Textron Canada (BHTC) 430 Series Helicopters AD/BELL 430/6 - Fuel Valve Switch Eurocopter AS 355 (Twin Ecureuil) Series Helicopters AD/AS 355/86 Amdt 1 - Tail Rotor Controls Eurocopter SA 360 and SA 365 (Dauphin) Series Helicopters AD/DAUPHIN/63 Amdt 1 - Tail Rotor Blade Tuning Weights AD/DAUPHIN/79 Amdt 1 - Life Raft Installation AD/DAUPHIN/84 - Main Rotor Hub-toMain Rotor Mast Bolted Attachment PART 39-105 - BELOW 5,700KG Ayres Thrush (Snow) Commander Series Aeroplanes AD/AC-SNOW/24 Amdt 4 - Wing Spar Cirrus Design SR20 and SR22 Series Aeroplanes AD/CIRRUS/5 - Fuel Line Chafing Damage Diamond DA40 Series Aeroplanes AD/DA40/4 Amdt 1 - Fuel Valve Universal Joints Pilatus PC-12 Series Aeroplanes AD/PC-12/48 - Centre Fuselage Frame 21 PART 39-105 - ABOVE 5,700KG There are no amendments to Part 39105 - Lighter than Air this issue Boeing 727 Series Aeroplanes AD/B727/93 Amdt 4 - Forward Entry Door Frame AD/B727/202 - Wing Front and Rear Spar Terminal Fittings Boeing 737 Series Aeroplanes AD/B737/285 - State of Design Airworthiness Directives AD/B737/286 - Fuselage Skin Scribe Lines AD/B737/287 - Engine Strut Aft Fairing Cavities Boeing 747 Series Aeroplanes AD/B747/171 Amdt 5 - Outboard Main Fuel Tank Boost Pump Wiring AD/B747/228 Amdt 1 - Station 2598 Bulkhead Forward Inner Chord - CANCELLED AD/B747/260 - Bulkhead Frame Support at Body Station 2598 - CANCELLED AD/B747/296 Amdt 1 - Body Station 2598 Bulkhead AD/B747/341 - Fuselage Lap Joints at Sections 41, 42, and 46 AD/B747/342 - Main Entry Door No. 3 Fuselage Cutout AD/B747/343 - Stretched Upper Deck Frame and Tension Tie AD/B747/344 - Escape Slide/Raft Pack Assembly and Cable Release Sliders Boeing 767 Series Aeroplanes AD/B767/221 - MLG Bogie Beam Pivot Pin British Aerospace BAe 146 Series Aeroplanes AD/BAe 146/120 - Wing Top Skin under Rib 0 Joint Strap British Aerospace BAe 3100 (Jetstream) Series Aeroplanes AD/JETSTREAM/90 Amdt 3 - Main and Nose Landing Gear - Life Limitations PART 39-105 - ROTORCRAFT PART 39-105 - ABOVE 5,700KG Agusta A109 Series Helicopters Cessna 550 (Citation II) Series JUNE 8, 2006 PART 39-105 - LIGHTER THAN AIR 52 FLIGHT SAFETY AUSTRALIA MAY–JUNE 2006 Aeroplanes AD/CESSNA 550/26 - Wing Fuel Boost Pumps Cessna 560 (Citation V) Series Aeroplanes AD/CESSNA 560/8 - Wing Fuel Boost Pumps Dassault Aviation Falcon 2000 Series Aeroplanes AD/F2000/14 - State of Design Airworthiness Directives Dornier 328 Series Aeroplanes AD/DO 328/59 - Hydraulic Pressure Dump and Relief Valve AD/DO 328/60 - Flight Control - Potentiometer Levers AD/DO 328/61 - Hydraulics Leakage and Functional Checks AD/DO 328/62 - Engine Controls - Cam Followers Fokker F50 (F27 Mk 50) Series Aeroplanes AD/F50/94 - Engine Mount Tubing and End Fittings Fokker F100 (F28 Mk 100) Series Aeroplanes AD/F100/75 Amdt 1 - High Pressure Compressor Kelowna Flightcraft (General Dynamics/Convair) Series Aeroplanes AD/CONVAIR/22 - Wing Lower Skin Inboard of Station 8 AD/CONVAIR/23 - Fuselage Stringer and Beltframe Attachment between Stations 140 and 889 AD/CONVAIR/24 - Main Landing Gear Drag Strut Pivot Bolt PART 39-106 - PISTON ENGINES Lycoming Piston Engines AD/LYC/115 - Lycoming Crankshaft Replacement Teledyne Continental Motors Piston Engines AD/CON/86 - ECI Cylinder Assemblies PART 39-106 - TURBINE ENGINES General Electric Turbine Engines - CF34 Series AD/CF34/5 Amdt 1 - Fan Disks AD/CF34/10 - Stage 5 and 6 Low Pressure Turbine Disks Rolls Royce Turbine Engines - RB211 Series AD/RB211/35 - High Pressure Turbine PART 39-107 - EQUIPMENT Fire Protection Equipment AD/FPE/17 - Meggitt Safety Systems Model 602 Smoke Detectors PART 39-106 - TURBINE ENGINES Rolls Royce (Allison) Turbine Engines - AL501 Series AD/AL501/1 - Second Stage Turbine Wheels AD/AL501/2 - 2nd Stage Turbine AD/AL501/3 - First Stage Turbine Wheels AD/AL501/4 - First Stage Compressor Disc AD/AL501/5 - Third and Fourth Stage Turbine Wheels Rolls Royce Turbine Engines - RB211 Series AD/RB211/35 Amdt 1 - High Pressure Turbine Turbomeca Turbine Engines - Arriel Series AD/ARRIEL/23 - Start Electro Valve - Fuel Leaks PART 39-107 - EQUIPMENT Instruments and Automatic Pilots AD/INST/54 - Aero Advantage Vacuum Pumps Propellers - Variable Pitch - McCauley AD/PMC/47 Amdt 2 - McCauley Threaded Propellers - CANCELLED AIRWORTHINESS BULLETINS 11 April 2006 AWB 02-013 Issue 1 - Evaluation of Service Documents - PMA and STC parts 7 April 2006 AWB 83-001 Issue 1 - Lycoming Engines Model L-TIO540-J2BD Engine Crankcase and Accessory Gear Housing Reliability 4 April 2006 AWB 85-001 Issue 4 - Textron Lycoming Engine Bearings 3 April 2006 AWB 25-010 Issue 1 - Pacific Scientific rotary seatbelt buckles 29 March 2006 AWB 01-016 Issue 1 - Suspected Unapproved parts produced by M&M International Aerospace Metals Inc. 27 March 2006 AWB 57-002 Issue 1 - Wing spar to fuselage attach fitting corrosion Airworthiness ADVISORY CIRCULARS PART 9 AMENDMENTS MAY 11, 2006 AD Amendment Number 5/2006 9-5 AME Specific Type Training Courses and Examinations Conducted by Approved Australian Operators, Maintenance and Training Organisations 9-91 Administration and Procedure – Aircraft Maintenance Engineer Licences – Category Airframe JUNE 8, 2006 AD Amendment Number 6/2006 9-0 General AME Licensing Information 9-4 Acceptance of Training Courses Conducted by Overseas Equipment Manufacturers, Operators and Training Organisations 9-5 AME Specific Type Training Courses and Examinations Conducted by Approved Australian Operators, Maintenance and Training Organisations 9-91 Administration and Procedure – Aircraft Maintenance Engineer Licences – Category Airframe 9-94 Administration and Procedure – Aircraft Maintenance Engineer Licences – Category Electrical 9-95 Administration and Procedure – Aircraft Maintenance Engineer Licences – Category Instruments LEADING EDGE HERE COME THE JETSONS Developments in small, high-tech jets could soon see private pilots operating in high altitude airspace in “personal air vehicles”. Richard Dinnen looks at the predicted wave of very light jets. O ur weekend-flying PPL holder is all smiles, cleared to FL 370. But way up high, RPT jet crews are frowning at the prospect of being made to share THEIR airspace with hundreds, perhaps thousands, of private jets. It sounds fanciful, but that is what’s coming, if the much-hyped Very Light Jets (VLJs) under development around the world ever get off the ground. Manufacturers report that more than 3,000 orders have been placed for the ten or so VLJ projects under development, even though none have made it to certification or sale. VLJs carry up to six people on 1,000nm IFR legs at up to 400kt and FL410. All are being marketed for single-pilot operations. They feature highly advanced engine and flight management systems, auto-pilots and satellite navigation. All this with an MTOW under 4,500kg and a power-plant small enough to take home in the boot of your car. Cessna, Honda, Eclipse, Embraer and others have invested heavily in their VLJ projects, gambling on predictions of 10,000 sales by 2020. The VLJ is designed to appeal to the smaller end of corporate aviation, shared ownership schemes, on-demand air taxi operations and the better resourced private pilots. Affordability is a major selling point, and that has some aircraft designers talking about the dawn of the era of the “personal air vehicle”, the sorts of craft everyone had in a TV cartoon series fondly remembered by many a pilot, The Jetsons. This is not as far-fetched as it seems. The VLJ has its roots in a NASA research program commissioned to develop small but advanced fixed wing aircraft for the routine transport of individuals between communities. Composites: VLJ proponents describe their creations as the first genuinely new development in small aircraft for decades, a bold step away from a long period of tweaking and re-badging existing products. While this claim is hotly contested in the aviation industry, VLJ projects are bringing major changes to the way aircraft are built, and to the manufacture of materials from which they’re assembled. The VLJs are stripped of as much weight and bulk as can safely be shed, allowing for roomier interiors and less demand on the typically low-thrust power plants (900 to 2,000 pounds of thrust at sea level). Not all the manufacturers are ready to tell us how they do it but composite materials are the key. Excel-Jet’s prototype, the MAY–JUNE 2006 FLIGHT SAFETY AUSTRALIA 53 LEADING EDGE Sport-Jet, has a fuselage of solid and cored laminate, relying on five solid laminate rings just 75mm wide and 9.5mm thick as the principal load bearing structures. The HondaJet, now in flight testing, features laminar-flow wing and nose sections for low drag and a co-cured composite fuselage. Honda has used an integrally stiffened skin to smooth out its aluminium wing. Most VLJ developers have chosen power-plants from Pratt and Whitney and Williams International, but Honda has developed its own engine, to be mounted above the wings of its HondaJet. The Diamond D-Jet and the Adam A700 VLJs will use the Williams FJ33 fan-jet, FAA certified in 2004. It delivers up to 1500 pounds of thrust for a dry weight of 300 pounds and uses low-noise wide-sweep fan technology and high efficiency core components. The current leaders on the orders board, the Eclipse 500, and the Cessna Citation Mustang will be powered by the Pratt and Whitney 600 series of turbofans, due for certification at time of writing. They deliver between 900 and 3,000 pounds of thrust, based on a new engine core design and scaleable technology. The HondaJet powerplant is the Honda HF118 turbofan, under development since 1999. It promises take off thrust of 1,670 lb and cruise thrust of 420 lb for a cruise speed above 400kt. Honda makes much of its claim to have developed the first ultra-compact Full Authority Digital Electronic Control (FADEC) engine management system for this engine type. It was originally intended for car engines, but designers quickly saw its potential for better small jet engine performance and reliability. FADEC systems are central to most of the current engines available for VLJ projects. Regulation: The success of the VLJ depends heavily on rapid progress to sale and delivery of aircraft once FAA certification is achieved. Aircraft assembly processes will be streamlined, even reinvented. One manufacturer is aiming at a completion rate of eleven days per aircraft and 1,000 aircraft per year. There’s much yet to learn before aviation regulators determine where the VLJ sits in the existing framework. CASA will treat VLJs as any other aircraft at the type acceptance stage, relying on CASR 21.29A to accept aircraft certificated by a recognised country, provided manufacturers supply sufficient safety data, operating manuals, and ongoing commitment to maintenance and support. CASA expects Australian operators will embrace the VLJ, and sees potential for fairly rapid growth of this sector. CASA expects Australian operators will embrace the VLJ, and sees potential for fairly rapid growth of this sector. Regulatory attitudes to the VLJs will largely be shaped by the US Federal Aviation Administration. The FAA has shown signs of encouragement, waiving some of the red tape for Cessna’s Mustang because existing regulations don’t adequately cover the current development processes or the newness of the design. But close scrutiny will be made of han- 54 FLIGHT SAFETY AUSTRALIA MAY–JUNE 2006 Cessna Citation Mustang Power 2x P&W PW615F Takeoff Distance 3,120ft MTOW 8,000lb Max Payload ( Full Fuel) 600lb Range 1,250nm Ceiling FL450 Seats 6 Max cruise Mach 0.90 Price $US2.275m Courtesy Embraer Phenom Adam Aircraft Industries A700 Power 2x Willams FJ33-4A MTOW: 7650lb Takeoff distance 2,950ft Landing 2,520ft Max Payload (Full Fuel) 725lb Range 1,100nm Ceiling FL 410 Seats: 6-8 Max Cruise 340kt Price $US2.25m RVSM standard Courtesy Excel-Jet Courtesy Cessna Courtesy Adam Aircraft VLJ TECH SPECS Embraer Phenom 100 Power P&W 617F Range 1,160nm Ceiling FL410 Seats 6-8 Max Cruise 380kt Price $US 2.85m Excel-Jet SportJet Power 1 Williams FJ33-4A MTOW 4,950lb. Max Payload (Full Fuel) 2,100lb. Range 1,300nm Ceiling FL410 Seats 4-6 Max Cruise 375 KIAS Price $US 1.15m LEADING EDGE Courtesy Aviation Technology Group Courtesy Honda The most commonly heard concern is that the VLJ will bring flight with hightech avionics and computerised systems within the price range of pilots who may struggle to fly the technology. Pilot training will be critical, and some manufacturers offer type training as part of the sale package. Many industry analysts remain sceptical of VLJ makers’ claims that thousands of these micro-jets will soon be cruising the high altitude jet lanes. But among those who concede it’s possible, some are Honda Motor Company HondaJet Power 2 GE/ Honda HF-118 MTOW 9,200lb. Range 1,100nm Ceiling FL410 Seats 6-8 max Cruise 389kt @ FL410 Price not known Aviation Technology Group Javelin MK-10 and MK- 20 Military Trainer Power 2x Williams FJ33-4M Range 1,250nm Ceiling FL 450 Seats 2 Max Cruise Mach 0.9 Price $US2.275m vate pilots to upgrade their skills with the support of aircraft manufacturers. And he is supported in claims the US airspace system will reach choking point even if no VLJs ever take to the skies. Industry planning and discussion papers point to a wide gap between VLJ capabilities and the way they will ultimately be used. While they could cruise economically above FL 300, with the extra cost of RVSM equipment thrown in, most predict VLJ operations below FL 290, placing some extra load on the airspace system, but not a crisis. The VLJ industry says the new jets will be used mosly at the thousands of airports not currently served by RPT jet or turbo-prop traffic. Most of those don’t have control towers or precision aids, so little will be required of the ATC system. But this is where many believe the biggest risks exist, not at lofty flight levels, but in the circuit of an uncontrolled strip, where the novice private VLJ pilot flies alongside the Sunday aviators and students. Richard Dinnen is an ABC journalist and student pilot. Courtesy Eclipse Aviation ...the VLJ will bring flight with high-tech avionics and computerised systems within the price range of pilots who may struggle to fly the technology talking of an airspace crisis.The US ATC system already struggles with outdated systems and high traffic volume. Some experts believe adding ten thousand new jets in a decade, some flown by amateurs, means delay is inevitable and disaster very likely. ATC sector controllers will have to juggle and separate RPT and VLJ traffic capable of a wide variety of speeds and climb and descent rates. In the approach and tower environment, RPT jets will mix it with VLJs piloted by aviators less familiar with precision approach aids and the dictates of high traffic environments. Predictions of unprecedented traffic jams around major air hubs abound. But the VLJ industry says the airspace crisis talk is hot air. The man most often heard spruiking, or defending, the VLJs is Vern Raburn, who launched industry leader Eclipse Aviation after years devising and selling IT for the likes of Bill Gates. While Raburn has a vested interest in the outcome, his advocacy of the VLJ is backed by some analysts and regulators. Raburn claims the VLJs offer the first genuine opportunity in decades for pri- Courtesy Diamond Aircraft Industries dling characteristics, performance and endurance of load-bearing composites, engine out performance, air frame and engine icing. Small cabins and close passenger proximity to fuel tanks also pose potential safety issues. Eclipse Aviation Eclipse 500 Power 2x P&W PW610F Takeoff Distance 2,155ft. Landing Distance 2,040ft. MTOW 5,640 lbs. Max Payload (full fuel) 720lbs. Range 1,280nm Ceiling FL410 Seats 6 Max Cruise 375 KIAS Price $US 1.495m Diamond Aircraft Industries Diamond D-JET Power 1x Williams FJ-33 Takeoff distance 2,372ft. MTOW 5,070 lbs. Max Payload ( Full Fuel) 505lb. Range 1,350nm Ceiling FL250 Seats 5 Max Cruise 315 KIASPrice approx $US1m All data not independently verified. Drawn from manufacturer promotional material and media releases. MAY–JUNE 2006 FLIGHT SAFETY AUSTRALIA 55 SAFETY CHECK Test your aviation knowledge VFR OPERATIONS (a) The glider must give way to the powered aircraft because the powered aircraft is n the glider’s right. (b) The glider must give way to the powered aircraft because the glider is overtaking. (c) The powered aircraft must give way to the glider because it is a glider. (d) The powered aircraft must give way to the glider since the glider, by definition, is not overtaking. 2. In the circumstances of question 1, at night aircraft A would see the following navigation lights of aircraft B: (a) The rear navigation light. (b) The RH navigation light. (c) Both the LH and RH navigation lights. (d) All three navigation lights. 4. If the static port of an aircraft became blocked during a climb, the vertical speed indicator would: (a) Remain at the previously indicated rate of climb. (b) Fall to a zero rate of climb indication. (c) Indicate a maximum rate of climb. (d) Indicate a maximum rate of descent. 3. A glider and a powered aircraft are on converging headings at similar altitudes with the glider in the powered aircraft’s 9 o’clock position. The powered aircraft is in the glider’s 2 o’clock position. In these circumstances: 5. An instantaneous vertical speed indicator (IVSI) produces an immediate trend indication by means of an input from: (a) External vertical tied gyro. (b) External rate gyro. (c) Internal rate gyro. (d) Internal piston. 6. Which of the following cockpit instruments respond to the rate of roll? (a) Artificial horizon. (b) Directional gyro. (c) Turn coordinator. (d) Rate-of-turn indicator. 7. An appropriate cruising level for a VFR aircraft intending to track 175(m) with 15 degrees of left drift would be: (a) 6,500ft. (b) 6,000ft. (c) 5,000ft. (d) 5,500ft. 8. An aerodrome forecast applies to expected meteorological conditions within a radius of: (a) 3nm from the aerodrome reference point (ARP). (b) 5nm from the aerodrome reference point (ARP). (c) 3nm from the centre of the runway complex. (d) 5nm from the centre of the runway complex. 9. A cruising level of 5,000ft is: (a) An IFR cruising level. (b) The highest level that a VFR flight may use without the need to comply with the hemispherical rule. (c) The lowest possible lowest safe altitude (LSALT). (d) The highest level that may be designated B050. 10. You are planning to cruise in a powered aircraft on a day VFR flight, at A025 over a terrain, shown on the applicable VNC chart with the terrain height tint showing between 600ft-1,640ft. In order to avoid controlled airspace, you must allow for a navigational tolerance of: (a) ± 5°. (b) ± 10°. (c) ± 1nm. (d) ± 2nm. Istockphoto 1. Aircraft A is overtaking aircraft B on a converging track and at a relative bearing from B of 120 degrees (4 o’clock position) at a similar level. In these circumstances: (a) A must give way to B since B is on the right of A. (b) B must give way to A since B is overtaking A. (c) A must give way to B since A is overtaking B. (d) B must give way to A since B is overtaking A. MAINTENANCE 56 (c) Outflow of air from the cabin. (d) Speed of the turbine in the air cycle machine. able to magnetic variation. (d) Right and this is attributable to magnetic variation. 3. An air conditioning system that uses engine hot bleed air to produce cold air for cabin air conditioning is called: (a) A ram-air, evaporative cooling unit. (b) A ram air, fan-assisted cooling unit. (c) A vapour cycle machine. (d) An air cycle machine. 4. Which of the following are all typical components of an air cycle machine (air conditioner): (a) Air-to-air heat exchangers, a turbine and a water separator. (b) A compressor, a thermal expansion valve, a desiccator/dryer and an evaporator. (c) A Vernatherm valve, a waste-gate, a desiccator drier and an air-to-refrigerant heat exchanger. (d) A Vernatherm valve, an expansion turbine and an evaporator. FLIGHT SAFETY AUSTRALIA MAY–JUNE 2006 Istockphoto 1. In a directional gyro (gyro heading indicator) the earth rate error is at a: (a) Maximum at the poles and decreases to zero at the equator and is proportional to the cosine of latitude. (b) Maximum at the poles and decreases to zero at the equator and is proportional to the sine of latitude. (c) Minimum at the poles and decreases to a maximum at the equator and is proportional to the sine of latitude. (d) Minimum at the poles and decreases to a maximum at the equator and is proportional to the cosine of latitude. 2. In the southern hemisphere, when an aircraft is accelerating on an easterly heading, the direct reading magnetic compass to indicate an apparent turn towards the: (a) South and this is attributable to magnetic dip. (b) North and this is attributable to magnetic dip. (c) Left and this is attribut- 5. Which of the choices in question 4 apply to a vapour-cycle air conditioning system? 6. The cabin pressure of a pressurised aircraft in flight is typically maintained at the selected altitude by controlling the: (a) Inflow of air to the cabin by varying the input shaft speed of the cabin blower. (b) Inflow of air into the cabin by proportional control of the cooled engine bleed air. 7. A “joggle” in a removed solid rivet indicates that the rivet has commenced to fail in: (a) Tension. (b) Compression. (c) Shear. (d) Torsion. 8. On an electrical commutator of a DC machine, the mica insulation between commutator segments is undercut to: (a) Indicate when the commutator has worn to the overhaul limit. (b) Direct cooling air to the brush working surface. (c) Accommodate expansion of the segments due to heating and to increase cooling of the brush working surface. (d) Prevent the brush from being lifted by the mica as the segment wears. SAFETY CHECK IFR OPERATIONS 2. The VOR operates in which of the following frequency bands? (a) LF 30 to 300 KHZ. (b) MF 300 to 3000 KHZ. (c) VHF 30 to 300 MHZ. (d) UHF 300 to 3000 MHZ. 3. Night effect is not a factor with the VOR as it is with the NDB, since the VOR signal is line of sight, with the sky wave being lost in space. True or false? (a) True. (b) False. 4. The VOR transmits two signals, a reference phase and a variable phase to determine each particular radial. What direction reference is the VOR aligned with? (a) True north. (b) Compass north. (c) Grid north. (d) Magnetic north. 5. If an ATC instruction was to “track inbound via the 270 radial,” which of the following statements is correct? (a) When established inbound, the aircraft will be heading 090 in nil wind with the Omni Bearing Selector (OBS) set to 270 and Course Deviation Indicator (CDI) in command sense. (b) When established inbound, the aircraft will be heading 090 in nil wind, OBS set to 090 and CDI in command sense. (c) When established inbound, the aircraft will be heading 270 in nil wind, OBS set to 270 and CDI in command sense. (d) When established inbound, the aircraft will be heading 090 in nil wind, OBS set to 270 and CDI in non-command sense. 6. An advantage of the Horizontal Situation Indicator (HSI) over the “raw data” VOR is that with the course bar set for the desired track, it will always be in command sense. True or false? (a) True. (b) False. 7. The location of a particular VOR is important to minimise errors due to buildings, fences, rocks etc. This error is referred to as: (a) Ground station error. (b) Terrain effect error. (c) Site effect error. (d) Vertical polarization error. 8. Although a rarity, a rapid oscillation or deviation of the CDI needle while the aircraft is in banked flight, and therefore possibly receiving other than horizontally polarized signals, is known as: (a) VOR aggregate error. (b) Vertical polarization error. (c) Airborne equipment error. (d) Ground station error. 9. Which of the following statements is true concerning a Doppler VOR? (a) Ground equipment antenna is the same as a normal VOR but it has the advantage of minimizing the site effect error and therefore increasing bearing accuracy. (b) Ground equipment antenna array is larger than the normal VOR, the site effect error is reduced but special airborne VOR equipment is required. (c) Ground equipment antenna array is larger than normal VOR, the site effect error is reduced and conventional airborne VOR equipment receives Doppler VOR equally as well as conventional VOR. Istockphoto 1. An aircraft is to cruise at 9,000 ft. For planning purposes, the rated coverage for a VOR is: (a) 60nm. (b) 90nm. (c) 120nm. (d) Rated coverage varies for each VOR and information is contained within the ERSA. The Aircraft Owners & Pilots Association of Australia GOT YOUR 2006 NATIONAL AIRFIELD DIRECTORY? 2006 RY FIELD DIRECTO NATIONAL AIR ADVERTISEMENT ERS AND PILOTS AIRCRAFT OWN RRP $50 ASSOCIATION OF AUSTRALIA The perfect gift for every pilot. This new improved edition is a must-have for any serious pilot. • Over 2000 listings from large airports to remote bed & breakfast locations. • Easy to read format. • Quick reference icons. • Updated information. • Destination information including taxi numbers, facilities & accommodation. Get your copy today from the AOPA Office Phone: 02 9791 9099 Email: mail@aopa.com.au Website: www.aopa.com.au MAY–JUNE 2006 FLIGHT SAFETY AUSTRALIA 57 SAFETY CHECK QUIZ ANSWERS VFR OPERATIONS 1. (c) An aircraft is said to be overtaking when within an angle of 70 degrees from the tail of another. At this point the wingtip navigation lights can not be seen (CAR 160). 2. (a) The wing tip (forward) navigation lights are designed so that they are not visible from the rear within a relative bearing of 70 degrees from the plane of symmetry. The definition of overtaking is based on this (CAR 160). 3. (c) Powered aircraft must give way to gliders (CAR 162). 4. (b) The bleed within the instrument would equalise the pressures either side of the capsule, resulting in a zero reading. 5. (d) With vertical accelerations, the piston is arranged to exert an instantaneous pressure change on the capsule producing an instantaneous indication. 6. (c) A rate-of-turn indicator responds to rate of yaw but a turn coordinator also has a rate of roll input. 7. (d) The rule is based on track and not heading. The old quadrantal rule no longer applies. Some relaxation of the rule applies below (but not at) 5,000ft. 8. (d) AIP GEN 3.5 3.3.1. 9. (a) The relaxation of the hemispherical rule applies below A050 but not at A050 (AIP ENR 1.7 3.3.3). 10. (c) The rule applies to height AGL not altitudes; the VNC chart tint is 660ft-1,640ft; your height AGL therefore ranges from 860ft to 1,840ft which, being in the range 0-2000ft, requires ± 1nm navigation tolerance (AIP ENR 1.1 19.11). MAINTENANCE 1. (b) It is caused by the rotation of the earth at 15 degrees per hour and is compensated for by deliberately unbalancing the inner gimbal ring. 2. (a) The acceleration errors are a maximum on easterly/westerly headings and are caused by the centre of gravity of the compass card being offset from the pivot due to magnetic dip. 3. (d) 4. (a) An air cycle machine uses engine hot bleed air, heat exchangers and compressor and expansion turbines to produce cool air. 5. (b) 6. (c) 7. (c) The rivet is failing in shear because of either compression or tensile forces between the two fastened surfaces. 8. (d) The copper segments wear faster than the mica insulation between the segments. Some high-current motors are specified with no undercut. IFR OPERATIONS 1. b) AIP GEN 1.5, p.2.2 (b). 2. c) – a) and b) are correct for the NDB. 3. a) 4. d) 5. b) 6. a) 7. c) 8. b) 9. c) A pilot therefore is unlikely to know which type of VOR is being received other than by looking at the ground antenna array. THE POWER OF IMAGINATION advertisement Imagine if there were no AOPA Australian GA needs AOPA and AOPA needs your support Join or re-join us now 58 FLIGHT SAFETY AUSTRALIA MAY–JUNE 2006 www.aopa.com.au Ph. 02 9791 9099 WHAT’S THE MESSAGE? LAST ISSUE’S WINNER A B Getty Images Getty Images Works A “Despite ridicule from his neighbours about concreting the paddock, farmer Bob knew that if he waited long enough, the planes would come “ Denis Medlow B “The captain insists that your transport be defuelled before loading” - Bill Bishop WRITE AN AMUSING CAPTION B A Istockphotos Istockphotos Getty Write an amusing caption of up to 25 words for pictures A or B. 2x $100 prizes for the best captions. Send your entry to: Flight Safety Australia, GPO Box 2005, Canberra ACT 2601 or email to: fsa@casa.gov.au by July 28, 2006. PICK THE PIC WHAT DO THESE SYMBOLS MEAN WHEN INSIDE THE SIGNAL CIRCLE? B A test of your ability to recognise aviation signs and symbols. Answer below A. Use hard surfaces only B. Aerodrome completly unserviceable A MAY–JUNE 2006 FLIGHT SAFETY AUSTRALIA 59 TEXT The Australian Executive Director's Message Progress on Lockhart River investigation Memorial services at Bamaga, Lockhart River and Cairns commemorated the recent anniversary of the May 2005 Lockhart River tragedy in North Queensland in which 13 passengers and two crew members lost their lives. The ATSB’s investigator-in-charge was able to attend the Cairns service in association with investigation duties. Given the evidentiary challenges including lack of useable CVR data, the ATSB investigation of this tragedy is progressing well and in line with the expected 18 month timing for an RPT accident of this magnitude and complexity. Progress to date includes issuance of a Preliminary Factual report, an Interim Factual report and related recommendations. On 24 January 2006 the ATSB issued two recommendations to CASA seeking review and clarification of crew qualifications for instrument approaches during air transport operations and the potential safety benefit of autopilots. On 3 April 2006 CASA advised the ATSB that it has amended a Civil Aviation Order to clarify the requirement for all instrument rating holders to hold an endorsement for any navigation aid being used to navigate an aircraft (including instrument approaches) of which they are a crew member. The ATSB has accepted the CASA response and the recommendation is now closed. CASA also advised the ATSB that it is currently reviewing Civil Aviation Order (CAO) 20.18 and examining the history of changes and international best practice as they relate to the fitment of autopilot equipment. On 10 February 2006 the ATSB issued another recommendation to CASA to review maintenance requirements for Cockpit Voice Recordings (CVRs) and Flight Data Recorders (FDRs) against international standards with the aim of improving reliability and availability of data. The ATSB also issued a recommendation to the Department to review legislation covering copying and disclosure of CVRs to ensure that this can be done for legitimate maintenance purposes. The ATSB is now undertaking the analysis and final report drafting phase of the investigation and expects to issue its final report before the end of 2006. 60 FLIGHT SAFETY AUSTRALIA MAY–JUNE 2006 Final report on the Mount Hotham fatal accident O n 11 May 2006 the Australian Transport Safety Bureau (ATSB) released its Final Investigation Report on the fatal aviation accident near Mount Hotham airport on 8 July 2005 that claimed the lives of the pilot and two passengers on board. The accident involved a Piper Navajo Chieftain aircraft registered VH-OAO which was being operated on a charter flight. The Chieftain was found on a tree covered ridge, approximately 5km southeast of the aerodrome at an elevation of 4,600 ft above mean sea level. The aircraft had broken into several large sections and an intense fire had consumed most of the cabin. The ATSB has reported that extreme weather and unsafe pilot attitudes and practices led to the ‘controlled flight into terrain’ accident at Mt Hotham in July 2005. The weather conditions included sleet and snow showers, and were conducive to visual illusions associated with a ‘flat light’ phenomenon. The aircraft was not equipped for flight in icing conditions. The ATSB in its final report was unable to determine why the pilot, after acknowledging that the weather was unsuitable, persisted with his attempt to land at Mt Hotham in accordance with neither the VFR nor proposed IFR procedures, but apparently seeking to follow the highway. However, it is possible that overconfidence as a result of previously avoiding accidents despite risk-taking, and commercial or family pressures, influenced the pilot’s decision making. Civil Aviation Safety Authority (CASA) Field Office staff had held concerns about aspects of the operator’s performance for some time. As a result, CASA staff continued to monitor the operator. However, formal surveillance of the operator in the two years prior to the accident had not identified any significant operational issues that would have warranted CASA taking action against the operator. In that situation, the safety of the flight was reliant on the safety culture of the operator, and ultimately depended on the operational decision-making of the pilot in command. As a result of this investigation, the ATSB has recommended that CASA publish educational material, to promote greater awareness of the flat light phenomenon for pilots operating in susceptible areas. The ATSB has also recommended that CASA review its surveillance methods, which may include cooperation with Airservices Australia, for the detection of patterns of unsafe practices and non-compliance with regulatory requirements. CASA has advised the ATSB that it is taking safety action including enhancing its operator risk assessment processes to enable it to more clearly identify and quantify operators presenting risks to aviation safety. The ATSB hopes that pilots with local knowledge that habitually take unnecessary risks will learn from this accident and not pay the ultimate price paid by the pilot and passengers of this aircraft. The full report including radar plots of the aircraft’s track into the Mt Hotham area is available on www.atsb.gov.au. N TEXT Aviation Safety Investigator Collision with ground Interim Factual Report on fatal Cessna 310R crash near Tamworth immediately prior to the accident. The aircraft had a current maintenance release and there were no recorded defects at the time of the accident. Damaged wire within the autopilot controller Damaged wire The investigation calculated the aircraft’s weight and balance based on fuel load records and estimated fuel burn rates for previous operations, including engine runs relating to the maintenance activity completed immediately prior to the occurrence flight. The investigation estimated that at the time of the occurrence, the aircraft was operating below the maximum permitted take-off weight and within the stipulated centre of gravity limits. The Automatic Terminal Information Service (ATIS) current at the time of the occurrence, reported that the wind was variable at eight knots with occasional crosswind of eight knots, CAVOK1, temperature 27°C and a calculated mean sea level pressure datum (QNH) of 1019 hPa. The wreckage trail extended over a distance of about 232 m. Ground impact marks and other physical evidence indicated that the aircraft struck the ground in an upright slightly right wing low, 35 to 50 degrees nose-down attitude, and that both engines were developing significant power at the time of impact. During the on-site examination of the wreckage, investigators located a tool that would normally not be expected to be carried on the aircraft. Metallurgical analysis showed no evidence that the tool had been trapped within, or had in any way interfered with the control systems of the aircraft. The pilot did not specifically transmit a distress call to ATC during the occurrence. The pilot advised that the aircraft was subject to ‘control difficulties’, that he was ‘losing direction of the aircraft’ and that the autopilot was ‘not on’. The aircraft was equipped with a Cessna 400B Nav-O-Matic Autopilot System. The autopilot controller recovered from the site showed evidence of thermal damage to a wire within the controller, consistent with current overload (Figure 1). That damage was inconsistent with postimpact fire damage. The ATSB is awaiting data from the manufacturer and other specialist agencies regarding the effect of the damaged wire on autopilot operation. The ongoing investigation will include examination of: • the aircraft’s autopilot and electric pitch trim systems • the inspection requirements for wiring to critical systems • the degree of autopilot system training provided during aircraft endorsement training. ■ MAY–JUNE 2006 FLIGHT SAFETY AUSTRALIA 61 Australian Transport Safety Bureau A t about 1326 Eastern Daylightsaving Time on 7 March 2005, the pilot of a Cessna Aircraft Company 310R, registered VH-FIN, commenced takeoff from runway 30 right at Figure 1: Tamworth on a ferry flight to Scone, NSW. Witnesses reported that the pilot initially maintained the runway heading, as cleared by air traffic control (ATC). When the aircraft was between 800 and 1,000 ft above ground level (AGL) and while making a shallow banked turn to the left, the pilot broadcast to ATC that he was experiencing ‘control difficulties’. Upon or shortly after reaching an early downwind position the aircraft was observed to enter a steep nose-down descent. While there were some inconsistencies in the available witness reports, it appeared that the aircraft may have rolled about its longitudinal axis at some stage on the final descent. The aircraft impacted the ground in a cleared paddock about 4 NM westsouth-west of Tamworth airport, fatally injuring the sole occupant pilot of the aircraft. The aircraft was destroyed by the impact forces and post-impact fire. The pilot was appropriately licensed and rated, held a valid class 1 medical certificate and was reported as being fit to fly. The results of post mortem examination and toxicology screening found no evidence of any physiological factor that may have impaired the pilot’s performance during the occurrence flight. The aircraft was maintained under a Civil Aviation Safety Authority (CASA) approved maintenance system. The aircraft had been subject to scheduled maintenance by a CASA approved maintenance facility Safety briefs ••••••••••••••••••••••••••••••••• ••••••••••••••••••••••••••••••••• Australian Transport Safety Bureau Engine failure Occurrence 200402948 At 1435 Eastern Standard Time on 10 August 2004, a Boeing Company B717200 aircraft, registered VH-VQA, was climbing to cruise altitude on a scheduled passenger service from Melbourne, Victoria to Hobart, Tasmania. As the aircraft passed through flight level 110, the crew heard a loud bang, with a corresponding increase in indicated left engine vibrations and the left engine began to spool down. The crew then shut the engine down in accordance with the operator’s procedures and returned for a landing. Post incident examination of the BR700715 engine found metal fragments and metallisation in the exhaust area. The engine was forwarded to the engine manufacturer for a detailed investigation that was supervised by a representative of the German Federal Bureau of Aircraft Accident Investigation. That investigation found that the engine failure was due to the release of a single blade from Stage-1 of the high pressure turbine (HPT), following the development of low-cycle fatigue cracking in its internal cooling passages. The manufacturer indicated that there had been four similar BR700-715 engine failures, with another engine failure under investigation. Computer stress modelling, carried out by the manufacturer on the HPT blades, found stress levels in the blade’s internal cooling passages, in the area of the occurrence blade’s crack propagation, that were potentially in excess of the manufacturer's original design intent. The thickness of the vapour aluminised surface coating in the internal cooling passages was also variable. In certain operational conditions the coating could crack, with the subsequent growth of the crack into the parent material. As a result of this and the other engine failures the operator and the engine manufacturer have completed a number of safety actions to prevent re-occurrence. N 62 FLIGHT SAFETY AUSTRALIA MAY–JUNE 2006 Flight Management System computer malfunction Infringement of separation standards Occurrence 200500285 Occurrence 200501628 The Boeing 717-200 was taxiing at Cairns Qld for a scheduled service to Brisbane Qld. As part of the preparation for the flight, the crew had entered flight plan details into the aircraft's flight management system (FMS). While taxiing, due to intermittent rain showers at Cairns, the 717 crew then programmed the FMS with wet runway speed figures for takeoff. The crew reported that late in the take-off roll the manually entered wet speeds were lost from the airspeed tape on the primary flight display and FMS-generated speeds were displayed. At rotation 'MAP FAIL' appeared on both navigation displays. The investigation found that flight management computer (FMC) 2 was unable to sequence the '400 ft course to altitude' leg associated with the SWIFT SIX standard instrument departure. Eventually, FMC 2 performed a software reset but was unable to recover and became unavailable for use by the crew. A similar progression then occurred for FMC 1 but, in accordance with its design, FMC 1 remained available for use but with the flight plan information cleared. Eventually the crew were able to enter the instrument landing system frequency, but FMS operation did not appear to be reliable. The aircraft was radar vectored for a return to Cairns while maintaining visual meteorological conditions. The crew conducted a visual approach to runway 15 and the aircraft landed 32 minutes after takeoff. The investigation determined that during the flight, the amount of generated VIA BITE data exceeded the memory size. As a result, BITE data from the event that initiated the FMS problem was overwritten and lost. As a result of this occurrence the operator has advised that a Flight Operations Memo will be issued to all 717 pilots highlighting this incident and detailing the FMS modes which remain available during abnormal FMS operation. N At 0543 eastern standard time on 14 April 2005, an Aero Commander 500-S (Aero Commander) aircraft became airborne off runway 32 at Brisbane airport, QLD, on a non-scheduled flight to Maryborough, Qld. At 0544, a Boeing Company 737 (737) aircraft on a scheduled passenger service from Darwin, NT, was established on the final approach path to land on runway 19 at Brisbane airport. The Brisbane aerodrome controller (ADC) accepted responsibility for separating the 737 with the Aero Commander once the 737 was established on the final approach path for a landing on runway 19. In consultation with the ADC, the approach controller assigned the pilot of the Aero Commander a heading of 090 degrees to comply with noise abatement procedures. The ADC reported that he had a mental model that the Aero Commander was going to turn right onto a heading of 360 degrees, once airborne, even though he had assigned a heading of 090 degrees to the pilot of the Aero Commander. The ADC later reported that, if he had realised that he was assigning a heading of 090 degrees to the pilot of the Aero Commander, he would not have accepted responsibility for separation because he could not visually separate the Aero Commander with the inbound 737 on that heading. A review of the recorded TAAATS data showed that separation reduced to a minimum of .95 NM horizontally, at which time vertical separation had reduced to 500 ft. The minimum radar separation standard was 3 NM, and the minimum vertical separation standard was 1,000 ft. There was an infringement of separation standards. The investigation was unable to determine why the ADC had a mental model that he was assigning a heading of 360 degrees to the pilot of the Aero Commander. N Loss of control STAR Non-Compliance Occurrence 200504925 Occurrence 200403006 Occurrence 200504615 At about 1800 Central Standard Time on 6 October 2005, a Robinson Helicopter Company model R22 Beta helicopter (R22), registered VH-HUZ, departed Border Downs, NSW on a private flight to the pilot’s property at Yalda Downs, NSW with the pilot and one passenger on board. At about 2017 Eastern Standard Time on 15 August 2004, a Mooney Aircraft Corporation M20K aircraft, registered VH-DXZ, descended into the ocean off Bokarina, Queensland. The pilot, who owned the aircraft and was the sole occupant, did not survive the impact. The pilot held a private pilot (aeroplane) licence and a night visual flight rules (VFR) rating. His logbook recorded his total flying experience at the time of the accident as about 1800 hours, 142 of which were at night. The pilot last flew at night on 19 June 2004, and in actual or simulated instrument meteorological conditions, during 1998. His three most recent flight reviews were logged as day flights, with no instrument or night flight recorded. On 15 September 2005, the crew of a Boeing Company 767-300 (767) aircraft, registered OE-LAZ, was cleared by air traffic control to fly the ARBEY TWO Standard Arrival Route (STAR) procedures for an approach to runway 27 at Melbourne International Airport. As the aircraft flew the STAR procedure, the controllers observed it overfly the PAULA airspace fix and continue on the downwind leg instead of turning right onto the base leg for runway 27, as required. The controllers provided the crew with radar vectors to position the aircraft onto the runway 27 localiser, and the aircraft landed without further incident. When subsequently queried about the STAR non-compliance, the crew stated that they had been unsure about how to complete the procedure after overflying PAULA. The procedure for the ARBEY TWO STAR for runway 27 specified that a right turn be made at PAULA to track to the Epping non directional radio beacon and intercept the localiser of the runway 27 instrument landing system. On 9 September 2005, another of the operators 767 aircraft was involved in a similar noncompliance with the ARBEY TWO STAR at Melbourne. On that occasion, the crew did not follow the published transition onto the STAR from the APPLE airspace fix to the north-west of Melbourne. On 17 September 2005, and again on 3 November 2005, controllers at Melbourne observed the operator’s 767 aircraft overfly the PAULA airspace fix and continue on the downwind leg instead of turning right and tracking to Epping as required. On 16 September 2005, the ATSB provided the Air Accident Investigation Branch, Flugunfalluntersuchungsstelle, of the Republic of Austria with details of the four 767 STAR non-compliance incidents at Melbourne. On 23 December 2005, the Flugunfalluntersuchungsstelle advised the ATSB that it had held meetings with the operator to discuss the 767 STAR noncompliances at Melbourne. The ATSB has received no other reports of STAR noncompliances at Melbourne involving the operator's 767 aircraft subsequent to the 3 November 2005 occurrence. N Witnesses at a number of properties along the route flown by the pilot reported that as the flight progressed, the pilot requested by radio for each of them to illuminate their external homestead lights. The owner of the property that included the accident site estimated that the helicopter was below 30 ft above ground level as it passed north of his property. Shortly after passing that property, the pilot commenced a climbing right U-turn before descending towards the ground at an estimated angle to the horizon of 20 to 30 degrees. The helicopter impacted the ground and was destroyed by impact forces and the post-impact fire. The pilot was fatally injured and the passenger suffered serious injuries. The pilot was not qualified to undertake the night Visual Flight Rules (VFR) flight, and should not have been performing the duties authorised by his private pilot (helicopter) licence at the time of the accident. In addition, the helicopter was not equipped for flight under those flight rules. The reported operating height of the helicopter minimised the time available for the pilot to recover from any disorientation in the dark night conditions before impacting the ground. In addition, it was likely that the climbing right Uturn eroded the already marginal outside references held by the pilot. The likely result was that the impact with the ground was almost inevitable. N The weather conditions in the area at the time of the occurrence were benign. Astronomical twilight occurred at 1846 and the moon set at 1637. The wreckage was recovered 13 days after the accident. An examination revealed that at the time of impact; the engine was delivering high power, the instrument lights were receiving electrical power, and the gyroscopic instruments were receiving pneumatic power. The circumstances of the accident are consistent with a loss of control due to the pilot becoming spatially disoriented after flying into an area of minimal surface and celestial illumination. Physiological and cognitive factors may have contributed to the development of the accident. However, the factors that contributed to the aircraft descending into the water could not be conclusively established. This accident highlights the need for night VFR pilots to manage the risk of spatial disorientation in dark night conditions by maintaining proficiency in instrument flight. N MAY–JUNE 2006 FLIGHT SAFETY AUSTRALIA 63 Australian Transport Safety Bureau Collision with ground SAFETY RULES MAINTENANCE REGULATIONS PROJECT The civil aviation safety regulations for maintenance are being re-written to align with the structure and safety outcomes offered by the European Aviation Safety Agencies rule set. Is that a in your When Mrs Donoghue sued a ginger bee triggered a revolution in law that has im industry. By Garth Cartledge. M advertisement To find out more, subscribe to online updates: http://www.casa.gov.au/newrules/maint/subscribe.htm 64 FLIGHT SAFETY AUSTRALIA MAY–JUNE 2006 ost people who use the term “duty of care” understand, in general terms, what it means. The principle behind duty of care is that you must take reasonable care to avoid acts or statements that a reasonable person would foresee as likely to injure or damage someone or their interests. This includes remaining silent when you ought to speak out to prevent harm occurring. The legal concept of “duty of care” has its origins in the 1932 English court case, Donoghue v Stevenson, in which SAFETY RULES a Mrs Donoghue successfully sued a ginger beer manufacturer for damages after becoming ill drinking the company’s product. To her horror, she had discovered a badly decomposed snail at the bottom of the bottle of ginger beer she was drinking. The courts found that Mr Stevenson owed Mrs Donaghue, or anyone else likely to buy his company’s product, a duty of care to ensure that their bottles contained no harmful contaminants. Breach of duty In determining whether there has been a breach of duty of care the courts apply a “but for” test: Would the incident have occurred but for the act or omission of the defendant? If your activities are likely to have any adverse effect on the safe operation of an aircraft, you owe a duty of care to any person reasonably likely to suffer injury, loss or damage as a result of any negligence on your behalf. The duty is owed by delegates of the Civil Aviation Safety Authority (CASA), whether they are CASA staff or members of the aviation community who exercise authority on CASA’s behalf. It is owed by aircrew when they perform their functions and it is owed by anyone who manufactures or maintains aircraft or aircraft parts. In fact, it is owed by any person responsible for anything at all impinging upon the safe operation of aircraft. Reasonable: The standard of care that is expected is what a “reasonable person” would do when performing that activity. For example, where it is alleged that a pilot has been negligent when flying, the courts would test the alleged negligence against the reasonably expected standards of a pilot with equivalent qualifications and experience. For a duty of care to exist, the loss, damage or injury must have been such that a reasonable person would have foreseen that their conduct involved a risk of loss, damage or injury to the person suffering harm. Factors determining whether there has been a breach of duty Bubble trouble: The include quesoriginal bottle of ginger tions about: beer was dark and • The likelihood opaque, with little of injury. chance of spying a snail • What precauinside. tions were required to eliminate the risk. • The potential seriousness of the injury. • The public utility of the defendant’s action. In determining whether there has been a breach of duty of care the courts apply a “but for” test: Woul d the incident have occurred but for the act or omission of the defendant? The law also requires an unbroken causal connection between the negligent action of the defendant and the plaintiff’s damage. So, for example, if a maintenance organisation does a poor job of repair, negligently using an incorrect part, and the aircraft crashes as a result of this, the maintenance organisation would be liable for damages. However, if the negligent use of the part did not contribute to the accident, there would be no liability. In short, duty of care requires that you must take reasonable care to avoid acts and omissions that the reasonable person would reasonable foresee would be likely to result in injury or harm. Figuratively speaking, you should take care to ensure that you do not leave any snails, decomposed or otherwise, in the bottles you are preparing for others. Michael Taylor er manufacturer in the 1930s, she mportant implications for the aviation Istockphotos a bottle? of care is also described in the courts as negligence. Some of the most visible manifestations of negligence litigation have been motor vehicle accident cases, and claims against local government councils involving accidents at beaches or incidents involving uneven footpaths. Aviation is an inherently dangerous activity that requires a high standard of care. You have a duty to take reasonable steps to prevent anyone suffering injury or loss if an aircraft fails to operate properly and causes damage or when landing facilities themselves create an unreasonable risk. This duty of care applies whether the person suffering harm is travelling in the aeroplane or is on the ground. Garth Cartledge is a CASA legal counsel. Caution: This article is not legal advice. Its purpose is not to provide guidance that can be relied upon in individual circumstances but to create awareness of the legal issues relating to duty of care and negligence. Accordingly, specific legal advice should be sought when facing a situation which may involve a duty of care. MAY–JUNE 2006 FLIGHT SAFETY AUSTRALIA 65 SHORT FINAL A BETTER APPROACH New technologies for instrument approaches are delivering safety benefits – but all systems have their quirks, says Ian Mallett. T he first non-directional beacons were deployed in 1928 and VORs around 1948. While these were both used initially for enroute tracking, pilots soon developed “home grown” instrument let-down procedures using these aids. Over time these designs were formalised to eventually become the International Civil Aviation Organization (ICAO) PANS OPS designs we know today. Essentially the design elements of all non-precision approaches are the same with very similar tolerances adjusted for the underlying system technology. Early approaches, and in particular those in Australia, were a single, circling approach that could be flown to either runway end. The NDB and the VOR represented the majority of instrument approaches around the world, even after the development of the ILS in the early 1950s – even today most IFR aircraft carry NDB and VOR aids. For years the circling non-precision approach has remained the IFR pilot’s primary approach. GNSS was added as the third non-precision approach type in the mid 1990s but again the basic approach design is similar to that of the NDB and VOR. In fact, the initial GNSS design used the same basic tolerances as the VOR/DME approach. Circling less safe: Following the Monarch accident in 1993 and studies into controlled flight into terrain by ICAO, the aviation community recognised that circling approaches, particularly at night, were inherently less safe (some 25 times so) than even a straight in non-precision approach. This then led to the re-publishing in Australia of many NDB and VOR approaches to a runway aligned design and – when approach rated GNSS receivers became available – to straight-in approaches now known as RNAV (GNSS). Any non-precision approach consists of three elements: the guidance system and associated receiver; the instrument design; and the pilot procedures to carry out the approach. While the flying tech66 FLIGHT SAFETY AUSTRALIA MAY–JUNE 2006 niques for these are similar, pilots need to have a good understanding of the subtle dif differences between the technologies to safely complete the different approach types. For example, knowing the various errors of an ADF is essential in maintaining your confidence and situational awareness when you are chasing a swinging ADF pointer during an NDB night approach. Systems knowledge is the only way of overcoming that most basic of all pilot questions, “What the *** is it doing now?” Systems knowledge is the only way of overcoming that most basic of all pilot questions, “What the *** is it doing now?” You get the same comments these days about GNSS units and aircraft autopilot and flight management systems. People forget that all technologies have their operational idiosyncrasies. A common problem of flight management systems is due to lack of awareness of what mode the system is in. For example, pilots have set the angle of descent into the rate of descent mode resulting in a number of accidents and incidents. There are mode awareness issues with GNSS as well. The other aids have their own idiosyncrasies and these, over the years, have been progressively incorporated into the instrument rating syllabus, pilot training packages and flying instructors’ skill and knowledge sets. Human factors: In developing the package of rules and training material for the GNSS non-precision approaches in 1997-8, the then GNSS implementation team realised that some of the human factors issues related to the basic receiver could only be overcome by modifications to the approach design and pi pilot training. There was no way that we could get the receiver re-designed! Hence such design characteristics as using the standard I – F – M as the finals waypoint naming convention and a 5nm track distance between waypoints to assist situational awareness, where possible. Hence also the requirement for GNSS enroute endorsement before a pilot can have a GNSS non-precision approach endorsed on an instrument rating. Since that time other non-precision approach improvements have evolved. These include the adoption of a stabilised approach path (displayed on the chart), other charting improvements and, of course, the necessary education and training that pilots must go through as they progress through their careers. Receiver manufacturers have also recognised the need for high level of GNSS/ FMS systems knowledge, and most now provide computer-based training packages for their equipment. Non-precision approaches remain the primary form of approach in Australia and will do so for some time, so a good knowledge of their fundamentals will remain essential knowledge for the IFR pilot. ICAO has recognised that approaches that have some form of vertical guidance or APV should be the minimum approach design standard as this (vertical guidance) can add some eight times the safety to the straight in approach. Australia is now working towards this goal. GNSS is a vast improvement in accuracy, but still has quirks. All non-precision approaches have underlying issues. In any case, we now have a system that is far more accurate than NDB. Ian Mallett is a CASA satellite technology specialist, and is head the Australian strategic air traffic management group (ASTRA), which involves industry and government stakeholders in advising on air traffic management planning.
