90
January–February 2013
SMS | Painting the picture
That was then | Performance degradation
Fatigue – a silent killer
UAS: intruder in
the circuit
Ballooning: the rocky
road to danger
PLUS
Macarthur Job
writes on the dawn
of the black box
Safety management systems
Painting the picture
risk management,
| ARTICLES | AIRWORTHINESS | REGULARS
workplace
ONTENTS
safety, security,
xt here
environment
and emergency
response. This has
resulted in less
duplication of effort
in administration of
these activities.
’
04
ATIGUE‑A
SILENT KILLER
ARTICLES
04 Painting the picture Safety management systems
in clear focus
16 Another tool in the kit Tips and traps for Part 145
maintenance organisations
implementing an SMS
18 Fatigue – a silent killer Why fatigue is dangerous
and how to manage it
26 That was then, this is now The insidious hazard of aircraft
performance degradation
30 AOC holders questionnaire The latest snapshot of
the aviation industry
18
34 Intruder in the circuit A series of violations combined with
unforseen circumstances resulted
in a remotely piloted vehicle making
a hazard of itself near Adelaide
36 Dawn of the black box Macarthur Job investigates
how accident-recording
technology became mandatory
on Australian aircraft
AIRWORTHINESS
46 The rocky road to danger Analysis of a hot-air balloon defect
leads to some surprising findings
48 Hot under the pump Is time catching up with
Cessna’s clever electro-hydraulic
retractible system?
52 Service difficulty reports Australian scientist Dr David warren
investigates the crash of a
de Havilland Comet in India
CONTENTS
David
A Dev
Inves
Accid
Issue 90 | January–February 2013
Trans A
Friends
on a be
while p
Macka
four cre
Austral
The dawn
of The 26
BLaCK BoX
36
REGULARS
Fifty
ago Australia became
70years
Av Quiz
70country
Flying ops
the first
in the world
72Maintenance
to mandate
flight recorders on
75 IFRaircraft.
operationsIt was a
commercial
bittersweet
for the device’s
80 Close victory
calls
Australian
inventor,
David
warren,
80 One
night over
Toowoomba
as Macarthur
Jobmadness
writes
82Mountain
86 Up, down, round and round –
the haves and the wills
88 ATSB supplement
News from the Australian
Transport Safety Bureau
94 ATC Notes
News from Airservices Australia
96 Accident reports
96 International accidents
98Australian accidents
102 Flight bytes
110 Coming next issue
112Calendar
Upcoming aviation events
The Ma
TAA wh
had es
corps,
standa
had no
contras
had wr
that tim
53 pas
promp
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slogan
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ARTICLES
04 Painting the picture
18 Fatigue – a silent killer
26 That was then: this is now
30 AOC holders questionnaire
34 Intruder in the circuit
36 Dawn of the black box
04
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Painting the picture
Painting
the picture
Many words have been written about safety management
systems but their role in making aviation safer can be
summed up in one ancient phrase: Know thyself. This
saying, attributed to Socrates, is as applicable to SMS as it
is to ancient Greek philosophy.
Aviation has reached the stage at which learning about
safety from accidents is no longer practical. Jet airliners
had 30 accidents per million departures in 1965 – in 2009
the corresponding rate was 0.71 per million departures.
In this environment safety concerns must be perceived,
reported and acted on before they become safety
problems, safety incidents – or accidents. Information
– about what is potentially dangerous and what the
organisation is doing to fix it – is the key. In short, an
aviation organisation should be self-aware about its safety
performance – it should know itself.
As in any scheme of self-improvement, discipline is
required. Self-knowledge may be revealed to the individual
in occasional quiet moments but an organisation requires
structure and process to fathom its own doings. Safety
management systems propose that organisations should
take a systematic approach to safety. Rather than waiting
for something to go wrong, safety should be managed,
just like many other aspects of organisational life such as
accounting, personnel and quality control.
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
Three letters,
SMS – standing for
safety management systems
– can cause fear and loathing in
some aviation organisations that do
not comprehend what they mean. SMS,
already widespread in regular public
transport aviation, and mandated for
aerodromes since 2005 will be required
for part 145 aviation maintenance
organisations from June 27 this year.
Flight Safety Australia looks at
the simple, safe and sensible
concepts behind
the hype.
05
06
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Painting the picture
The art world provides a more inspiring way of thinking
about SMS, with several unexpected but useful analogies.
Painting techniques such as the pointillism of 19th century
neo-Impressionists, or the photo-realism of contemporary
artist Chuck Close, create complex and vivid pictures with
thousands of small dots of colour. A well-functioning SMS
is like such an artwork: each individual report is, in itself,
just a dot of colour. But together they paint a picture of the
organisation and its hazards.
Flight Safety Australia spoke to practitioners, theorists and
regulators of SMS. Their perspectives were diverse, but
had several common themes: SMS is simpler than many
aviation operators fear, and is, at heart, a formalisation of
what competent operators are already doing.
The regulator: Peter Boyd, CASA
executive manager of standards
‘SMS performs a similar function to an accident: both
are a way to discover the flaws in your operation,’ CASA
executive manager of standards Peter Boyd says.
‘It’s asking the what-ifs; what could go wrong? what are we
vulnerable to?’
Regulation is necessary for safety but has limits on what
it can control, Boyd says. ‘Regulation can only cover the
known and general aviation safety hazards. SMS covers
the specific aviation safety hazards particular to an
organisation because it comes from that organisation.’
Boyd says most aviation organisations are happy to
embrace the concept of SMS.
‘An SMS is commonsense things you’ve got to do, but
you also have to write them down to lock them into your
management system so they’re consistently done. Most of
the opposition to SMS is really all about that writing task.
We find most embrace the concept but some are unhappy
at the work involved.
‘Another analogy I’ve heard is building a wall without
mortar, like an old stone fence. You have to accept that you
will have to check it and replace bricks from time to time.
It’s a system that’s got to be kept up-to-date all the time –
it’s always developing and adapting.’
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
WHAT IS THIS
THING CALLED SMS?
A safety management system is a set of practices to
integrate safety into the management of an organisation.
Consultancy Baines Simmons says: ‘A safety management system
is a businesslike approach to safety. It is a systematic, explicit and
comprehensive process for managing safety risks.
As with all management systems, a safety management system provides
for goal setting, planning, and measuring performance. A safety management
system is woven into the fabric of an organisation. It becomes part of the
culture, the way people do their jobs.’
ICAO lists four major components of an SMS:
| Safety policy, objectives and planning | Safety risk management |
| Safety assurance | Safety promotion – training and communication |
The last time Flight Safety Australia looked at SMS we said: ‘In this
scheme, information is central. Information gathered and freely
offered by frontline staff; information recorded and analysed by
management (with the involvement of frontline staff) for its safety
implications; information then widely disseminated throughout the
organisation, both to address identified safety concerns, and
to develop a safety culture. And last but not least,
information on how the safety system itself
is operating.’
07
08
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Painting the picture
The hangar: Jim Pilkington, Hawker Pacific
Jim Pilkington is vice president of quality and systems
at Hawker Pacific, a historic and diverse company with
interests in aviation sales, maintenance, support services,
flight operations and fixed-base operations.
Hawker Pacific’s aviation activities cover both civil and
military operations and its SMS has to cover all facets of
the operations and be accepted by both civil and military
regulators within Australia and overseas.
In 2011 Hawker Pacific was also the first maintenance
organisation to be certified under CASA’s new Part 145
aviation maintenance regulations, which have a strong
emphasis on SMS.
‘The key to it for us is our database and integration of many
safety and quality-related elements’, Pilkington says.
‘We’ve operated an SMS for about seven years but the
serious merge and integration towards an Integrated Safety
Management System (ISMS) commenced about four
years ago,’ he says. ‘We integrated aviation occurrence
reports, internal and external audits, risk management,
workplace safety, security, environment and emergency
response. This has resulted in less duplication of effort in
administration of these activities.’
‘Key to our integration was our database – we use the
Omnisafe OSMS database, a web-based application –
which provides the common recording and analysis point
for all these activities. Importantly, it also allows us to code
and analyse the data against safety performance indicators
that we set and monitor.
‘The database application has enabled us to pick up trends
and we know more about our strengths and particularly, our
weaknesses. Over time we get to know the error causes
and contributing factors.’
The concept of integrating various management functions
into the SMS should be a consideration for smaller aviation
organisations, Pilkington says.
‘I do feel for the smaller organisations in a relatively lowrisk environment. The regulations require an SMS and for
the SMS to be of value there needs to be data. However,
in these environments, little will be generated. That’s even
more reason to integrate more elements under the SMS
umbrella because that way it can generate information that
can be valuable to the operation.’
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
We integrated
‘aviation
occurrence
reports, internal
and external audits,
risk management,
workplace
safety, security,
environment
and emergency
response. This has
resulted in less
duplication of effort
in administration of
these activities.
’
09
10
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Painting the picture
The runway: Dr Peter Cock, Perth Airport
Executive General Manager
Aerodromes have had to implement SMS since 2007.
Perth Airport Executive General Manager Operations
and Customer Experience, Dr Peter Cock, says the SMS
approach that was proactively implemented at Perth
Airport in 2002 has improved the airport’s performance
in both business and safety. He illustrates this with an
appropriately cheesy analogy.
‘Operations were safe before SMS, but to use James
Reason’s Swiss cheese analogy, SMS is like having more
layers, smaller holes and less chance of them lining up,’
he says.
Cock nominates three distinct benefits of the SMS
approach.
Firstly, it integrates safety with other operations. ‘SMS
shows us the importance of integrating and involving
people in an organisation. Great things happen when you
have the right people in the same room to tackle safety
issues.’
Secondly, he says an SMS drives a proactive safety
approach simply by regularly placing safety on the agenda.
‘It’s easy as a manager to be busy with the day-to-day
operations, but when you take time out to actively consider
safety there’s no escaping the subject.’
Thirdly, it drives senior management coordination of safety.
‘By placing safety on the management agenda, it ensures
responsibility and accountability.
‘Some organisations have persistent safety issues that
never get resolved and go into the too-hard basket. That
can’t happen with SMS. It shines too powerful a light on
these issues.’
Cock says there is a discernable link between the discipline
of SMS and the reward of an improved safety culture.
‘Our CEO, Brad Geatches, has a mantra: “Systems drive
behaviour, and over time behaviours form attitudes – this is
the real cultural equation.
It’s important for people on the ground to know that
management places a high importance on safety”.’
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
Cock can reel off several specific examples where
regular and scheduled consideration of issues under
the SMS has improved the airport’s operations.
‘To minimise the risk of bird strike, we now focus on
reviewing lead indicators, such as how climate is likely
to influence future bird populations on the airport,
migratory patterns and habitat. We strive to be proactive
and start our control programs early.
‘With airfield works, we consider early how we schedule
operations. We also consider whether certain works
should be brought back or forward to minimise
disruptions to customers and ensure the number of
airfield work sites does not exceed the capacity of our
safety team.
‘And the SMS thought process has driven us to work
more closely with a wide range of stakeholders, from
Airservices Australia to contractors on the ground.’
Cock also sees efficiency benefits when an SMS is
included in management. He gives an example. ‘One
of the things it does is help us ask questions much
earlier. When we look at a plan from a safety point
of view, we find ourselves picking up any issues and
saying “this needs to be considered at this stage”,
and this approach has helped us to drive engagement
earlier in the process.’
However, he emphasises that an SMS is never a fixed,
end state. ‘There’s no finishing line. As your business
evolves, your SMS has to evolve as well,’ he says.
‘SMS is a way of managing risk and maximising
opportunity - and that’s what business is about.’
shows us
‘SMS
the importance of
11
integrating and
involving people
in an organisation.
Great things happen
when you have the
right people in the
same room to tackle
safety issues.
’
12
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Painting the picture
The professor: Sidney Dekker
Most safety systems theorists worry about safety events.
The author of Just Culture, and several other works on
aviation and system safety, Professor Sidney Dekker,
worries about safety systems. In particular, he wonders
if the simple cause and effect notion of how accidents
happen is enough to defend against modern air transport
incidents, many of which involve unimagined scenarios,
such as an engine failure causing information overload on
the flight deck of a Qantas Airbus A380.
‘There is something seductive about the Newtonian reflex
to go down and in to find the broken part and fix it,’ Dekker
writes in Patient safety: a human factors approach.
‘We can try to tell professionals to be “more professional”,
for example, or give them more layers of technology to
forestall the sorts of component failures we already know
about (only to introduce new error opportunities and
pathways to failure). Complexity theory says that if we really
want to understand failure in complex systems, that we
“go up and out” to explore how things are related to each
other and how they are connected to, configured in, and
constrained by, larger systems of pressures, constraints
and expectations.
Dekker, who soloed in a glider at 14 and adds to his
academic insights with sabbaticals when he flies as first
officer on a Boeing 737NG, says implementing SMS
intelligently can contribute to up and out thinking. He
nominates three areas an organisation needs to pay
attention to in its SMS:
§The first is a need to be careful about what an SMS
counts as safety data. ‘That which we can count doesn’t
necessarily count in terms of accident potential. And vice
versa: that which counts in an accident is not always
what can be counted in an SMS,’ he says.
‘That enthusiasm to look further upstream and further
into the organisation is very empowering, and I think is
in part responsible for the increasing safety we see in
commercial aviation today. But the risk baked into it is
that we count that which we can count.
‘What we’ve seen in recent accidents is that even
organisations that had SMS, that counted things, ticked
the right boxes, were able to drift into failure by a gradual
erosion of margins that couldn’t be picked up by the way
they counted things.’
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
don’t think SMS
‘ Iwould
be possible
at the scale we
have it today if
we did not have
the computing
power and the
cheapness and
ease of collecting
and storing
data ... even
smaller operators
are capable of
living up to SMS
expectations.
’
13
14
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Painting the picture
The countermeasure, Dekker says is ‘to be continually
inquisitive about what you put into your SMS. In order
to be continually inquisitive you have to take in outside
opinion, you can’t just breathe your own air, either as a
regulator or an operator.’
§ A second concern is that the sheer volume of data
produced in the SMS process can be paralysing.
‘An interesting accompaniment to the growth of SMS is
the ease and low cost of data collection and storage,’
Dekker says. ‘I don’t think SMS would be possible at the
scale we have it today if we did not have the computing
power and the cheapness and ease of collecting and
storing data. It’s a huge advantage; it means even
smaller operators are capable of living up to SMS
expectations. But there’s a risk. It’s that we gather and
store data for its own sake.‘
Dekker says it’s important to ‘constantly keep the
discussion alive about what data goes in, what stays in
and what goes out.
‘One of the things that we should think about is if the
data we gather doesn’t give us interesting, actionable
intelligence about our organisation, we should think
about slicing it differently – looking at other correlations
that we may not have explored previously. We could do
some gaming and discover other interesting trends that
may have remained hidden in the huge conglomerate of
data that we have gathered.’
§ Dekker’s third concern is that SMS can be seen as
‘McDonaldisation’ of safety. ‘McDonaldisation is making
the customer do the work,’ he says. ‘In this case it refers
to one way for the regulator to deal with its own restraints
and budget pressures by making the customer do
the work.
While McDonaldisation can be a negative it also has
positive aspects. ‘One that it implies very strongly is a
joint commitment between regulator and operator. That the
regulator isn’t the only one saying “safety is important’’.
‘The other is that it implies a mutuality and discussion
between operator and regulator that may not have existed
before. The operator can say, “if you want us to be safe,
this is really what we should be showing you.’’
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
15
if the data we
‘...gather
doesn’t give us
interesting, actionable
intelligence about
our organisation, we
should think about
slicing it differently ...
’
‘Finally, it implies trust and collaboration between
regulator and operator, not necessarily only an
adversarial relationship ... so that when the regulator
and inspector show up you’re good Boy Scouts for
a day, then go on with what you’re doing. It implies
trust and continuity.
‘There’s a mental leap for all involved, both the
regulator and the operator, and I think it is very
much a work-in-progress. Aviation is not unique in
this. You see this cultural leap in all kinds of safetycritical industries.’
Further information:
Alan J. Stolzer, Carl D. Halford, John J. Goglia,
Implementing Safety Management Systems in Aviation,
Ashgate, Surrey, 2011
Australian Transport Safety Bureau, A systematic
review of the effectiveness of safety management
systems, Dr Matthew J.W. Thomas
www.atsb.gov.au/publications/2012/xr-2011-002.aspx
CASA SMS webpage including SMS resource kit
www.casa.gov.au/sms
Photo: Gulfstream
16
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Painting the picture
Another tool in the kit:
SMS and maintenance organisations
Grazing an aircraft wing on a hangar can easily see repair
costs run into tens of thousands of dollars. Leaving a tool in
the fuselage can damage components, or even foul control
lines as it rattles around.
And a seemingly innocuous mistake, such as fitting
bolts just over half a millimetre too small to an aircraft
windscreen, can send the captain hurtling through the
windshield at 17,300 feet, as happened on British Airways
Flight 5390 in June 1990.
So it makes good commercial sense to have a safety
management system (SMS) in place, not just to help
prevent major incidents and litigation but also smaller
mistakes that can quickly add up to costly sums.
By 26 June this year all CASR Part 145 approved
maintenance organisations will need to have an SMS
in place. CASA Safety Systems Inspector Bruce Reilly
says the new requirements will bring Australian aviation
in line with International Civil Aviation Organization
(ICAO) standards.
Reilly, who has extensive aircraft maintenance
experience with major airlines and small general
aviation operations in Australia and overseas,
says developing an SMS is easier than it
seems if you focus on the core aim of
identifying hazards and managing
safety risks.
‘You have a lot of processes already
in place — look at your current
maintenance control manual, CASA’s
sample exposition and the Part 145
Manual of Standards, work out what
you’ve got and fill in the gaps,’ he says.
‘If you integrate the SMS into your
maintenance organisation exposition
(MOE), it is not quite as challenging as it
may initially appear.
‘This will also ensure that in the majority of
cases the cost of implementing an SMS will be
Photo: Ruag Aerospace
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
TOP TIPS: SMS for
Part 145 approved
maintenance
organisations
1. Read the SMS
guidance material before
writing your SMS.
2. Write your SMS considering the relevant
Part 145 maintenance regulations.
3. Integrate SMS in things you’re already
doing. For example, maintenance error
management, change management and
safety education and training.
4. Do not confuse SMS with occupational
health and safety. SMS relates to the safe
operation of aircraft not, for example,
a person cutting their finger.
5. Ensure safety performance targets
are specific and measurable.
relatively low, as many of the main elements that
make up an SMS are already in place within the MOE.’
To help maintenance organisations, CASA has released
additional SMS guidance material as a framework
to build and develop a safety management system
specifically for a small, non-complex AMO.
‘The person who has been assigned the role of Safety
Manager should be the person developing and writing
the SMS, in association with the person developing the
MOE,’ Reilly says.
‘As this is a new role, they will most likely be on a rapid
learning curve.
‘However, there is a lot of good, easy-to-read guidance
material available and I recommend that before putting
pen to paper, they sit down and have a chat with their
local Safety Systems Inspector.’
Reilly says one of the main challenges for maintenance
organisations is fostering a safety culture.
‘In a small organisation, just one person can
make or break SMS culture. It needs to be
supported from the top down — it’s in
everyone’s best interests.’
17
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CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Fatigue – a silent killer
FATIGUE‑A
SILENT K­ ILLER
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
One hour after Zlatko Glusica woke up on
May 22, 2010 he was dead, along with 157
other people, in the incinerated wreckage of
Air India Flight 812 at the bottom of a ravine
in Mangalore.
Captain Glusica’s last sleep had not been in
a bed, but behind the controls of a passenger
jet carrying 166 people. What he had
presumably intended to be a refreshing, short,
‘power nap’ during cruise flight had turned into
deep slumber, during which the first officer
dutifully flew the Boeing 737. (See ‘Falling off
the mountain,’ Flight Safety Australia Sept-Oct
2011) Glusica awoke suffering from the mental
and physical impairment caused by sleep
inertia. An unstabilised landing approach
followed, breaking both standard operating
practices and regulations. This resulted in
Flight 812 overshooting the runway, sliding
over a cliff and catching fire, killing all but eight
of those on board.
The Indian Civil Aviation Ministry inquiry report
said Glusica had slept for over 90 minutes
during the flight, and the American National
Transportation Safety Board said it was the
first time snoring had been heard on a cockpit
voice recorder (CVR).
Fatigue has been a factor in aviation accidents
since aircraft have been able to make longdistance flights. On 13 March 1954 a BOAC
Constellation undershot the runway at
Singapore, killing 32 people. Its crew had been
on duty for 21.5 hours.
19
20
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Fatigue – a silent killer
In August 1993, a Douglas DC-8 crashed
beside the runway at the US Naval Air Station at
Guantanamo Bay, Cuba, when the captain lost
control. The cargo aeroplane was on the last leg
of a three-sector flight from Atlanta. The captain
had been awake for 23.5 hours, the first officer
for 19 hours, and the flight engineer for 21 hours.
In addition, the accident occurred at the end of
the afternoon circadian low, when alertness is
likely to be impaired.
In a 2012 survey (of around 6000 pilots) for the
European Cockpit Association (ECA), more than
half said tiredness had hampered their ability to
fly. Four in 10 British pilots admitted having fallen
asleep at the controls of an aircraft, with a third of
these waking up to find their co-pilot asleep
as well.
The research also suggested that the issue
is under-reported. Fearing the reaction of
employers, 70 to 80 per cent of tired pilots said
they would not file a fatigue report, or declare
they were unfit to fly.
The ECA says long duty and standby hours,
night flights and disruptive schedules contribute
to pilots spending long periods awake.
Data from the Australian Transport Safety Bureau
(ATSB) suggest that over the last 10 years there
have been approximately 78 Australian aviation
incidents or accidents in which human fatigue
has been identified as a possible contributory
factor. There is also growing evidence, both here
and overseas, that flight crews are falling asleep
(or experiencing micro-sleeps) at the controls on
a regular basis, but that many of these incidents
go unreported.
The problem of fatigue
Over time, evolution has equipped humans
with an internal biological clock that regulates
sleep and wake periods. These natural circadian
rhythms are repeated about every 24 hours,
so the body is more awake during the day,
but experiences a reduction in activity in the
midnight-to-dawn period.
Work schedules/shifts that require people to
be awake and active at night, or to work for
extended periods, disrupt circadian rhythms,
affecting sleeping and eating patterns and task
performance and potentially contributing to a
sense of personal dislocation and imbalance.
Other workplace-related causes of fatigue
include environmental issues (such as excessive
noise or temperature extremes); workplace
stress (bullying, constant change, or threats
to job security) and burnout. Lifestyle (diet,
exercise, alcohol and other drugs), illness, some
medications, and psychological factors such as
depression, anxiety and grief, can also contribute
to fatigue.
Fatigue is increasingly being viewed by society
as a safety hazard. Studies have shown that
the effect of driving while sleep deprived is
equivalent to driving while drunk. In 2011, 3329
crashes were recorded as being fatigue related –
almost twice as many as those involving alcohol.
Operators need to develop adequate hazard
identification and risk assessment processes,
in particular relating to the different fatigue issues
for flight crew, cabin crew and maintenance
personnel.
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
21
The three-tier approach to fatigue management
Limitations
†
†
Customisable
Data-driven
†
†
†
†
Prescriptive
Type-of-operation specific
More flexible
Less restrictive
†
†
Prescriptive
Somewhat restrictive
Operator obligations
7
FRMS
2
3
4
5
6
FATIGUE
MANAGEMENT
1
BASIC
†
†
†
†
Policy and documentation
Risk management processes
Safety assurance processes
Safety promotion processes
†
†
†
†
†
Hazard identification
Limitations taking into account
identified hazards
Continuous monitoring
Transitional procedures
Training for FCMs
†
No additional obligations
1. Basic limits 2. PTS multi-crew 3. PTS multi-crew,
non complex 4. PTS single pilot 5. Aerial work, exc.
flying schools 6. Aerial work–flying schools 7. FRMS
PTS (Public transport services)
Putting the issue to bed‑
how to manage fatigue in
an organisation
CASA will shortly release a notice of final rule-making
(NFRM) illustrating suggested approaches to the
complex question of managing fatigue risk in the
diverse Australian aviation environment.
The NRFM will be published on the CASA website
www.casa.gov.au/fatigue
CASA flying operations inspector, William Cox, says
about 55 per cent of operators currently comply with
flight and duty times via CAO 48, 35 per cent via
standard industry exemptions and about 10 per cent
via a fatigue risk management system (FRMS).
‘The change to CAO 48 will involve a threetiered approach, to give operators the flexibility
to choose the regime they wish to operate
under. The first tier is somewhat restrictive, primarily
a prescriptive means of fatigue management.
Tier 2 offers wider limits, moderated by operator
risk management (i.e. more work for the operator).
Lastly, tier 3 offers all operators the opportunity
for fatigue management by an FRMS approach
tailored specifically to their organisation.
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CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Fatigue – a silent killer
‘The FRMS approach has been available
to Australian operators for some time,’ Cox
says. ‘There is now a newer approach to
FRMS that clearly shows the path an operator
(and a regulatory authority) should follow to
ensure that risks are adequately managed.
There will be some commonality with existing
operator systems (training, risk management,
continuous improvement etc.), and CASA
supports operators in absorbing common
systems where possible.
The comprehensive approach:
fatigue risk management
systems
‘We hope to have a new civil aviation order by
the end of this year and operators will be able
to migrate towards the new order early next
year. The time frame for this migration will be
around two years.
Good quantitative data work best when the
sample population is large. Can enough data
to properly apply scientific principles be obtained
if an operator has a fleet of fewer than, say,
10 aeroplanes?
‘Regular public transport (RPT) operators will
be able to comply with the restrictive tier 1 or
tier 2 (appendices 2-4), or tier 3 FRMS.
In a paper presented to the recent International
Cabin Safety Conference in Amsterdam, Adrian
Young, of Dutch airline Denim Air, said that he
believed there might be a role for national or
international authorities to act as a clearing
house for current scientific data. He added
that he was ‘not calling for more rulemaking;
anything but’. However, clear, uncontroversial
information that would assist the sector was
required. Industry associations could possibly
play a role in this too, but all AOC holders could
not reasonably be expected to accurately judge
the validity of results in an ever-evolving science,
he added. Neither should the regulations drive
operators into the arms of expensive consultants.
‘Operators may find that the middle tier will be
subject to further risk management as a result
of their particular demographic. Details of this
will be explained in the ‘operators obligations’
section of the new order.
‘We expect these systems to improve over
time. Operators will be expected to learn from
experience as they develop their systems, and
understand how changes (new aircraft/routes
etc.) could impact on fatigue management.’
ICAO requires that a fatigue risk management
system (FRMS) be: a data-driven means of
continuously monitoring and managing fatiguerelated safety risks, based upon scientific
principles and knowledge as well as operational
experience that aims to ensure relevant personnel
are performing at adequate levels of alertness.
The elements of a fatigue risk management system (FRMS) can be grouped into four parts.
•Safety policy and objectives
•Safety assurance
•Safety risk management
•Safety promotion
These four parts can be identified as being similar to the SMS that operators are required
to have by ICAO regulations. This approach makes the work involved in developing a
fatigue risk management system (FRMS) clearer to both management and operational staff.
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
Fatigue and cabin crew
Much of the work on flight time limitations (FTL)
and fatigue risk management systems (FRMS)
has been aimed at flight crew members and their
tasks in the high-workload environments
of take-off and landing, including monitoring
all the automated systems of a modern aircraft.
However, operators also need to consider
the physically demanding elements of
cabin service.
A number of fatigue risks for cabin crew can
be identified:
•Delayed reactions in fire fighting/emergency
response/evacuation
•Poor communication with other crew
members and passengers
•Incorrect procedures in operating doors
and equipment
•Impaired concentration on safety-critical tasks
•Reduced ability to handle disruptive
passengers
When fatigue management rules for other
aviation personnel (e.g. cabin crew and
maintenance engineers) are made, the structure
of CAO Part 48 will probably evolve into general
and personnel-specific sections.
There is no blood
test for fatigue
23
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CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Fatigue – a silent killer
Wake up soldier! An extreme
approach to fatigue
The pilots are amazed to discover that it simply
works’, said a senior Israel Air Force officer.
Fatigue management has become an issue
within the armed forces. The Israeli army is
supplying aviators and special operations
forces with a caffeine-charged chewing gum
that dramatically enhances their ability to cope
with fatigue on missions lasting more than 48
consecutive hours. Before introduction of the
gum, soldiers often chewed on freeze-dried
coffee to stay awake during night operations.
The food supplement gum is part of ongoing
efforts to curb fatigue-related injuries and
deaths and is also included, along with other
foodstuffs designed to increase vigilance and
endurance, in the meals ready to eat (MRE)
issued to U.S. field units on high-intensity
combat operations in Afghanistan.
‘There are no side effects, except for the
disgusting taste. It improves the soldiers'
alertness and their cognitive performance.
Troops sent on 72-hour missions are also
issued with Modafinil, a prescription drug for
treating an assortment of sleep disorders, and
some Australian pilots in Afghanistan are using
ephedrine-derivative medications.
Fatigue 101
•Fatigue is a physiological state of reduced mental or physical performance capability
resulting from sleep loss or extended wakefulness, circadian phase, or workload (mental
and/or physical activity) that can impair people’s alertness and ability to safely operate an
aircraft or perform safety-related duties.
•There are two main types of fatigue:
• Transient: experienced following a period of work, exertion or excitement. This can
normally be dispelled by a single sufficient period of sleep.
• Cumulative: may occur after delayed or incomplete recovery from transient fatigue,
or as the after-effect of too much work or over-exertion without sufficient opportunity
for recuperation. These cumulative effects can result in serious sleep deprivation.
•The only effective treatment for fatigue is adequate sleep.
•Fatigue is a physiological problem that cannot be overcome by motivation, training
or willpower.
•There is no blood test for fatigue.
•Staying awake for 17 hours has the same effect on performance as a blood alcohol content
(BAC) of 0.05 per cent. Staying awake for 21 hours is equivalent to a BAC of 0.1 per cent.
•An employer can provide a long rest period in an excellent environment but this is of no use
if the opportunity to rest is not taken.
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
25
Further reading
CASA’s latest information on fatigue, with a link to the new fatigue
management toolkit www.casa.gov.au/fatigue
‘Proof that fatigue kills’ – a presentation by David Learmount, of
Flight International, to an FRMS forum in Farnborough, U.K.
www.eurocockpit.be/sites/default/files/Fatigue_Kills_Proof_
D_Learmount_SP_09_0528.pdf
A European Parliament article about a survey on pilot fatigue
www.theparliament.com/latest-news/article/newsarticle/pilotfatigue-commonplace-in-europe/
Download a European Cockpit Association (ECA) flight duty period
calculator www.eurocockpit.be/pages/ftl-calculator
A Victorian government Better Health Channel article on the
symptoms and causes of fatigue www.betterhealth.vic.gov.au/
bhcv2/bhcarticles.nsf/pages/Fatigue_explained
A Queensland government review of fatigue in the
workplace www.deir.qld.gov.au/workplace/subjects/
fatigue/about/index.htm
The only effective
treatment for fatigue
is adequate sleep
26
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
That was then: this is now
That was then:
this is now
Your aeroplane
matched its flight test
data when it was new,
but how long ago was
that? Don’t bet your
life that it will still
do so after several
decades of service,
writes CASA engineer
Neville Probert
New aeroplanes always leave the factory looking
shiny and magnificent with multiple coats of paint.
Their performance is also magnificent – new
engines and propellers, and airframes in perfect
condition. They will never fly better.
For aeroplanes, ageing is literally a drag. The performance
figures in the aircraft flight manual that comes with commercially
manufactured aeroplanes have been determined by flight testing.
Before rate-of-climb information for commuter and transport
category aeroplanes is published in the flight manual it is reduced
by a small amount. This is to allow for deterioration in engines,
propellers and airframes over the life of the aeroplane, and also
to recognise that it is unlikely that any flight crew in the real world
will be able to match the results achieved by the manufacturer’s
test pilots. The difference between what a test pilot does –
flying a fully briefed test routine, at a safe altitude – and, for
example, climbing for your life as an obstacle looms
ahead – will almost always favour the test pilot.
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
Climb gradient information published in the flight manual is used
to ensure obstacle clearance immediately after take-off with one
engine inoperative. For a twin-engined commuter category or
transport category aeroplane, take-off climb gradients published
in the flight manual are 0.8 percentage points less than the
gradients measured in flight tests. For example, if the aeroplane
manufacturer carries out a series of tests on a representative
aeroplane with one engine inoperative at a particular weight,
altitude and temperature, and these tests result in an average
climb gradient of 2.0 per cent, the climb gradient published in
the flight manual will be only 1.2 per cent for this weight, altitude
and temperature. For a four-engined aeroplane, take-off gradients
published in the flight manual are 1.0 percentage point less
than those measured in flight tests. Information pertaining to a
transport category aeroplane’s performance in the en-route
phase with one engine inoperative is also reduced by a small
amount before being published in the flight manual:
1.1 per cent for twin-engined aeroplanes and
1.6 per cent for four-engined aeroplanes.
27
For four-engined aeroplanes,
performance in the en-route
phase with two engines
inoperative is reduced by
0.5 per cent.
The same is not true of
aeroplanes in other categories.
Flight manuals for most
aeroplanes in the normal,
utility and acrobatic categories
have performance information
that contains no provision for
deterioration of the engines,
propellers or airframes
(The exception is for normal,
utility or acrobatic multiengine jets weighing more
than 6000 pounds (2721kg)).
There is also no provision
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CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
That was then: this is now
made for the pilot failing to
match the performance of the
manufacturer’s test pilots.
For example, if the
manufacturer of a normal
category aeroplane measures
a climb gradient of 2.0 per cent
at a particular weight, altitude
and temperature, the climb
gradient published in the flight
manual for that weight, altitude
and temperature is likely to be
2.0 per cent.
There are several things pilots
and operators of normal,
utility and acrobatic category
aeroplanes can do to avoid
finding out the hard way that
their aeroplane’s performance falls short of the performance
specified in the flight manual.
•Ideally, careful attention to detail during training flights or
instrument renewals will show any shortfall in the aeroplane’s
performance compared with the performance specified in
the flight manual. If the aeroplane always performs as though
its weight is 150kg more than its actual weight at the time,
consider operating the aeroplane as though its empty weight
is 150kg over that shown in the aeroplane’s records.
•The performance of the aeroplane will reflect the condition
of its engines and propellers. Don’t be surprised if the
aeroplane’s performance deteriorates as the time in service
of engines and propellers increases.
•Perhaps less obviously, the performance of the aeroplane will
deteriorate as the airframe accumulates antennae, patches
and other external evidence of repairs and modifications
carried out during the life of the airframe. Ill-fitting doors
and hatches don’t help either.
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
External features added to the airframe inevitably contribute to
the aeroplane’s drag coefficient, reducing climb performance
and cruise speed and increasing the fuel required for each flight.
This increase in drag coefficient makes the aeroplane perform
as though its empty weight is more than it really is. When you
add any piece of equipment to your aircraft, Civil Aviation
Order 100.7§ 6 requires you to record the weight change
and make it part of weight and balance calculations,
but there is no requirement for the aeroplane’s
aerodynamic performance to be re-assessed after
each addition of an external feature.
Individually, these external features may be
innocuous, but their cumulative effect could be
a significant degradation of performance. If an
aeroplane already has one or more external
antennae, any decision to add another
29
should be accompanied by
consideration of removing one
that is already there. If two
or more repairs have been
made in one area it could be
possible to consolidate them,
so that their contribution to
drag coefficient is significantly
reduced. A few minutes spent
fine-tuning the installation
of doors and hatches will be
time well spent. You can be
sure that when the aeroplane
manufacturer carried out
performance tests not
one antenna was installed
and all the doors and hatches
fitted perfectly!
30
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
AOC holders questionnaire
Two thousand and twelve
AOC HOLDERS SAFETY QUESTIONNAIRE (AHSQ)
Each year CASA conducts a survey of Air Operator’s Certificate
(AOC) holders to collect information on their activities and to gather
industry-wide safety information.
CASA uses the information received in the AHSQ for a wide variety of
purposes, including:
† identifying emerging safety risks
† measuring activity levels within the industry to assist with resource allocation
† gathering information to assist with the development of legislation.
The 2012 AHSQ commenced early in the year and responses were received
from almost all AOC holders. CASA values all input received from industry
and we would like to thank all AOC holders for their efforts in providing
these responses.
Industry overview
Operators
Hours flown
Staff numbers
Aircraft
The Australian aviation industry includes around
850 operators, who undertake a mix of operations
classified as aerial work, charter, or regular public
transport (RPT). Despite the relatively low number of
RPT operators these operations account for 48 per cent
of all hours flown within Australia, followed by charter
(27 per cent) and aerial work (25 per cent).
RPT
35
1,195,250
15,166
662
Charter
431
680,168
3951
2029
Note: AOC holders can undertake more than one category of operations
Aerial work
473
632,883
3137
1074
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
The largest of the RPT operators flew almost half the hours in this sector, with
90 per cent of all RPT hours flown by just four RPT operators.
The charter sector has a broader profile, with half the charter hours flown by
18 operators, six of which also performed RPT operations. The aerial work
sector is broader again, with 27 operators having flown half the hours in this
sector. Nine of these operators also performed charter work. However, for
most of these operators, aerial work constitutes the majority of hours flown.
As can be seen in the figure below, the majority of aerial work hours are
flying training, followed by ‘other’ – which includes aerial agriculture, and
air ambulance.
Flying training
Mustering
Other
Pipeline
98,791.3 hrs
12,049.2 hrs
Ambulance
Search & rescue
70,196.2 hrs
4960.8 hrs
330,273.9 hrs 54,963.9 hrs
Towing
576.0 hrs
Charter
27%
Aerial work
25%
RPT 48%
Surveying & photography
61,070.4 hrs
31
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CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
AOC holders questionnaire
FLEET
In this year’s AHSQ, 3793 distinct tail registration
numbers were reported, representing 27 per cent of
all VH-registered aircraft.
Two-thirds of AOC holders (66 per cent) reported that they
operated fewer than five aircraft, with the remaining onethird of operators evenly split between those using more
than five and fewer than 10 aircraft (17 per cent) and those
operating 10 or more aircraft (17 per cent).
One hundred and twenty-seven operators (two-thirds of
which were charter operators) reported having 10 or more
aircraft in their fleet, with the remaining third evenly divided
between aerial work and RPT operators.
STAFF
AOC holders employ around 22,000 staff in their organisations,
including more than 9000 pilots, 3000 ground operations
personnel, 4000 cabin crew, and 5000 administrative and
other staff.
Ground
operations 15%
Pilots
43%
Cabin crew
18%
All other staff
24%
According to the 2011 Australian Bureau of Statistics
census figures, 43,061 people listed their industry as
‘Air and Space Transport’. It is estimated that approximately
half of these would be directly employed by AOC holders,
with the other half employed by organisations providing
supporting functions (e.g. engineers, ground handlers,
and other occupations.)
EXPECTATIONS
The majority of organisations (428, or 61 per cent) expected
their workload to stay the same during 2012, while almost
30 per cent (212 operators) expected their workload to
increase, and 8 per cent (58 operators) expected their
workload to decrease.
33
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
RPT
2011
2012
Stay the same
Decrease
Charter
Increase
2011
2012
Non-charter
No response
2011
2012
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
The figures are very similar between the 2011 and 2012
AHSQs, although the proportion of charter and aerial work
operators who expect their workload to decrease has
dropped. This is possibly indicative of renewed optimism,
as Australia moves beyond the global financial crisis of
2007/2008. RPT operators are generally more optimistic
when it comes to forecast growth.
RISK PERCEPTION
Operators were presented with nine risks to aviation safety
and asked to rate them as high, medium, or low. The top
three risks for all three sectors were:
1. unsafe operators allowed to continue operating
(e.g. CASA not detecting unsafe operations or not
effectively prosecuting)
2. the ability to hire suitably qualified staff
3. economic conditions/profitability (e.g. cutting corners
to save money, low staff morale, distraction due to
economic insecurity).
It is interesting to note that all three sectors nominated the
same three risks, although in a different order.
CONCLUSION
This article presents only a small sample of the information
from the 2012 AOC Holders Safety Questionnaire. The
valuable data collected serves to inform CASA about potential
aviation safety issues and opportunities for safety education
and promotion activities. Participation of the operators in the
2012 survey is greatly appreciated.
The 2013 AOC Holders Safety Questionnaire will be distributed
to industry in the first quarter of 2013, so keep an eye out for
further information. The questionnaire will focus on the themes
of unmanned aircraft systems (UAS), regulatory change, and
aerial work operations.
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CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Intruder in the circuit
The operators of a remotely piloted aircraft (RPA)
were lucky to feel only embarrassment rather
than grief after their aircraft got lost near a busy
aerodrome. It’s an example of why RPA operators
must take them seriously as aircraft.
Intruder in the circuit
Aviation in itself is not inherently dangerous. But to
an even greater degree than the sea, it is terribly
unforgiving of any carelessness, incapacity or
neglect. So said Captain Alfred Gilmer Lamplugh
in 1931, in one of the first attempts to understand
the risks of the air.* His words are just as resonant
today. They apply even in the almost complete
personal safety of operating an unmanned aircraft
from a ground station.
In July 2012, an RPA operator, preparing for
its unmanned aircraft system (UAS) operator’s
certificate application, managed to lose one of its
RPA. The RPA ended up in the hands of the Royal
Australian Air Force, which was alarmed to discover
that it had flown across the final approach path to
RAAF Edinburgh. There were training aircraft in the
circuit at the time.
The CASA investigator who handled the case takes
up the story: ‘this company was looking to get into
the UAS industry. The people involved had been
involved in aerial photography and decided to start a
new company, using RPA.
‘The organisation was looking to get a UAS
operator’s certificate and as part of this they decided
to do some trial flights. They went to an airfield at
Calvin Grove in northern Adelaide, where they had a
written agreement with the owner.
‘Unfortunately for them, Calvin Grove happens to
be right in the middle of the Edinburgh control zone.
That in itself is not necessarily a problem, but there
are requirements when you operate in control zones.
There is a regulation that says you can only operate
in control zones with the permission of the airfield
operator and with ATC clearance.
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
‘On this particular day they chose to conduct
their trials without notifying the tower. Their
intention was to fly the RPA only within 300
metres of the airfield and below 100 feet above
ground level (AGL). No one would have been
any the wiser, except that on this particular day
they lost control of the RPA. It was last seen
spiralling up above 400 feet. It got caught in the
prevailing winds and crossed the approach path
to RAAF Edinburgh’s runway 18.
‘As in the old saying, what goes up must come
down. On this occasion it landed in someone’s
backyard. It could have been worse. It could
have conflicted with an aircraft on final or in
the circuit area. There’s also the issue that it
could have come down on top of something, a
building, a car, or a person. This time it landed
in a backyard and no one was hurt.’
The resident called the Air Force, which was
initially alarmed to discover that an RPA
equipped with an autopilot, GPS receiver and
hi-resolution digital camera had been flying near
one of its bases. The potential for snooping, or
worse, was obvious. But when the operators
placed lost ads in a nearby shopping centre the
mystery was solved. Geometrical analysis of the
pictures taken by the camera showed the RPA
had reached a height of about 1100 feet above
ground level. At about the time it was reported
lost, a DA42 training aircraft was on an ILS final
approach to Edinburgh. It would have been at
about 155 feet, nearly 1000 feet lower than the
maximum recorded height of the RPA, but the
actual separation between the two aircraft could
not be determined. It was clearly too close for
comfort, and the prospect of about 5 kg of
RPA colliding with the windscreen, or one of
the engines, of a light twin aircraft flown at low
speed and altitude by a low-hours pilot was not
to be taken lightly.
The RPA operators, meanwhile, had enlisted
the help of the airfield owner to fly a grid search
in his aircraft. This was done with all proper
permissions and clearances. Indeed, the
RPA operators behaved honourably after the
35
incident, despite the prospect of administrative
penalties. The inspector found both the controller
and the company head ‘polite, cooperative and
willing to assist’.
The operator told the CASA investigator: ‘our
considered hypothesis is that the most likely
cause of the fly-away was internal electrical noise
causing the gimbal servos to chatter or move
at random. This would cause excessive current
demand from the BEC (battery eliminator circuit).
The BEC voltage would drop and could cause
the R/C (radio control) receiver to brown out’.
If power returned to normal after the R/C receiver
was out of range the RPA would have reverted
to fail safe mode, holding its control surface
positions but shutting off the motor, the operator
surmised.
The operator voluntarily made changes to their
RPA operation, the main one being to do their
testing at another property, near Murray Bridge,
far from city, suburbs, airports, or control zones.
The investigator says the story carries a strong
safety message for all aircraft operators, manned
or otherwise: safety starts before you take off.
‘When you operate a UAV you are flying an
aircraft – the fact that you might have bought
the airframe from a toy shop is neither here nor
there’, he says. ‘You are entering the aviation
industry and with that comes increased risk.
‘You are in aviation - the same business as
Qantas. You have to consider the risks and
dangers of injury to people on the ground, or
damage to property on the ground before your
aircraft leaves the ground.
‘You need to be aware of those risks and ensure
that not only do you comply with requirements
– which set the minimum safety standards –
but also need to try to minimise the possible
consequences of your operations.’
* Lamplugh, a pioneering pilot turned insurance underwriter, was
addressing the Royal Aeronautical Society on October 29 1931,
giving the first lecture it had ever heard about accident trends.
A report can be found in the online archive of Flight International.
www.flightglobal.com/pdfarchive/index.htm
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CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
The dawn of the black box
The dawn
of the
BLACK boX
Fifty years ago Australia became
the first country in the world
to mandate flight recorders on
commercial aircraft. It was a
bittersweet victory for the device’s
Australian inventor, David Warren,
as Macarthur Job writes.
Powerhouse Museum
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
1953
Australian scientist Dr David Warren
investigates the crash of a
de Havilland Comet in India
1954
David Warren publishes
A Device for Assisting
Investigation into Aircraft
Accidents report
37
1956
First prototype coupled with FDR/
CVR is designed (explicitly for
post-crash examination purposes)
by David Warren
Trans Australia Airline’s Fokker F-27
Friendship Abel Tasman, flew into the sea
on a beautiful moonlit night in June 1960,
while preparing for a final approach to
Mackay, Queensland. Its 25 passengers and
four crew were all killed, making it one of
Australia’s two worst fatal airline accidents.
The Mackay disaster was a savage blow for
TAA which, although government owned,
had established a reputation for esprit de
corps, innovation and high operational
standards. In its 14 years of operation it
had not even scratched a passenger, in
contrast to ANA which, in the same period,
had written off no fewer than five DC-3s (at
that time still a front line airliner), and killed
53 passengers. This abysmal record had
prompted a macabre industry joke, ‘prang
your way with ANA’, mocking the company’s
slogan, ‘Wing your way with ANA’.
The tragic blemish on proud TAA’s formerly
unstained record prompted not only a
major technical accident investigation by
the Department of Civil Aviation, but also a
public inquiry.
The Board of Accident Inquiry did not
convene until 4 October to allow it to have
the benefit of the Department’s investigation.
Under a senior judge, Mr Justice Spicer, the
inquiry sat for 16 days and heard from 95
witnesses. The council appearing for the
Department, Mr J.E. Starke, QC, told the
inquiry that, since 1953, the Department had
been working on an instrument to record
in-flight pilot conversations and readings of
all vital instruments that would be of great
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CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
The dawn of the black box
1957-58
David Warren builds a
prototype FDR called the
ARL Flight Memory Unit
1960
the ARL system becomes the
Red Egg, made by the British
firm of S. Davall & Sons
1960
Trans Australia Airline’s Fokker F-27
Friendship Abel Tasman crashes into
the sea, on final approach to Mackay,
Queensland, killing all 29 onboard
assistance in determining the cause of an aircraft accident. He said
the device had not yet been perfected, but that the Director-General,
Sir Donald Anderson, had told him that when it was, it would be fitted
to all aircraft.
This statement prompted Mr Justice Spicer, in his final summing up
on 8 December 1960, to comment: ‘it had proved impossible to
reach a firm conclusion on the cause of the accident because
there was no way of finding out what happened on the aircraft
in the last few minutes of its flight. It would have been helpful
to have a record of any conversation between the captain and
first officer during the period and of the readings of the flight
instruments up to the moment of impact’.
He recommended that as flight recorders were under development for
use in the investigation of accidents, the Department should continue
to pursue the matter with a view to installing such equipment in airline
aircraft ‘at no distant date’.
Mr Starke QC’s statement to the inquiry was incorrect. The flight
recording equipment referred to was being developed, not by the
Department of Civil Aviation, but by Dr David Warren of the then
Department of Supply’s Aeronautical Research Laboratories (ARL).
Warren’s expertise was in fuels research, and in this capacity he
had been a member of an expert panel examining reasons for the
mysterious in-flight explosions of three near-new de Havilland Comet
jet liners.
The Comets were of interest because of their possible future use by
British Commonwealth airlines on the Australia-UK air route. Warren
reasoned if the pilots had some warning of the impending disaster,
and there had been a record of their conversation, there was a good
chance it might have revealed what was happening to the aircraft.
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
1963
the black box becomes a
mandatory feature for all
airline aircraft
1965
the black box moves
from the landing wells
to the rear of the aircraft
1965
requirement for the black
box to be painted orange
or yellow for visibility
From boyhood, Warren had had a strong
interest in electronics. As a teenage pupil
at school, he built ‘crystal sets’, simple
unpowered radio receivers capable of picking
up the transmissions of nearby broadcasting
stations in sufficient strength to be listened to
with a pair of headphones, which he would
sell to fellow pupils for the princely sum of five
shillings, thereby considerably enhancing his
pocket money. (As a more junior boy at the
same school, I have a clear memory of David
Warren clamping a pair of headphones to my
young ears so I could listen to the music!).
Drawing on his considerable electronics
background, he set out, initially as a private
venture, to develop a small recorder that would not only record a crew’s conversation,
but also pertinent instrument readings. With the support of his superintendent at ARL,
Dr Lawrence Coombes, and an instrument engineer, he completed a prototype by
1958. Its recording medium was a continuous loop wire, making it as fireproof as
possible. It would record cockpit conversations and up to eight instrument readings
over the last four hours of any flight, before the wire recycled, automatically erasing the
older information.
Although the prototype was successfully flight tested with the cooperation of the
Department of Civil Aviation and ARL outlined the details of Warren’s development to all
sections of the Australian industry, no one seemed to show any interest.
Four years later, former Air Marshall Robert Hardingham, at that time secretary of
Britain’s Air Registration Board, was making an informal visit to ARL. Hardingham was
an old friend of Dr Coombes, who introduced Warren to him. When Warren explained
the flight recorder, Hardingham was highly impressed. He told Coombes, ‘Put this lad
and his gadget on the next courier flight to London!’
ARL again wrote to the Department of Civil
Aviation, referring to ARL’s report on the
recorder four years before, and offering to
make the prototype available for tests, pointing
out that its development had been slowed ‘by
lack of any official recognition’.
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CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
The dawn of the black box
1966
Ansett-ANA Viscount 800, VH-RMI
develops a fire in its No. 2 engine
en route from Mt Isa to Brisbane
1968
1999
High-capacity airline fatality
occurs in north-west Western
Australia, MacRobertson-Miller
Viscount 700 VH-RMQ
Time magazine describes
David Warren as ‘the most
neglected inventor’
The department’s reply remains difficult to
understand, to say the least. In a long letter,
analysing projected amendments to US
Civil Air Regulations, it pointed out that there
was no recorder adequate for their purposes
yet available, and that no aeroplane
certified for flight below 25,000 feet would
be required to install flight recorders. The
letter inexplicably concluded: ‘Dr Warren’s
instrument is intended for a fundamentally
different purpose ... and consequently has
little immediate direct use in civil aircraft.’
A response from the RAAF was even more
dismissive: ‘The recording would yield more
expletives than explanations ... loss of aircraft
is an accepted risk with predictable cost ...’
The powerful Australian Federation of Airline
Pilots was scathing. ‘Such a device is not
required ... it would be like having a spy in
the cockpit ... no crew would take off with
Big Brother listening.’
Meanwhile, in contrast, Warren’s month-long
visit to the UK generated much interest. The
UK-based EMI company offered to take over
the remaining development, provided they
were granted sole production rights. The
company planned to manufacture some of
the recorders at its Australian plant, but ARL
were later dismayed to receive a letter from
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
1999
2000
David Warren is awarded
the Australian Institute of
Energy’s medal
David Warren is awarded the
Hartnett Medal of the Royal
Society of the Arts
2001
David Warren is given the Royal
Aeronautical Society’s Lawrence
Hargrave Award
the company saying that their ‘financial experts could not agree that
the project was likely to be profitable’.
Months later, ARL’s efforts to create industry interest in their flight
recorder was given impetus when the Minister for Civil Aviation,
Senator Shane Paltridge, tabling the report into the F-27 Mackay
accident in Federal Parliament, announced that, from the beginning of
1963, airline aircraft would be required to be equipped with recorders
for both instrument data and cockpit conversations. The requirement
would apply to all turbine-powered aircraft with all-up weights of
12,500 pounds and above. The minister believed Australia was the
first country in the world to take this action.
ARL’s hoped-for renewed interest was hindered by the fact that no
commercial manufacturer appeared to be interested in developing a
production version of the flight recorder. The one exception was the
UK-based S. Davall & Sons, but it was awaiting details of what the
British Ministry of Aviation would specify for the installation of flight
recorders. In 1965, this led to the Davall Flight Deck Wire Recorder,
based on Warren’s original design, being ordered by British European
Airways, Aer Lingus, Alitalia and other European airlines.
The Department of Civil Aviation, though it had shown little interest
in ARL’s development apart from an encouraging letter from the
senior officer responsible for air safety investigation, agreed to assist
ARL with further flight testing. But it did not expect their flight recorder
could be in production by the required fitment date. ARL now realised
that for any commercial manufacturing they would have to look
to overseas.
With the required fitment date of 1 January 1963 looming, Australia’s
domestic airlines made the joint decision to order the flight recorders
being developed by United Data Control in the U.S.A. For ARL and
David Warren, it was a knockout blow.
By the beginning of 1963, the ordered U.S. flight recorders were
still not available, so the Department granted a two-year extension
because of ‘development and production difficulties’. Even so, after
the cockpit voice recorders arrived and were fitted, they were found to
be unacceptable because of tape jamming problems.
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CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
The dawn of the black box
2002
David Warren is officially
recognised in the Australia
Day Honours list
2008
2010
Qantas names one of its Airbus
A380s after him in honour of
his services to aviation
David Warren dies at
the age of 85
During August 1966, all the voice recorders were removed from
aircraft and returned to the U.S. for modification.
Thus, a month later, when an Ansett-ANA Viscount 800, VH-RMI,
developed a fire in its No. 2 engine while en route from Mt Isa to
Brisbane and broke up in flight while on emergency descent west
of Winton, its extensive wreckage trail yielded broken pieces of metal
flight data recording tape, but no cockpit voice recording.
The subsequent inquiry was also chaired by Mr Justice Spicer.
He again strongly emphasised the value of cockpit voice recorders,
saying that every effort should be made to obtain satisfactory
recorders. The Department later gave approval for the installation
of more recently developed U.S. Fairchild recorders as an alternative
to the United Data Control equipment.
The final airline fatality in the saga of Australian flight recorder history
(and indeed in the 40-year evolution of safe Australian airways
operations), occurred in north-west Western Australia on the last
day of 1968. Near the end of a scheduled flight from Perth to Port
Hedland, a MacRobertson-Miller Viscount 700, VH-RMQ, called flight
service, reporting it was commencing descent. A few minutes later it
called again to pass the usual 30-mile inbound report and advise it
had descended through 7000 feet. Nothing more was heard. Half an
hour later, a light aircraft reported burning wreckage 28nm south of
Port Hedland. The Viscount’s starboard wing had separated in flight.
There were no survivors.
For the first time, the investigation had the advantage of both flight
data and cockpit voice recordings, both yielding information right up
to the point of impact. The greater part of the flight was normal, with
the Viscount cruising in smooth air at 19,000 feet, and the wing had
failed without warning as the aircraft descended into the top of thermal
turbulence at just under 7000 feet. The moment of failure was clearly
distinguishable on the voice recording from the marked change in
wind noise as the wing failed and the aircraft began its fatal plunge
to the ground.
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
The failure was finally attributed to a fatigue
crack in the main spar, initiated some years
before by a steel bush, one of a number in
the spar carrying bolts for wing attachments,
being forced into its intended hole in the spar
when it was distorted, broaching metal
from the hole.
David Warren, described as
‘the most neglected inventor’,
was included under the
heading David Warren –
with an ingenious invention,
he helped make air travel
safer for millions of people.
Today, flight data and cockpit voice recorders
are essential equipment for all major airliners
throughout the world and have helped solve
many otherwise inexplicable accidents. But
until 1999, David Warren’s contribution to
its development remained almost unknown.
In October that year, Time magazine, to
mark the 40th anniversary of its Australian
publication, featured people who had been
the Pacific’s most outstanding contributors
of the century.
David Warren at last received recognition.
He was awarded the Australian Institute of
Energy’s medal for that year, and a year later
the Hartnett Medal of the Royal Society of
the Arts. A year later he was given the Royal
Aeronautical Society’s Lawrence Hargrave
Award for 2001.
In 2002, he was officially recognised in
the Australia Day Honours list, being
appointed an Officer in the General Division
of the Order of Australia for his ‘service to
the aviation industry, particularly through
the early conceptual work and prototype
development of the black box flight data
recorder’, and in November 2008, Qantas
named one of its new Airbus A380s after him
in honour of his services to aviation. David
Warren died in July 2010, at the age of 85.
43
AIRWORTHINESS
46 The rocky road to danger
48 Hot under the pump
52 Service difficulty reports
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CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
The rocky road to danger
The rocky
road to danger
A potentially catastrophic failure of a burner on a
common commercial hot air balloon is a reminder that
airworthiness vigilance is just as important for balloons
as it is for any other aircraft.
It’s an industry sector that carries over 150,000
fare-paying passengers every year – a number that
is growing fast. It uses type-certified aircraft, flown
by operators that are certified and audited like
airlines, and its fleet is maintained by qualified and
authorised technicians.
And its aircraft are powered using BBQ gas LPG in aerospace grade containers, of course.
Balloons are considered aircraft, no matter how
domestic their technology may first appear.
This means that managing the airworthiness of
balloons is a serious matter, and not merely ‘BBQ
maintenance’.
Australia has the tragic distinction of having the
worst ballooning accident in history: 13 people
lost their lives in 1989 when two hot air balloons
collided near Alice Springs. But, as in winged
aviation, while operational factors have historically
presented the greatest hazard, airworthinessrelated hazards lurk just beneath the surface.
One such hazard is the potential for cracking in
the load frames and burner assemblies. These
structures, often made from stainless steel,
connect the basket to the balloon envelope, and
also hold the burner cans in place. As with any
metal structure, they are susceptible to cracking.
CASA recently received a service difficulty report
(SDR) where cracking caused a burner to become
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
47
dislodged – thankfully, this happened when the
balloon was on the ground. Had it been in the air,
however, the story could have been tragic: burners
are heavy (about 12kg) and emit flames extending
for several metres. A burner held in place only
by its lightweight handlebar, could have easily
caused catastrophic damage to control cables,
the balloon envelope, and attachment wires and
fittings. In short, the balloon would have very likely
been lost, and with some balloons carrying up to
20 passengers, a simple crack in a burner frame
could have the potential for a tragedy.
After further investigation, it was found that the
particular balloon with the broken burner frame had
travelled many hundreds of kilometres – not in the
air, but via road transport, including hundreds of
kilometres over unsealed outback roads.
A preliminary analysis by the manufacturer
revealed that, in all likelihood, the extensive ground
handling loads had eventually shaken the structure
to the point of cracking. A major defect was now
just a matter of time.
This was not, however, the first time such a
failure had occurred. CASA received a report in
2007 of an almost identical failure which led to
Airworthiness Bulletin 14-001, advising operators
of Cameron Balloon Stratus double burner units
to inspect the gimbal assembly on their balloons.
Advice from the manufacturer indicated that
ground transportation loads were placing stresses
on the welds in these sections, and leading to
cracks and complete failures.
And these few instances have not been the only
reported cracking event on balloons, although
they represent more serious occurrences. More
than 20 instances of cracking of various kinds
and severity have been reported to CASA since
2007. Many cases are picked up as part of regular
maintenance inspections, but in some cases they
are found in-service.
Grant McHerron, Picture This Ballooning
One cracked weld was found only after the pilot
noticed the basket frame had a slight movement
in a section beneath its padding. This happened
after a flight.
Ground handling has been identified as the main
culprit by several manufacturers as the leading
cause of cracking. Such practices are mixed, and
cause mixed results: some practices focus on
gentle unloading at a launch site, others involve
‘dropping it off the side’ of a ute. Sometimes
burners and frames are completely dismantled
before transport (some manufacturers specify
this in their flight manuals); but often they’re
attached for the journey to and from a flight.
Leaving burners attached, can lead to cracks –
but alternatives, such as loading burners loose
in the back of a ute can cause more damage.
CASA has recently released AWB 14-002,
advising balloon owners and operators of the
importance of following manufacturer’s advice
concerning ground transportation. Operators
should also ask manufacturers to clarify any
instructions if required and, should a crack
be found at any time, report it to both the
manufacturer and as an SDR to CASA.
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CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Hot under the pump
Hot under the pump
Owners and operators of single-engine
retractable gear Cessnas need to be
aware of potential fire hazards in the
undercarriage system
Retractable gear Cessna singles have a dedicated
following of pilots who appreciate their extra speed,
accept the extra maintenance involved and enjoy the
flight management challenge of their extra complexity.
The retraction mechanism used in the 172RG, R182,
C210L, M, N, R and several other models is a clever
design that typically utilises the original fixed gear mainwheel leaf spring or tube gear legs.
Early models used an engine-driven hydraulic pump, but
most now have an electro-hydraulic system, which uses
hydraulic actuators driven by an electrically powered
pump. During retraction or extension, microswitches
on the gear doors and ‘up’ and ‘down’ locks control
switching the pump on and off.
Cessna elected not to reintroduce retractable singles
when it started production again in 1996, after a
10-year break, meaning that any single-engine Cessna
retractable is now at least 27 years old. That’s a lot of
gear cycles, and lot of time for problems to emerge as
systems deteriorate.
In September 2012, the U.S. Federal Aviation
Administration received a report of an in-flight fire in a
Cessna 172RG. ‘A fire started in flight on the cabin side
of the firewall and rapidly accelerated. The fire originated
from the area of the landing gear's hydraulic power pack
system and resulted in a complete hull loss, with injuries
reported,‘ the FAA said.
The FAA investigation found the landing gear hydraulic
power pack motor wiring was not properly protected or
adequately secured. It concluded that the in-flight fire
could have resulted from improper installation of the
terminal lugs, or improperly installed (or missing) terminal
covers and associated wiring.
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
The fire had been fuelled after starting, the FAA found. ‘Flammable
materials, or a flammable material source near or in contact with the
hydraulic power pack system within the aircraft's cockpit/cabin, had
caused the fire to accelerate’, it said.
The FAA came to a dry but unsettling conclusion: ‘This condition, if
not corrected, could result in a fire in the aircraft’s cockpit, damage
to and/or loss of aircraft, and injuries and/or fatalities’.
It noted that the same style of hydraulic power pack was also used
on Cessna models R182, TR182, FR182, 210N, T210N, 210R, T210R,
P210N, P210R, and the twin-engine T303 and C337G and H models.
The FAA is planning to issue an airworthiness directive, making it
compulsory for Cessna owners to comply with Cessna service letter
SEL-29-01.
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CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Hot under the pump
SEL-29-01 says: ‘Cessna has received a report of
electrical arcing at the positive terminal connection on
the hydraulic power pack motor for the landing gear’.
The problem is defined as an issue with the power pack
motor and the diode connected across the top of the
motor. Owners and operators would do well to follow
SEL-29-01 as soon as possible.
However, when CASA airworthiness engineers looked
at the history of single-engine Cessna retractable
undercarriage incidents in Australia, they found a bigger
and more worrying picture.
There were at least 42 malfunctions of electro-hydraulic
single-engine Cessna landing gear systems on the
service difficulty report (SDR) database. Most of these
could be directly related to allowing the motor to run on
and become hot. In 10 cases the SDR clearly stated that
the electric motor ran on due to a malfunction in one of
the undercarriage sequencing microswitches. In one of
these cases smoke had appeared in the cabin, indicating
that the electric motor had become very hot.
In another 29 cases the problem was reported as a failure
of the up/down gear lock or microswitch, which might
have caused the motor to run on. There were two cases
described as brush/armature problems within the motor,
and one reported incident where the hydraulic pump
was not able to create enough pressure in the hydraulic
system to turn the motor off.
‘Any time the pump motor stays on things tend to
overheat,’ says CASA senior engineer, maintenance,
Roger Alder. ‘It can run on after you extend the gear,
or when you retract the gear.’
‘If you lose any one of the controlling or sequencing
microswitches for the motor, the gear will go up or down
and reach the end of its travel, but the motor will keep on
running – and getting hotter.’
‘Normally, at least three conditions have to be satisfied,’
Alder says. ‘To turn the motor off when the cycle is
finished the gear has to be down or up and locked, all
the microswitches have to operate correctly, and
pressure has to build up in the hydraulic system and trip
an internal switch that stops the motor.
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
‘But if you should have a lock malfunction, lose a wire,
suffer damage to any of the microswitches, or have a wornout hydraulic pump which is not able to reach the required
pressure and finally switch the system off – it will keep
on running. If the pressure switch is punctured and won’t
compress it will keep on running. If the up or down locks or
micros don’t work, the pump will keep on running.’
‘The SDRs tell us that in many cases, in addition to the
microswitch either just failing or suffering damage, the
wiring to the microswitch failed due to fatigue of the
soldered joint and hardening of the protective wiring sleeves
where the wires are soldered to the switch – typical ageing
wiring problems,’ Alder says.
There were at least 42 malfunctions of
electro-hydraulic single-engine Cessna
landing gear systems on the service
difficulty report (SDR) database. Most of
these could be directly related to allowing
the motor to run on and become hot.
The later production single engine retractable gear
Cessnas have a subtle modification – an additional panel
light – that lets the pilot know whenever the motor is
running. If the light stays illuminated for more than a few
seconds after the gear has either extended or retracted
it indicates a problem and it’s time to take action. A gear
pump running light can also be installed into earlier model
aircraft in accordance with a supplementary type certificate
or CAR21M modification approval. This modification
has already been incorporated into many Australianregistered aircraft.
The Cessna single-engine retractable undercarriage
design was mainly intended for smooth, sealed runways,
not the harsh, rough outback strips of Australia. While
this fairly complex undercarriage design has survived
surprisingly well in this environment, these systems,
including wiring systems – need and deserve special care,
particularly considering how long they have been around.
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CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Service difficulty reports
27 September – 30 November 2012
Airbus A380-842 Air conditioning system smoke/
fumes. SDR 510015909
Note: Similar occurrence figures not included in this edition
Significant fumes and visible smoke on flight deck
AIRCRAFT ABOVE 5700kg
affecting crew. Investigation found no definitive cause.
Airbus A320-232 Air conditioning system odour.
Airbus A380-842 Flight control system power
SDR 510015983
supply failed. SDR 510015773
Strong ‘sweaty sock’ odour on flight deck and in cabin.
Flight control back-up power supply failed.
Investigation found no definitive cause for the smell.
Airbus A380-842 Galley oven odour.
Five similar defects.
SDR 510015935
Airbus A320-232 Galley oven contaminated.
Burning electrical smell from forward economy
SDR 510015709
galley ovens Nos. 1 and 3. Investigation continuing.
Rear galley oven contaminated with burnt food, oven
P/No: 4326001006600. One similar defect
seal damaged. One similar defect.
Airbus A380-842 Passenger seat fitting unlocked.
Airbus A320-232 Hydraulic pump low pressure.
SDR 510015975
SDR 510015632
Passenger seat 22EF forward RH attachment foot
Green hydraulic system low pressure. Suspect hydraulic unlocked. Investigation found clamp pad and clamp
pump faulty.
pad stud missing from cam assembly. P/No: 1005294127.
Four similar defects.
Airbus A320-232 Passenger oxygen system door
faulty. SDR 510015942
Airbus A380-842 Potable water tank leaking.
Passenger oxygen box doors located at rows 18RH
SDR 510015764
and 20LH failed to open during testing iaw JEOA320Forward LH potable water tank leaking from end cap.
23-0004 (1012).
Investigation continuing. P/No: 38000600.
Airbus A321-231 Cabin cooling valve odour.
Airbus A380-842 Service door panel missing.
SDR 510015842
SDR 510015692
Musty/humid/stale smell noticed during climb. Smell
Forward cargo control panel door 132BR missing.
reproduced on ground, but disappeared when trim air
P/No: L5327206201400.
valve switched off. P/No: 746A000006.
ATR 72212A Door access panel open.
Airbus A321-231 Galley coffee maker fumes/odour. SDR 510015804
SDR 510015812
Forward cargo door unlock light illuminated during flight.
Light burning smell reported. Isolated to coffee
Forward cargo door upper latch, blow out panel, control
brewers in aft galley. Coffee brewers found serviceable. panel and air conditioner service panel found to be
P/No: 425000111.
open on arrival.
Airbus A330-202 Elevator tab actuator leaking.
ATR 72212A Flight compartment windows window
SDR 510015833
cracked. SDR 510015897
Pitch trim actuator suspect faulty. Investigation continuing. Captain's No. 2 side window cracked in middle/inner ply.
P/No: 10212701000. TSN: 8985 hours. TSO: 8985 hours. P/No: NP1588621. TSN: 2646 hours/2599 cycles.
Airbus A330-203 Elevator skin damaged.
ATR 72212A Nose/tail landing gear suspect faulty.
SDR 510015903
SDR 510015629
RH elevator trailing edge filler missing from area
Nose landing gear leg suspect damaged/overstressed
approximately 76.2mm (30in) inboard of tip. Area
when aircraft pushed back with the brakes still applied.
of missing filler approximately 15.2mm (6in) long by
Towbar damaged and NLG leg removed for inspection.
25.4mm (1in) wide.
Investigation continuing. P/No: D226985006.
TSN: 1802 hours/1691 cycles/12 months.
Airbus A330-203 Empennage structure seal
missing. SDR 510016015
ATR 72212A Wheel brake fuse overheated.
Stabiliser LH upper apron fairing sideslip fairing seal
SDR 510015898
missing. P/No: F5508056023400.
Nos. 1 and 2 wheel fuses blown due to overheating.
Airbus A330-243 Emergency lighting unserviceable. P/No: C20586120.
SDR 510015891
ATR 72212A Window serviceable. SDR 510015834
Numerous defects and damage to emergency
Delamination of forward LH side cockpit window
lighting system. Numerous examples of damaged
noticed during flight. Delamination was within limits.
insulation found.
P/No: NP1588623. TSN: 2598 hours/2512 cycles.
Airbus A330-303 Horizontal stabiliser seal missing. BAC 146-100 Air data computer failed.
SDR 510015827
SDR 510015676
LH horizontal stabiliser upper slide lip seal missing.
No. 1 air data unit (ADU) unserviceable/
P/No: F5508056023400.
overcompensating. P/No: PND60151SN130838.
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
BAE 146-100A Windshield rain/ice removal system
wire short circuit. SDR 510015578
RH ‘A’ windshield arcing. Damaged wire at connection
‘E’ was shorting to the frame.
BAE 146-200A Windscreen delaminated.
SDR 510015740
Pilot and co-pilot ‘A’ windscreens suspect cracked.
Windscreens delaminated at the top edge, giving the
appearance of cracking. Delamination was within
limits; windscreens found to be serviceable.
BAE 146-200 Altimeter sticking. SDR 510015625
Newly fitted standby altimeter pointer sticking.
Replacement altimeter pointer also sticking.
P/No: WL1704AM1.
BAE 146200 Flight management control display
unit unserviceable. SDR 510015913
Flight management system (FMS) control display unit
(CDU) unserviceable on fitment.
P/No: 1842001010012SN1332.
BAE 146300 APU bleed air duct split.
SDR 510015809
Oil smell on flight deck when APU air selected on.
APU bleed air flex duct split. Duct replaced;
simultaneous APU and air conditioner runs produced
no odour. P/No: 4501690A.
TSN: 16,540 hours/18,476 cycles/125 months.
BAE 146-300 Hydraulic pipe leaking.
SDR 510015973
Loss of green hydraulic system fluid. RH main landing
gear actuator pipes leaking. Investigation continuing.
BAE 146-300 Landing gear position and warning
system suspect faulty. SDR 510015743
LH main landing gear failed to indicate locked up.
Investigation could find no definitive cause for the defect
and could not replicate the problem. LH uplock printed
circuit board replaced as a precaution.
BAE 146RJ100 Aircraft inspection required.
SDR 510015647
Aircraft had a rejected take-off from approximately
60 knots due to object on runway. Rejected take-off
inspection found no faults.
BAE 146RJ100 Windshield cracked. SDR 510015888
LH ‘B’ windshield outer pane cracked. No signs of
overheating or impact found. P/No: NP1701023.
TSN: 96 months.
Beech 1900C Wing panel land delaminated.
SDR 510016016
RH upper inboard wing panel bonded repair failed
and separated. Minor damage to RH fuselage side.
P/No: 1141200601.
53
Beech 1900D Wheel cracked. SDR 510015956
Nose wheel outboard half cracked from tie bolt hole.
Crack length approximately 4mm (0.157in). Found during
eddy current inspection. P/No: 114800121.
Beech 1900D Wing spar fitting hole worn/elongated.
SDR 510015795
LH and RH wing webs P/Nos: 118-120024-25 and
118-120024-27 had outboard flap actuator attachment
holes elongated (worn).
Beech 300 Aircraft data acquisition system
failed/faulty. SDR 510016005
Aircraft data acquisition system (ADAS) internal short
circuit. P/No: TWINA0102.
Beech 300C Main power pack suspect faulty.
SDR 510015778
Landing gear hydraulic power pack suspect faulty.
Power pack noticeably warm and circuit breaker tripped.
Investigation continuing.
Boeing 717-200 Air conditioning system unknown
odour. SDR 510015853
Electrical burning smell and smoke noticed after
windscreen anti-fog switched on, investigation continuing.
Boeing 717-200 Exterior lighting power supply
faulty. SDR 510015739
Upper strobe light beacon power supply failed. Burning
smell in cabin. Power supply removed and replaced,
operational test carried out with no further defects or
burning smells.
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CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Service difficulty reports
Boeing 717-200 Windscreen serviceable.
SDR 510015805
During the landing flare the aircraft struck a bat just
below the captain’s windscreen. Investigation found
the windscreen serviceable.
Boeing 717-200 Fuselage lightning strike.
SDR 510015776
Evidence of multiple lightning strikes under
forward fuselage.
Boeing 737-476 APU failed. SDR 510015785
APU auto shutdown in flight. Investigation found no
definitive cause for the failure.
Boeing 737-476 Drag control actuator sheared.
SDR 510015860
Ground spoiler actuator end sheared. P/No: 65485113.
TSN: 54,435 hours. TSO: 59,435 hours.
Boeing 737-476 Engine panel missing.
SDR 510015660
LH aft acoustic panel liner skin missing.
Evidence of bird strike.
Boeing 737-476 Galley oven smoke/fumes.
SDR 510015735
Smoke/fumes from aft galley oven. Broken wire at
temperature sensor lug and cut-off switch tripped.
P/No: GEMN2585015.
Boeing 7377FE AC inverter unserviceable.
SDR 510015747
Static inverter unserviceable. P/No: 100201022090.
TSN: 5,205 hours/2,271 cycles.
Boeing 73781D Air conditioning system odour.
SDR 510015966
Smell described as being like LP or camping gas in rows
16ABC and 17ABC – quite strong but of short duration
(10 minutes). Investigation found no definitive cause.
Boeing 737838 APU failed. SDR 510015923
APU failed and would not restart. Initial investigation also
found metal contamination of starter/generator oil filter
and APU magnetic plug. Investigation continuing.
P/No: 38007021. TSN: 18,367 hours. TSO: 386 hours.
Boeing 737838 Galley station equipment suspect.
SDR 510015901
Suspected unapproved materials used in manufacture
of various galley components. P/No: CDSP10271157.
Boeing 737838 Wheel bolt sheared. SDR 510015631
Main wheel tie bolts (2off) sheared.
Boeing 737838 Wing access panel leaking.
SDR 510015643
LH wing No.1 fuel tank access panel 532GB leaking.
Investigation found hairline cracking of anchor nuts
(2off). P/No: 112N61012.
Boeing 737838 Wing panel bracket missing.
SDR 510015741
LH wing trailing edge panel bracket missing from area
between inboard and outboard flaps.
Boeing 7378BK APU bleed air system clamp
broken. SDR 510015806
Left wing/body overheat light illuminated after
shutdown. APU pneumatic bleed duct 'V' clamp failed.
P/No: BACC10DU400ABE.
Boeing 7378FE Aileron centering unit dirty.
SDR 510015846
Aileron felt notchy passing through neutral position.
Grime and debris found on aileron feel and centering unit
roller and cam. Unit cleaned, tested serviceable.
Boeing 7378FE Air distribution system outlet
broken. SDR 510015746
Gasper air outlet broken and fouling on oxygen generator
release pin cable on top of passenger service unit (PSU).
P/No: 374011.
Boeing 7378FE Brake failed. SDR 510015787
LH inboard brake disintegrating. Wheel seized on brake.
P/No: 26123121. TSN: 7575 hours/4935 cycles.
TSO: 7575 hours/4935 cycles.
Boeing 7378FE Air cycle machine seized.
SDR 510015642
LH air cycle machine (ACM) impeller fan failed and
unit seized. Investigation continuing.
P/No: 22064002. TSN: 4424 hours/1719 cycles.
Boeing 7378FE Cabin cooling system sensor
unserviceable. SDR 510015856
Equipment cooling supply fan off light illuminated.
Supply flow sensor faulty. P/No: 0123FA2.
Boeing 7378FE Elevator tab spring broken.
SDR 510015751
RH elevator tab forward outboard spring broken.
P/No: 251A24391.
Boeing 7378FE Escape slide girt bar incorrectly
stowed. SDR 510015705
R1 emergency escape slide girt bar incorrectly stowed,
causing it to jam in stowage bracket.
Boeing 7378FE Fuel tank panel housing cracked
and leaking. SDR 510016008
RH wing tank access panel 632DB dome nut housing
cracked and leaking.
Boeing 7378FE Fuel cross-feed valve
unserviceable. SDR 510015704
Fuel cross-feed valve unserviceable, allowing fuel
imbalance. P/No: 125334D2.
TSN: 10,232 hours/8236 cycles.
Boeing 7378FE Hydraulic pump unserviceable.
SDR 510015665
Hydraulic system ‘A’ electrical hydraulic pump
unserviceable. Metal contamination of hydraulic system.
P/No: 5718610. TSN: 7828 hours/4434 cycles.
Boeing 7378FE Hydraulic pump seal unserviceable.
SDR 510015761
Electric hydraulic pump leaking from bleed cap.
Investigation found bleed cap packing unserviceable.
P/No: NAS16124.
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
Boeing 7378FE Passenger oxygen mask distorted.
SDR 510015749
Aft RH toilet oxygen mask kinked, possibly restricting
flow. P/No: 289801237.
Boeing 7378FE Pitot tube blocked. SDR 510015823
Captain’s airspeed indicator disagreed during take-off
and lagged during cruise. Pitot tube blocked by unknown
object. P/No: 0851HT1. TSN: 25 hours/12 cycles.
Boeing 7378FE Pneumatic sense line leaking.
SDR 510015847
Pressure regulating shut-off valve control sense line
leaking. P/No: 1613596.
Boeing 7378FE Pneumatic shut-off valve sticking.
SDR 510015919
Bleed air crossover manifold shut-off (isolation)
valve sticky in operation. P/No: 2760000101.
TSN: 10,405 hours/6352 cycles.
Boeing 7378FE Toilet water heater suspect faulty.
SDR 510015789
Acrid smell in cabin coming from under sink
compartment in R2 toilet. Investigation found water heater
inoperative. P/No: 24E507040G04.
Boeing 7378KG Passenger oxygen door failed
to deploy. SDR 510015666
Passenger oxygen mask door at row 13 ABC failed to
fully open during deployment. Door not seated correctly,
but opened normally when re-seated.
Boeing 7378Q8 Air intake anti-ice/de-ice system
connector loose. SDR 510015641
No. 1 engine anti-ice valve electrical connector loose,
with yellow inspection band visible.
Boeing 7378Q8 Flight management computer
suspect faulty. SDR 510015703
Flight management computer (FMC) had discrepancy
in fuel quantity indications. Program pin module M1991
switch in the ‘off’ position.
Boeing 747-438 Recirculation fan smoke/fumes.
SDR 510015958
Fumes on upper deck. Investigation found a faulty lower
recirculation fan. P/No: 732591F. TSN: 37,379 hours.
TSO: 18,300 hours.
Boeing 747-438 Air distribution pump suspect
faulty. SDR 510015653
Chiller boost pump suspect faulty. Chiller boost
fan not running and circuit breaker P8-415 tripped.
Investigation continuing.
Boeing 747-438 ATC transponder control panel
suspect faulty. SDR 510016012
Double transponder failure. suspect caused by faulty
control panel. Investigation continuing. P/No: G699011.
Boeing 747-438 Crew oxygen cylinder low quantity.
SDR 510015945
Loss of oxygen from two crew oxygen bottles.
Green discharge indicator missing. Investigation
continuing. P/No: B423651.
55
Boeing 747-438 Emergency lighting battery failed.
SDR 510015726
Emergency lighting battery smoking on trickle charge
bench. Connecting tag on cell No. 1 had shorted the
cell, causing a high-rate discharge inside the battery
pack. P/No: D71701100.
Boeing 747-438 Fuel dump system drive shaft
sheared. SDR 510015659
No. 2 fuel override/jettison system transfer valve
butterfly drive shaft sheared at edge of butterfly.
TSN: 94,268 hours. TSO: 94,268 hours.
Boeing 747-438 Landing gear retract/extension
system faulty. SDR 510015984
RH landing gear lever unable to be selected to ‘Up’.
Investigation continuing.
Boeing 747-438 Tyre separated. SDR 510015755
No. 3 main wheel tyre tread separated and tyre deflated.
Damage also found to several fairings aft of wheel well.
Investigation continuing. P/No: 161U00011.
TSO: 256 hours.
Boeing 767-336 Main landing gear truck nut loose.
SDR 510015912
LH main landing gear truck positioning actuator gland
nut lockwire broken and gland nut loose.
Boeing 767-338ER Aerodynamic fairing partially
separated. SDR 510015996
RH upper wing to body fairing (panel 192FR) partially
separated. Section approximately 203.7mm by 304.8mm
(8in by 12in) missing from fairing. Investigation continuing.
P/No: 110T3213188.
Boeing 767-338ER Air distribution fan terminal
block burnt. SDR 510015884
RH recirculation fan P37 terminal block TB5132 No. 6
terminal post badly burnt. Investigation continuing.
Boeing 767-338ER Flight compartment window
seal faulty. SDR 510015605
Cockpit window seal had missing sealant at aft upper
corner. Length of missing sealant approximately
76.2mm (3in). P/No: SF15141T4871.
Boeing 767-338ER Fuel storage access panel
leaking. SDR 510015871
LH wing fuel tank access panel leaking.
P/No: 112N61013.
Boeing 767-338ER HF communication system
receiver failed. SDR 510015961
Both HF receivers failed. Problem fixed by cycling
circuit breakers.
Boeing 767-338ER Hydraulic system O ring split.
SDR 510015885
Hydraulic delta P differential indicator O ring seal split and
leaking. Indicator located on LH engine-driven hydraulic
pump filter.
Boeing 767-338ER Nacelle/pylon access panel
missing. SDR 510015652
LH engine strut inboard access panel 436AR missing.
P/No: 311T106577.
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CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Service difficulty reports
Boeing 767338ER Static port contaminated.
SDR 510015622
Smooth areas around all three static ports contaminated
with what appears to be duct tape residue. Sticky residue
has attracted dust etc. causing the smooth area to
become raised and rough.
Boeing 767338ER Rudder control system faulty.
SDR 510015997
RH rudder ratio changer module faulty.
P/No: 285T0014104. TSO: 58,299 hours.
Bombardier BD7001A10 Emergency lighting torch
suspect faulty. SDR 510015695
Maglite torch became hot during use. Further use
and investigation could not duplicate the problem.
P/No: 106000355.
Bombardier DHC8102 Engine oil cooler split.
SDR 510015880
RH engine oil cooler split and leaking. P/No: 28E997.
Bombardier DHC8102 Engine oil temperature
gauge unserviceable. SDR 510015879
No. 1 engine oil temperature gauge unserviceable.
Bombardier DHC8314 Brake housing cracked.
SDR 510015748
Main landing gear brake housing contained numerous
cracks in five of six cylinder bores. Found during
fluorescent penetrant inspection.
P/No: 21517. TSN: 3858 hours. TSO: 661 hours.
Bombardier DHC8315 Air conditioning system
smoke/fumes. SDR 510015774
Transient oil fumes in cabin and cockpit. Investigation
found no definitive cause.
Bombardier DHC8315 Flight compartment
windshield cracked. SDR 510015852
Pilot windshield cracked after arcing observed on
descent. TSN: 6960 hours/1320 cycles/67 months.
Bombardier DHC8315 Hydraulic system union
cracked and leaking. SDR 510015756
Complete loss of fluid from No. 2 hydraulic system.
Hydraulic pressure manifold inlet union sheared.
P/No: AEB2151011. TSN: 915 hours/945 cycles.
TSO: 915 hours/945 cycles.
Bombadier CL6001A11 Fuselage floor beam
corroded. SDR 510015730
Floor beams corroded beyond limits. Investigation
also found numerous areas of corrosion in both LH
and RH wings.
Bombadier CL6002B16 APU contam-metal.
SDR 510015609
APU shut down unexpectedly. Initial investigation
found metal contamination of oil system. Investigation
continuing. P/No: 38008041. TSN: 3742 hours.
TSO: 3742 hours.
Cessna 750 Wing tank panel lands corroded.
SDR 510016002
Wing fuel tank panel lands corroded beyond limits.
Found during NDI inspection.
Embraer EMB120 Aileron control cable suspect
faulty. SDR 510015899
Aileron control cables suspect faulty. Incorrect data on
engineering order EO-1528.
Embraer EMB120 Autopilot computer faulty.
SDR 510015690
Yaw trim runaway with autopilot and yaw damper
engaged. Faulty autopilot computer and faulty rudder
servo. P/No: 6228315402.
Embraer EMB120 Trailing edge flap control unit
suspect faulty. SDR 510015607
Trailing edge flap control unit suspect faulty.
During landing, a flap overspeed condition occurred.
Investigation continuing. P/No: 3075001017.
Embraer EMB120 Wheel cracked. SDR 510015905
Main wheel outboard hub half cracked from bolt hole.
Crack length approximately 15mm (0.59in). Found during
eddy current inspection. P/No: 31544.
Embraer ERJ170100 Engine oil pressure transducer
failed. SDR 510015819
No.1 engine low oil pressure indication. Crew conducted
in-flight shutdown and air return. Investigation found the
oil pressure transducer had failed. P/No: 4120T16P01.
Embraer ERJ170100 Windshield shattered.
SDR 510015857
LH windscreen shattered after cycling windscreen
heater on/off. Signs of electrical arcing of the heater
element in a delaminated area of the windshield due
to moisture ingress. P/No: NP18730111.
TSN: 12,214 hours/9,527 landings/73 months.
Embraer ERJ170 Aileron control stiff.
SDR 510016001
Ailerons stiff to move and do not return to neutral when
released. Investigation continuing.
Embraer ERJ190100 Aileron control cable frayed.
SDR 510015950
Outboard aileron cables (3off4) P/Nos: 190-05549-401,
190-04212-401 and 190-05551-401 frayed, with broken
wires in area of rib 21 pulleys. Found during inspection
iaw SB190-57-0038. P/No: 19005549401.
Embraer ERJ190100 Aircycle machine smoke/
fumes. SDR 510015760
Smell/fumes from No. 2 Aircycle machine (ACM).
Investigation continuing.
Embraer ERJ190100 Central display unit failed.
SDR 510015906
No. 1 multi-function display (MFD) failed, associated
with a strong electrical smell. Investigation found
MFD 1 display unit 2 failed internally. P/No: 7037620813.
TSN: 11,251 hours/7815 cycles.
Embraer ERJ190100 Elevator tab actuator
contaminated. SDR 510015845
Horizontal trim actuator lubricated with two different
greases. Embraer advised to change actuator due
to unknown compatibility of the mixed greases.
P/No: 4162001003.
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
Embraer ERJ190100 Flight environment data probe
unserviceable. SDR 510015867
Captain's altitude indicator over-reading. Air data
smart probe replaced and system tested serviceable.
P/No: 2015G2H2H9. TSN: 4657 hours/3200 cycles.
Embraer ERJ190100 Fuselage floor seat track
corroded. SDR 510015887
Forward cabin floor structure RH seat track beam
corroded beyond limits. P/No: 17003263001.
Embraer ERJ190100 Galley oven smoke/fumes.
SDR 510016010
Smoke/fumes from rear galley oven.
Investigation continuing. P/No: 8201110000.
TSN: 27,299 Hours/16,109 Cycles.
Embraer ERJ190100 Galley water brewer odour.
SDR 510015821
Burning smell from galley. Water boiler found faulty.
P/No: 4360004850018. TSN: 691 hours/505 cycles.
Embraer ERJ190100 HF system connector loose.
SDR 510015937
No HF 1 and HF 2 operation. Investigation found HF
antenna loose at lower connection.
Embraer ERJ190100 Landing gear selector valve
connector loose and leaking. SDR 510015835
Hydraulic leak noticed on walk-around. Leak found to be
coming from undercarriage selector valve return line at
connection to check valve.
Embraer ERJ190100 Nose landing gear failed
to extend. SDR 510015732
Nose landing gear failed to extend normally.
Gear extended using alternate method.
Investigation continuing.
Embraer ERJ190100 Leading edge slat sensor
unserviceable. SDR 510015822
Flap position sensor found to be faulty. Sensor replaced
and tested satisfactory.
P/No: 5913840. TSN: 12,411 hours/8,714 cycles.
Embraer ERJ190100 Power lever quadrant stiff.
SDR 510015627
Throttle control quadrant levers stiff and notchy in
operation. P/No: 426000185.
TSN: 4505 hours/3241 cycles/3241 landings/19 months.
TSO: 4505 hours/ 3241 cycles/3241 landings/19 months.
Embraer ERJ190100 Stabiliser control unit
unserviceable. SDR 510015964
Pitch trim control problems. Horizontal stabiliser actuator
control electronics (HS-ACE) control unit faulty.
P/No: 4165001007. TSN: 11,868 hours/8387 cycles.
Embraer ERJ190100 Stabiliser actuator resolver
unserviceable. SDR 510015965
Horizontal stabiliser actuator resolver unserviceable.
P/No: RS14421.
Fokker F27MK50 Air-conditioning system odour.
SDR 510015613
Fuel smell in cabin. Investigation found no definitive
cause of the smell and it could not be replicated.
57
Fokker F27MK50 Brake antiskid control box faulty.
SDR 510015708
Landing gear anti-skid control box faulty.
Investigation also found wheel speed sensor connector
plugs corroded. P/No: 60041252
Fokker F27MK50 Brake rotor broken.
SDR 510015673
No. 2 main wheel brake unit had a broken rotor.
Investigation continuing. TSN: 3654 hours/2699 cycles.
TSO: 2662 hours/1922 cycles.
Fokker F27MK50 Passenger door jammed.
SDR 510015736
Passenger door jammed and unable to be opened
from inside aircraft. Door finally opened from outside.
Investigation could find no definitive reason for the fault
but it is suspected that FOD had jammed the door
mechanism, but had then been dislodged.
Fokker F27MK50 Passenger seat cracked.
SDR 510015750
Passenger seat central cross member cracked.
Found during inspection iaw AD/Seat/14 A2.
P/No: DM034371.
Fokker F27MK50 Prop/rotor anti-ice/de-ice
system failed. SDR 510015707
RH propeller anti-ice system failed.
Investigation continuing.
Fokker F28MK0100 Altitude controller servo
motor suspect faulty. SDR 510015654
No.1 elevator servo motor suspect faulty. Investigation
continuing. TSN: 100,367 hours/100,299 cycles.
TSO: 368 hours/300 cycles.
Fokker F28MK0100 Cargo door gas strut
unserviceable. SDR 510015696
Mid cargo door lock lever gas strut depressurised.
P/No: 192813.
Fokker F28MK0100 Emergency lighting circuit
board odour. SDR 510015830
Emergency light power supply unit circuit breaker found
burnt. Power supply unit and battery pack replaced.
Fokker F28MK0100 Fire warning system suspect
faulty. SDR 510015796
APU fire warning system activated. Extinguisher was not
fired. Investigation found APU fire extinguisher contents
low. Further investigation found no evidence of fire, heat
damage or fuel/oil leakage.
Fokker F28MK0100 Fuel tank leaking.
SDR 510015790
RH wing fuel tank leaking into fuselage dry bay.
Investigation continuing.
Fokker F28MK0100 Landing gear up-lock bracket
damaged. SDR 510015714
RH main landing gear door up-lock bracket damaged.
Fokker F28MK0100 Landing gear sequence valve
leaking. SDR 510015694
RH main landing gear sequence valve leaking.
Investigation found damage to the landing gear door and
main landing gear tyre due to contact with each other.
58
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Service difficulty reports
The sequence valve rod assembly was found to be bent.
Inboard seal retainer and door up-lock also damaged.
Fokker F28MK0100 Nose landing gear actuator
bolt sheared. SDR 510015865
Nose landing gear actuator attachment bracket bolt
found sheared with shims missing. P/No: NAS130419.
Fokker F28MK0100 Nose landing gear flange
cracked. SDR 510015820
Fokker F28MK0100 Trailing edge flap actuator
drive shaft failed. SDR 510015943
LH wing trailing edge inboard flap driveshaft failed at
inboard end P/No: A83022405.
Fokker F28MK0100 Trailing edge flap control
system faulty. SDR 510015971
Flap disagreement message after take-off. Aircraft
returned to base. Investigation continuing.
Fokker F28MK0100 Trailing edge flap control
system out of adjust. SDR 510015970
Flap disagreement warning after take-off. Investigation
found the flap system out of adjustment with the primary
and dog stops, with the radial variable differential
transducer (RVDT) also needing adjustment.
Fokker F28MK0100 Wheel cracked. SDR 510015840
During eddy current inspection a crack approximately
24mm (0.94in) long was detected on one of the outboard
hub flange bolt holes. P/No: 5011166. TSO: 304 landings.
Fokker F28MK0100 Wing fairing door disconnected.
SDR 510015753
RH flap fairing door disconnected at guide roller.
Found during inspection following hard landing.
Investigation continuing.
Fokker F28MK0100 Pressure outflow valve tube
cracked. SDR 510015815
Cabin would not pressurise. Sense line to the
primary outflow valve from the controller had cracked.
P/No: D73208433.
Lear 36 Nose landing gear servo unserviceable.
SDR 510015851
Nose wheel steering servo failed during ground handling
of aircraft. P/No: 80017104. TSN: 284 hours/145 cycles/
12 months. TSO: 3 hours/1 cycle.
Lear 45 Main landing gear SUP. SDR 510015757
LH and RH main landing gear P/Nos: 200-0200-011
and 200-0200-012 suspect unapproved parts (SUP).
A records search found that both landing gears had been
removed from a salvaged aircraft. P/No: 2000200011.
TSN: 2383 landings.
Lear 45 Pneumatic distribution system manifold
cracked. SDR 510015967
Bleed air manifold cracked at welded joints.
P/No: 12945054V6001.
Lear 45 Pneumatic distribution system manifold
cracked. SDR 510015968
Bleed air manifold cracked at welded joints.
P/No: 12945054037. TSN: 8293 hours/15,082 cycles.
Raytheon 850XP Landing gear position microswitch
suspect faulty. SDR 510015768
LH main landing gear down-lock microswitch suspect
faulty. During rigging following switch replacement it was
found that the bolt holding the serrated washer in the
adjustable link to the cam lever was loose and the lever
was able to move in the adjustment slot. Split pin was
installed but the nut was able to be tightened to the next
split pin hole. P/No: 9006EN42.
TSN: 2298 hours/1760 cycles/1760 landings.
Raytheon 850XP Starter-generator unserviceable.
SDR 510015807
Starter generator fan bearing distressed; starter gen
removed and replaced. P/No: 23080005.
TSN: 1459 hours. TSO: 614 hours/443 cycles.
Saab SF340B Aileron control system bearing
unserviceable. SDR 510015706
Aileron control stiff in operation. Investigation found
LH and RH inboard aileron bellcrank bearings dry.
P/No: MS2764116.
Saab SF340B Autopilot system bearing stiff.
SDR 510015894
Aileron controls stiff in operation. Bearings in the roll
disconnect unit had deteriorated due to age and lack
of use during an extended period of inactivity.
Saab SF340B Fire wire failed. SDR 510015895
RH bleed air leak indication. Fire wire internal insulation
breaking down between the inner and outer elements.
P/No: 51533378.
Saab SF340B Passenger compartment light
fitting overheated. SDR 510015948
Cabin light fitting above row 4A overheated.
P/No: 6500111.
AIRCRAFT Below 5700kg
Beech 200BEECH Fuselage stringer bracket
cracked. SDR 510015598
Stringer extension bracket cleats cracked on LH side
at stringers 9, 10 and 11. Found during inspection iaw
AVCON SB08-01. TSN: 2196 hours/2354 landings.
Beech 58 Elevator control system bearing
unserviceable. SDR 510015877
Elevator flutter under load. Suspect caused by
unserviceable LH centre elevator bearings. When
bearings changed no flutter occurred. Aircraft used for
aerial baiting involving high-G turns. P/No: M3276453A.
Beech 58 Main landing gear attachment bolt
sheared. SDR 510015868
Main landing gear brace and link assembly bolt found
sheared. P/No: NAS464533M.
Beech E55 DC alternator failed. SDR 510015734
Alternator failed internally. Failed parts entered
engine crankcase.
Cessna 152 Elevator tab trim chain FOD.
SDR 510015928
Elevator trim chain jammed by rivet tail limiting travel.
FOD. P/No: S2295P2569.
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
Cessna 152 Fuselage, stabiliser attachment fitting
cracked. SDR 510015910
LH vertical fin attachment fitting cracked through
radii from aft edge running forward. Crack length
approximately 30mm (1.18in). Found during inspection
iaw AD/Cessna150/31 Amdt 4 and confirmed using
dye penetrant inspection. P/No: 04310093.
TSN: 11,067 hours.
Cessna 172N AC voltage regulator failed.
SDR 510015872
Voltage regulator failed during ground run following
initial installation. P/No: VR515GA.
Cessna 172R Aileron control system nut cracked.
SDR 510015593
LH aileron bellcrank nut cracked. Nut had been replaced
only about 200 hours before, for the same reason.
P/No: MS21042L4. TSN: 200 hours.
Cessna 172R Static system valve FOD.
SDR 510015939
Alternate static air source valve port covered by part
number identification placard. Found during inspection
iaw AD/Cessna170/83. P/No: 201314218
Cessna 172S DC alternator failed. SDR 510015655
Alternator failed. Rotor open circuited. P/No: 991059111.
TSO: 1329 hours/22 months.
59
Cessna 210N Wing spar cap cracked.
SDR 510015596
RH wing lower spar cap cracked. Found during
inspection iaw SEL-57-01-R1. Crack confirmed using eddy
current inspection. P/No: 12212354. TSN: 17,280 hours.
Cessna 182Q Master cylinder bracket damaged.
SDR 510015990
Pilot's LH brake master cylinder mounting brackets
P/Nos: 0411550 and 0411549 damaged and deformed.
Suspect brackets manufactured from too light a material. Cessna 402B Trailing edge flap gearbox drive shaft
sheared. SDR 510015644
P/No: 51152413. TSN: 14,676 hours/27,193 cycles.
Cessna 402C Hydraulic line corroded and leaking.
SDR 510015934
Hydraulic suction line from reservoir corroded through
and leaking in area approximately mid-way between
forward bulkhead and the base of the pilot's seat.
P/No: 581710262.
Cessna 402C Indicating/recording system circuit
breaker failed. SDR 510015869
Pilot lost all avionics during flight. Circuit breaker switch
had mechanically failed. P/No: CM358950.
Cessna 182S Control column screw missing.
Cessna 404 LH main landing gear squat switch
SDR 510015883
Co-pilot control column attachment screw had fallen out unserviceable. SDR 510015991
P/No: 1CH16.
and was lying inside column. Movement not restricted.
Found during inspection iaw SEB-27-01.
Cessna 441 Landing gear failed to retract.
TSN: 3011 hours/143 months.
SDR 510015664
Cessna 210N Flight control terminals cracked and Nose landing gear drag brace over centre mechanism
adjusted and pneumatic check valve and filter replaced.
corroded. SDR 510015890
Retraction tests OK.
RH aileron cable in cockpit and RH rudder cable in aft
fuselage corroded and cracked in AN669 swaged fittings. Cessna 510 Elevator trim system seized.
Investigation of all other flight control cables continuing. SDR 510015587
Found during inspection iaw AWB 27-001 issue 3.
Trim eventually freed. Sealant on ground recognition
P/Nos: various. TSN: 729 hours.
light bubbled, allowing moisture ingress.
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CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Service difficulty reports
Cessna P210N Elevator trim tab cracked.
SDR 510015882
RH elevator trim tab cracked in area above horn.
P/No: 123466510. TSN: 7499 hours.
Cessna TU206CA1 Roof lining retaining rod loose.
SDR 510016004
Cabin roof lining retaining rod became loose due to age
of lining and short circuited on a wiring terminal on the
aft cabin door flap anti-extension microswitch causing
the flap retraction electrical system to short circuit.
TSN: 8389 hours.
Diamond DA42 Aileron control roller split.
SDR 510015658
RH aileron pushrod roller guide assembly roller (1off3)
split, causing excessive wear on aileron pushrod.
P/No: RG1128020. TSN: 2729 hours.
Diamond DA42 Landing gear door hinge cracked.
SDR 510015580
LH main landing gear forward door hinge cracked
along hinge line P/No: D6052877100. TSN: 657 hours.
12 similar defects.
Diamond DA42 Rudder pedal cracked.
SDR 510015926
LH rudder pedal cracked at weld attachment
to tube. P/No: 2227290100. TSN: 2607 hours.
Four similar defects.
Gippsland GA8 Fuel storage seal deteriorated.
SDR 510015672
Fuel leaking from aft fuel vent plenum under RH wing.
Vent line stand pipe seals brittle, cracked and leaking,
allowing fuel to seep into the plenum when the tanks
were full.
Gippsland GA8 Fuselage, stabiliser attachment
bracket corroded. SDR 510015670
Rear horizontal stabiliser attachment brackets
P/Nos: GA8538021233 and GA8538021234 had
intergranular corrosion.
Gippsland GA8 Horizontal stabiliser rib distorted.
SDR 510015667
Horizontal stabiliser LH second rib damaged/deformed.
Lower skin dented and oil canning. Suspect caused
by FOD. P/No: GA85510217113219.
Gippsland GA8 Trailing edge flap arm corroded.
SDR 510015668
Trailing edge flap and aileron drop arms had severe
intergranular corrosion around bonding strap attachments
and wing interface. P/No: GA8572011011013015.
Gippsland GA8 Rudder attachment fitting hinge
bracket worn. SDR 510015671
Rudder hinge brackets on vertical stabiliser severely
worn where hinge bolt penny washer contacts them.
P/No: GA8553021249255261.
Gippsland GA8 Wing plate corroded.
SDR 510015669
LH wing fuel tank drain plate had severe intergranular
corrosion. P/No: GA828205221.
Pacific Aerospace CT4B Rudder balance weight
broken. SDR 510015808
On pre-flight inspection, minor deformation found on
rudder tip. On further inspection, rudder balance weight
found detached. Rudder balance weight attachment
rib had failed. P/No: 07230631. TSN: 11,550 hours.
Partenavia P68B Fuel line corroded.
SDR 510015826
Rough running with erratic fuel indications. Small
corrosion holes in fuel cross feed line and white liquid
(water-based) contamination found. TSN: 6634 hours.
Partenavia P68B Wing spar corroded.
SDR 510015700
RH wing forward spar lower spar cap had light surface
corrosion and light exfoliation corrosion.
Piper PA28161 Wing structure cracked.
SDR 510016013
LH wing aft pressed bead cracked in two places at
WS 131.55. Crack lengths approximately 57.15mm (2.25in)
in forward radius of top beam and 25.4mm (1in) in aft
radius of bottom bead. P/No: 35118030.
Piper PA31350 DC circuit breaker loose connection.
SDR 510015731
Loose connection between boost pump circuit breaker
and bus bar caused high resistance and overheating.
P/No: 454656.
Piper PA31350 Landing gear door failed to close.
SDR 510015855
After selecting gear down, inner gear doors failed
to close.
Piper PA31350 Park brake valve unserviceable.
SDR 510015875
Failed control arm. P/No: 492152. TSN: 14,408 hours.
Piper PA31350 Rudder torque tube rusted.
SDR 510015977
Rudder torque tube assembly corroded/rusted beyond
limits. Suspect caused by inadequate surface protection.
Found during inspection iaw AD/PA-31/130.
P/No: 4004009.
Piper PA34200T Aileron hinge fitting corroded.
SDR 510015902
Aileron hinge fitting had minor surface corrosion.
Found following discovery of cracked paint during
inspection. P/No: 3721000. TSN: 10,948 hours.
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
61
Reims F406 Wheel bearing loose. SDR 510015824 Swearingen SA227DC Air intake anti-ice/de-ice
system B nut loose. SDR 510016009
Nose shimmy noticed during landing, right brake failed
after landing. RH main wheel bearing loose. P/No: 40169. LH engine fire warning system activated. Engine
feathered and fire extinguisher fired. Initial investigation
Socata TB20 Trinidad Electrical wiring loom worn
found no evidence of fire but lower fire detector had
and damaged. SDR 510015569
possible damage to the wiring. Inlet anti-ice valve outlet
LH and RH wing wiring looms running along aft spars
‘B’ nut finger tight and leaking hot air onto the upper
wearing on rivet tails. Outer sheathing worn through.
forward thermocouple.
Swearingen SA227DC Power lever cable loose.
SDR 510015862
LH power lever had excessive play. End fitting on power
lever loose. P/No: 3219012123.
Swearingen SA227DC Stall warning system stick
shaker suspect faulty. SDR 510015777
Stick shaker activated twice during take-off.
Investigation continuing.
Swearingen SA227DC Stall warning system suspect
faulty. SDR 510015624
Stick shaker activation for approximately five
seconds, followed by a LH SAS warning light.
Investigation continuing.
Swearingen SA226TC Fuselage cargo hold
Component
contaminated. SDR 510015878
Amplifier faulty. SDR 510015940
Cargo area contaminated and damaged by leakage of
undeclared dangerous goods. containing sulphuric acid. Autopilot actuator amplifier unit faulty. Intermittent loss
of both roll channels. P/No: 41800468800.
P/No: 2720039.
Cylinder leaking. SDR 510015574
Escape slide CO2 cylinder leaking. Suspect green
fitting attaching pressure head to cylinder defective.
P/No: D17862105. TSN: 50 months. TSO: 2 months.
Piston Engine
Continental IO360HB Reciprocating engine cylinder
separated. SDR 510015775
No. 1 cylinder head separated from barrel. Threaded
area pitted and eroded from the inside out. Borescope
inspection of other cylinders found No. 6 cylinder had
a small black sludge line in the head area.
P/No: 658189A1PO15. TSO: 292 hours.
Continental IO520B Magneto/distributor points
disintegrated. SDR 510015900
RH magneto points and bearing damaged.
Drive cushions and retainer also damaged.
Rubber contamination of oil filter. TSN: 836 hours.
Continental IO520C Engine fuel injector line worn.
SDR 510015994
LH engine No. 3 cylinder fuel injection line chafed.
Found during investigation iaw AD/Con/60.
P/No: 628152. TSN: 308 hours/21 months.
Continental IO520F Fuel distributor valve leaking.
SDR 510015979
Engine fuel manifold/distributor leaking due to ruptured
diaphragm. P/No: 63135115A27.
TSN: 377 hours/147 months. TSO: 377 hours/147 months.
62
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Service difficulty reports
Continental IO550C Reciprocating engine piston
failed. SDR 510015608
No. 2 cylinder piston damaged due to detonation.
Molten metal contamination of engine. P/No: 654857.
Continental IO550N Reciprocating engine low
oil pressure. SDR 510015992
Engine suffered a gradual loss of oil pressure, resulting
in engine failure. Ballistic parachute deployed.
Investigation continuing.
Continental TSIO520R Reciprocating engine
piston damaged. SDR 510015770
No.1 cylinder piston damaged by detonation.
Engine had been running lean of peak.
Continental TSIO520VB Reciprocating engine
exhaust valve burnt. SDR 510015716
RH engine No. 2 cylinder exhaust valve burnt.
TSN: 1886 hours. TSO: 1896 hours.
Lycoming HIO360G1A Reciprocating engine valve
worn. SDR 510015626
No.1 cylinder valve worn and not fully sealing on valve
seat. Suspect valve guide and seat out of alignment,
causing seating problem. P/No: LW19001.
TSN: 199 hours.
Lycoming IO360A1B6 Engine exhaust pipe
separated. SDR 510015908
Smoke coming from LH engine. Engine shut down.
Investigation found No. 1 cylinder forward exhaust
segment missing and No. 3 cylinder exhaust segment
separated from cylinder head. Heat damage to cowling
and components in the engine bay.
Lycoming (model unknown) Tappet body spalled.
SDR 510015987
Severe spalling on tappet bodies. Camshaft lobes worn
severely. P/No: 72877. TSN: 1292 hours.
Lycoming IO360A3B6 Reciprocating engine
camshaft worn and damaged. SDR 510015933
Metal contamination of engine oil filter. Valve travel for
Nos. 1 and 2 cylinder inlet valves less than for the other
valves. Both valves operated by the same cam lobe, so
it is suspected that this cam lobe is worn/damaged.
Found during inspection iaw AD/Eng/4 Amendment 11.
Three similar defects.
Lycoming IO360L2A Fuel control servo
contaminated. SDR 510015663
Engine fuel servo contaminated with green dye residue
in area behind venturi and air diaphragm.
P/No: 25765362. TSO: 170 hours.
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
Lycoming IO360L2A Magneto points
unserviceable. SDR 510016026
RH magneto contact points damaged. Suspect
rivet holding points had loosened and dislodged.
P/No: M3081.
Lycoming IO540AB1A5 Spark plug unserviceable.
SDR 510015848
Owner experienced engine stop on run-up to holding
bay. Previous intermittent engine 'miss' had been
experienced. Engineer determined dirty injectors at fault.
Injectors cleaned but this did not fix the fault. Owner did
his own research and believes miss due to faulty spark
plugs. P/No: REM38S.
Lycoming IO540AE1A5 Engine collector cracked.
SDR 510015600
LH exhaust collector cracked in area of attachment to
muffler. P/No: C16932. TSN: 881 hours.
Lycoming IO540K1A5 Engine fuel pump
unserviceable. SDR 510015675
Engine-driven fuel pump leaking from drain and joint
in pump housing. P/No: 201F5003. TSN: 750 hours.
Lycoming LO360A1G6 Reciprocating engine
cylinder cracked and leaking. SDR 510015818
No. 4 cylinder cracked and leaking at oil return to
crankcase. P/No: LW12427. TSN: 1102 hours.
Lycoming LTIO540J2BD Fuel control unit
unserviceable. SDR 510015918
Engine fuel control unit (FCU) unserviceable.
P/No: 25245009. TSO: 878 hours.
Lycoming LTIO540J2BD Reciprocating engine
valve lifter pitted. SDR 510015922
Metal found in engine oil filter. Strip investigation found
two cam followers (valve lifters) badly pitted on contact
faces P/No: 15B26064. TSN: 1292 hours.
Twelve similar defects.
63
Lycoming O235H2C Reciprocating engine piston
damaged. SDR 510015841
Pilot observed low power during flight. On inspection
low compression noticed on No. 3 cylinder. Cylinder
and piston also found to be damaged.
Lycoming O320B2C Magneto distributor separated.
SDR 510015814
Magneto distributor block bush found separated from
distributor block. P/No: 10357424.
TSN: 3356 hours/76 months. TSO: 1064 hours/35
months. Two similar defects.
Lycoming O320B2C Reciprocating engine
cylinder exhaust valve leaking. SDR 510015638
Nos. 2 and 3 cylinder exhaust valves not seating
correctly. Low compression on cylinders.
P/No: LW19001. TSO: 1881 hours.
Lycoming O320J2A Magneto bearing loose.
SDR 510015911
Magneto bearing loose and spinning in housing.
Magneto shaft also loose.
P/No: IO6006141. TSO: 59 hours.
Lycoming O360A4M Magneto points unserviceable.
SDR 510015616
Magneto points failed. SDRer Slick service bulletin
SB1-12. P/No: 43714370. TSN: 23 hours. TSO: 23 hours.
Lycoming O360F1A6 Magneto points unserviceable.
SDR 510015769
Magneto points unserviceable. Found during inspection
iaw Slick SB 1-12 and AWB 85-012. P/No: M3081.
TSN: 14 hours.
Lycoming O360J2A Reciprocating engine oil
system contaminated - metal. SDR 510015606
Metal contamination of engine oil filter. Fine particles
of non-ferrous copper-coloured material found.
Investigation continuing. P/No: 0360J2A. TSN: 221 hours.
Lycoming TIO540A2C Reciprocating engine tappet
body spalled. SDR 510015656
Engine tappet body face beginning to break up. No metal
contamination of oil system. Fault only found due to strip
and inspection following propeller strike. P/No: 15B26064.
TSN: 173 hours.
64
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Service difficulty reports
Packard Merlin V16507 Reciprocating engine
piston damaged. SDR 510015874
Engine inspected following rough running. B4 cylinder
piston ring land damaged with a piece missing and
impact damage to the piston, valves and cylinder head.
P/No: 616640. TSO: 35 hours.
Packard Merlin V16507 Reciprocating engine
piston ring worn and damaged. SDR 510015873
Engine pistons, piston rings and piston liners had
accelerated wear and scoring. Engine had only
completed approximately 2.2 hours of ground runs and
1.8 hours flying. Suspect caused by incompatibility of
piston rings with cylinder liners. TSO: 2 hours.
PWA R985AN14B Reciprocating engine rivet
sheared. SDR 510015772
Engine cam plate rivet sheared. P/No: 9317.
Propeller
Hamilton Standard 14SF7 Propeller blade cracked.
SDR 510015590
RH propeller blade cracked around leading edge
approximately 762mm (30in) from blade tip. Crack length
approximately 100mm (4in). P/No: SFA13M1R0AD.
TSN: 44 months. TSO: 3786 hours/2606 cycles.
Hartzell HCB4MP3C Propeller assembly incorrect
fluid. SDR 510016003
Aeroshell 5 grease used in propeller. Grease approved
by propeller manufacturer but not by aircraft
manufacturer. P/No: HCB4MP3C. One similar defect.
Hartzell HCC3YR2 Propeller blade loose.
SDR 510016014
Propeller blades abnormally loose in hub.
Investigation continuing. P/No: HCC3YR2UF.
TSO: 2225 hours/36 months.
Rotorcraft
Agusta Westland AW139 DC power distribution
panel unserviceable. SDR 510015802
Burning smell and caution light noticed by crew. K5
relay hot and discoloured, Removed and replaced power
distribution panel. P/No: 3G2430V00551.
TSN: 1973 hours/5367 landings/58 months.
Bell 206B3 Fuel storage system contaminated.
SDR 510015957
Aircraft SDRuelled using diesel fuel from drum stocks.
Approximately one tank of diesel used.
Bell 206B3 Hydraulic pump O ring worn.
SDR 510015717
Hydraulic pump output shaft O ring seal
P/No: M83248/1022 and lip seal P/No: CR4985 worn
and leaking. Loss of hydraulic fluid. TSO: 3475 hours.
Bell 412 Fuselage beam cap cracked.
SDR 510015634
RH fuselage lower beam cap cracked in area aft of
cross-tube tunnel. P/No: 205030161010.
Bell 412 Main rotor gearbox bearing spalled.
SDR 510015611
Main rotor transmission planetary gear assembly roller
bearing spalled. Roller bearing set had been replaced
45 hours previously. Metal contamination of transmission
P/No: 214040108005. TSN: 45 hours.
Bell 429 Rotorcraft tail boom bracket cracked.
SDR 510015727
LH lower tail rotor gearbox mount bracket cracked.
P/No: 429035704111.
Eurocopter AS332L Main rotor gearbox
contaminated-metal. SDR 510015792
Main rotor gearbox chip detector activated. Small
amount of scale on the detector. Ground run serviceable.
P/No: 332A32100703P. TSN: 2728 hours.
Eurocopter AS350B2 Main rotor head spring
broken. SDR 510015886
Main rotor hub vibration absorber spring broken.
Investigation found another spring cracked.
P/No: 704A33641004. TSN: 881 hours/732 cycles.
Eurocopter AS350B3 Tail rotor head bearing
unserviceable. SDR 510015697
Tail rotor laminated half bearings on pressure side
unserviceable. Found during inspection in accordance
with Eurocopter AS350 ASB No 01.00.65.
P/No: 704A33633261. TSN: 21 hours.
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
Eurocopter AS350BA Fire warning system
intermittent. SDR 510015850
Intermittent engine fire warning displayed in cockpit.
Investigation continuing.
Eurocopter AS350BA Tail rotor blade cracked.
SDR 510015630
Tail rotor spar cracked. Crack length approximately
150mm (5.9in). P/No: 355A12004008. TSN: 3412 hours.
Eurocopter AS365N Engine air intake cracked.
SDR 510015962
No. 2 engine air intake cracked at 5 o'clock
position. Crack length approximately 90mm (3.54in).
P/No: 365A54502201. TSN: 301 hours.
Eurocopter EC225LP Fuselage support structure
cracked. SDR 510015915
Transmission deck skin cracked adjacent to flexible
plate forward attachment point. Area part of primary
structure. TSN: 1744 hours.
65
Kawasaki BK117B2 Tail rotor bolt worn.
SDR 510015810
While replacing washers on pitch change link, one
bolt found stepped. No vibration had been reported.
P/No: 1053170211. TSN: 927 hours/37 months.
MDHC 369D Passenger compartment window
failed. SDR 510015610
LH rear window failed. Piece of window separated
and departed aircraft. P/No: 369450641NSN.
TSN: 1800 hours.
Robinson R22 Alpha Tail rotor control bearing
loose. SDR 510015639
Tail rotor pitch control shaft bellcrank bearing loose.
P/No: A0311. TSN: 1427 hours.
Robinson R22 Alpha Tail rotor gearbox
contaminated - metal. SDR 510015917
Metal contamination of tail rotor gearbox chip detector.
Suspect hard facing coming off bearing. P/No: A0211.
Robinson R22 Beta Engine/transmission clutch
assembly seized. SDR 510015781
P/No: A1882. TSN: 534 hours.
Robinson R22 Beta Main rotor control bearing
loose. SDR 510015784
Cyclic control system yoke bearing P/No A1035 loose in
yoke housing. TSN: 3475 hours.
Robinson R22 Beta Mixture control lever cracked.
SDR 510015604
Mixture control lever broken through cable attachment
hole. P/No: I55597. TSN: 1030 hours.
Robinson R22 Beta Tail rotor gearbox
contaminated-metal. SDR 510015765
Main rotor gearbox contaminated. Metal found on
chip detector. P/No: A0066. TSN: 1402 hours.
TSO: 1402 hours.
Robinson R44 Engine exhaust collector cracked.
SDR 510015600
LH exhaust collector cracked in area of attachment
to muffler. P/No: C16932. TSN: 881 hours.
Robinson R66 Engine exhaust brace broken.
SDR 510015881
Engine exhaust braces (2off) cracked and separated
at lower section. TSN: 499 Hours/794 Cycles.
Eurocopter EC225LP Landing gear warning
system circuit board faulty. SDR 510015793
Landing gear warning light. Faulty landing gear circuit
board. P/No: SEO2082. TSN: 3175 hours.
66
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Service difficulty reports
Schweizer 269C1 Tail rotor gearbox adapter
damaged. SDR 510015925
Tail rotor input adapter gear tooth chipped on non-drive
side of tooth. P/No: 269A6030005. TSN: 231 hours.
Sikorsky S76A Engine RPM indicating system
connector contaminated -water. SDR 510015594
Engine N1 sensor connector contaminated with
moisture. Aircraft and engine bay had been washed and
degreased recently.
Turbine Engines
Garrett TPE331 Turbine engine compressor
unserviceable. SDR 510015863
First stage of compressor found damaged beyond limits
after ingesting a bird.
GE CF3410E Turbine engine oil vent tube
distorted. SDR 510015591
No. 1 engine centre vent tube deformed at aft end
and collapsed at mid span. P/No: 3413201501.
GE CF348E5 FADEC unserviceable.
SDR 510015783
No. 1 engine full authority digital engine control
(FADEC) unserviceable. P/No: 4120T00P50.
TSN: 12,183 hours/9698 cycles.
GE CF680C2 Engine bleed air system suspect
faulty. SDR 510015602
RH engine bleed air overheat. Investigation continuing.
GE CF680E1 Turbine engine turbine seal
unserviceable. SDR 510015866
Linear indications found on rotating inter-stage seal.
Part will be replaced with serviceable item.
P/No: 1778M69P04. TSN: 35,471 hours.
TSO: 35,471 hours.
GE CF680E1 Turbine engine turbine damaged.
SDR 510015603
RH engine LPT fourth stage turbine and stators
damaged. Suspect caused by contact between stators
and turbine. Investigation continuing.03-Dec-12
GE CFM567B EEC suspect faulty. SDR 510015592
Master caution light during take-off. Engine electronic
engine control (EEC) and pitot systems inspected, but
no faults found.
GE CT79B Turbine engine stalled. SDR 510015646
LH engine compressor stall with rapid temperature
and torque fluctuations. Engine removed for
further investigation.
IAE V2527A5 Turbine engine bird strike.
SDR 510015989
Strong ‘oil’ smell in cockpit and cabin. Investigation of
No. 1 engine found metallic flakes on chip detector and
bird remains and traces of oil leakage on bleed valves.
Engine oil leak considered to be the source of the fumes.
Engine removed for further investigation.
Lycoming ALF502R5 Turbine section retaining
ring broken. SDR 510015577
No. 4 engine first stage HPT1 disc rotor retaining ring
broken into several pieces. Debris exited exhaust
causing damage to turbine stators and rotors, as well
as metal splatter. P/No: 2121180040507.
Lycoming ALF5071F Turbine engine high
temperature. SDR 510015752
No. 4 engine over-temped to 640 degrees C for
approximately 23 seconds. Engine removed for
inspection. P/No: 200304015. TSN: 33,488 hours/30,233
cycles. TSO: 521 hours/285 cycles/6 months.
Pratt & Whitney JT15D1 Turbine engine turbine
blade damaged. SDR 510015779
RH engine exhaust duct contained a significant quantity
of metal flakes. Borescope inspection found damage
to HP turbine blades, with sections missing from
some blades.
Pratt & Whitney PT6C67C Fuel control unit drive
shaft failed. SDR 510015612
No. 2 engine fuel management module driveshaft
sheared. TSN: 2097 hours.
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
Pratt & Whitney PT6T3B Turbine engine turbine
vane ring cracked. SDR 510015636
Compressor turbine vane ring cracked beyond limits.
Found during borescope inspection. P/No: 3027851.
Pratt & Whitney PT6T3B Turbine governor
unserviceable. SDR 510015813
Torque split noticed on approach. Turbine governor
found to be leaking oil. P/No: 25249995.
TSN: 5418 hours. TSO: 930 hours.
Pratt & Whitney PW125B Compressor bleed valve
unserviceable. SDR 510015744
RH engine handling bleed valve unserviceable.
Bleed valve remained open, then suddenly closed.
P/No: 01R311282501.
TSN: 28,423 hours. TSO: 6,478 hours.
Pratt & Whitney PW125B FCU unserviceable.
SDR 510015745
RH engine fuel control unit (MFCU) unserviceable.
P/No: 324485824. TSN: 28,938 hours. TSO: 13,532 hours.
Rolls-Royce BR700715A130 Turbine engine bird
strike. SDR 510015972
Bird strike on No. 2 engine during landing. Bird strike
inspection carried out but no damage found.
Rolls-Royce RB211524H Turbine engine sense
line broken. SDR 510015832
During take-off roll, 'right engine bleed off' displayed.
Take-off stopped at approximately 25kt. RH engine
sense line broken. P/No: UL30084.
67
Rolls-Royce Tay62015 Turbine engine compressor
blade cracked. SDR 510015601
LH and RH engine fan blades cracked. Three blades
on LH engine and two blades on RH engine affected.
Found during ultrasonic inspection iaw Alert Service
Bulletin TAY-72-A1775. P/Nos: Various.
TSN: 654 hours/524 cycles.
Rolls-Royce Tay65015 FFR unserviceable.
SDR 510015662
RH engine fuel flow regulator (FFR) unserviceable.
Rolls-Royce Trent97284 Engine odour.
SDR 510015849
Oil smell detected and remained in cockpit and cabin
until shut down.
Rolls Royce Trent97284 Turbine engine accessory
gearbox cracked and leaking. SDR 510015907
Engine accessory gearbox cracked and leaking in area
adjacent to fan case mount assembly. Crack length
approximately 6.35mm (0.25in). Crack confirmed by
NDT inspection. Investigation continuing.
Turbomeca Arriel 2B Turbine engine combustion
chamber swirl plate cracked. SDR 510015649
Engine combustion chamber swirl plate cracked.
Found during Mod Tu166 inspection iaw SBA 292 72.
P/No: 029237711002923779100292370380.
TSN: 2501 hours/2743 cycles/3394 landings/92 months.
Turbomeca Arrius 2F Turbine engine chip detector
faulty. SDR 510015595
Engine chip detector light illuminated. Investigation found
no metal on the detector, but the chip detector was faulty.
P/No: 9520011643. TSN: 1767 hours.
TO REPORT URGENT DEFECTS
CALL: 131
757
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/
REGULARS
70Quiz
80 One night over Toowoomba
82 Mountain madness
86 Up, down, round and
round – the haves and the wills
88ATSB
94Airservices
96Accidents
102Flight bytes
110Next issue
112Calendar
70
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Av quiz
FLYING OPS
1. An aircraft design consideration that avoids a sudden drag rise approaching
supersonic speeds, by ensuring that there are minimal changes in crosssectional area distribution from fore to aft, is called the:
a)
b)
c)
d)
area rule.
critical mach rule.
four times rule.
Sears-Haack rule.
2. A sudden and significant form of drag produced when an aircraft approaches
the critical mach number is termed:
a)
b)
c)
d)
wave drag.
form drag.
induced drag.
profile drag.
3. Along a taxiway, the edge lighting is coloured:
a)green.
b)white.
c) white unless there is centreline lighting, and blue if there is not.
d) blue, and the centre line lighting is omnidirectional green.
4. One US gallon of avgas is equivalent to approximately:
a)
b)
c)
d)
4.5 litres, and weighs approximately 3.2 kilos.
3.7 litres, and weighs approximately 2.7 kilos.
1.2 imp. gallons, and weighs approximately 3.2 kilos.
0.75 imp. gallons, and weighs approximately 7.5 kilos.
5. Carburettor icing:
a)
b)
c)
d)
is more likely at higher power settings.
is most likely at ambient temperatures around -4ºC.
can occur at ambient temperatures up to 38ºC.
will not occur at ambient temperatures above 20ºC.
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
6. Dew point depression is the difference between:
a)
b)
c)
d)
the wet and dry bulb temperatures, and fog is more likely as the difference increases.
ambient temperature and dew point, and fog is more likely as the difference increases.
the wet and dry bulb temperatures, and fog is more likely as the difference decreases.
ambient temperature and dew point, and fog is more likely as the difference decreases.
7. The password for the new NAIPS must contain at least:
a)
b)
c)
d)
seven (7) alphanumeric characters, and must be changed every six (6) months.
seven (7) alphanumeric characters, and is valid indefinitely.
six (6) alphanumeric characters, and must be changed every six (6) months.
six (6) alphanumeric characters, and is valid indefinitely.
8.When submitting a flight plan via NAIPS the estimated time of departure is
now designated:
a)ETD, followed by HHMM UTC.
b)ETD, followed by DDHHMM UTC – if more than 120 hours ahead.
c)EOBT (Estimated off blocks time).
d)EDT (Estimated departure time).
9.When requesting a NAIPS restricted area briefing, information on all restricted
areas in a forecast area is obtained by entering:
a)
b)
c)
d)
only the forecast area number.
the forecast area number followed by 00.
the forecast area number preceded by 00.
0, then the forecast area number followed by 0.
10.When ordering a specific pre-flight information bulletin (SPFIB) via
NAIPS, unnecessary information is reduced by specifying a height band.
Selecting ‘low’ limits the information to:
a)
b)
c)
d)
below 10,000 ft.
10,000 ft and below.
below 11,500 ft.
11,500 ft and below.
Correction
As a sharp-eyed reader observed, there was an error in the answers to the Nov-Dec
issue #89 Flying Ops quiz. The correct answer to question 7 on pg. 67 is (b).
Flying ops answers
1(a) 2(a) 3(d) AIP AD 1.1.4.10 4(b) 5(c) 6(d) 7(a) 8(c) NAIPS manual page 74 9(a) NAIPS manual page 33 10(a) NAIPS manual page 44
71
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CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Av quiz
MAINTENANCE
1. On a V belt and pulley drive system such as may be seen on some
helicopters, the actual drive occurs because of friction between the:
a)
b)
c)
d)
bottom of the belt and the base of the pulley groove due to belt tension.
bottom of the belt and the base of the pulley groove due to wedging action.
sides of the belt and the pulley groove due to the wedging action.
sides of the belt and pulley groove due to wrap angle.
2. Stress corrosion of stainless steel as in SAE - AISI 303 Se, used in control
cable fittings, is causing control failures here and overseas and
is a serious concern. Stress corrosion:
a) cannot be readily detected visually and a 15-year retirement life for such cables
is recommended.
b) cannot be readily detected visually and a 20-year retirement life for such cables
is recommended.
c) starts at the surface and progresses inwards, so can be readily detected under
strong magnification.
d) can only be detected by magnetic particle inspection.
3. An unintended consequence of the use of corrosion inhibiting
compounds (CICs) on structural joints can be a loss of:
a) shear strength in the rivets.
b) tensile strength in the rivets.
c) tensile strength in a lap joint due to reduced friction between the
overlapping sheets.
d) shear strength in the rivets of lap joints due to reduced friction between
overlapping sheets.
4. An underwater locator device (ULD or ULB), as fitted to a flight or voice
recorder, is actuated by:
a) electrical conductivity when immersed, and may therefore be accidently actuated
by debris on the contact area.
b) electrical conductivity when immersed, and cannot be accidently actuated if dry.
c)G forces, and therefore may be accidently actuated by bumping.
d) water pressure, and is therefore immune to accidental operation.
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
73
5. The signal from an underwater locator device (ULD):
a) is above the human audible range and cannot be detected with anything other
than specialised display equipment.
b) is above the human audible range but, as a rough check, can be heard when
beaten against a high-frequency sound such as rattling a bunch of keys.
c) is in the VHF band and can be detected by a normal aircraft radio.
d) is in the UHF band and can be detected by satellite.
6. An electrical resistor colour-coded brown, black, red, silver has a
resistance value of:
a)
b)
c)
d)
10 K ohm or 10,000Ω with a tolerance of 5 per cent.
10 K ohm or 10,000Ω with a tolerance of 10 per cent.
1 K ohm or 1,000Ω with a tolerance of 5 per cent.
1 K ohm or 1,000Ω with a tolerance of 10 per cent.
7. Chlorine-based packing materials used with stainless steel or titaniumbased components:
a) are the preferred materials for salt haze environments.
b) must be renewed at specified intervals.
c) may leave a residue that promotes stress corrosion, particularly at elevated
temperatures.
d) do not present any risk.
ULBeacon | Wikimedia
74
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Av quiz
8. A fluid line identified by a blue stripe bordered by a rectangle curved on
two sides relates to:
a)coolant.
b) fire protection.
c)de-icing.
d) instrument air.
9. ATA Chapter 35-10 refers to:
a)
b)
c)
d)
passenger oxygen.
crew oxygen.
crew lights.
passenger lights.
10.A standard hardware part number of MS20257 refers to a:
a)
b)
c)
d)
continuous hinge.
cable fork end.
cable stud end.
cable pin eye end.
Boeing 787, Brisbane | © Lee Gatland
Maintenance answers
1(c) power is transmitted via the sides of the belt 2(a) AWB 27-001, which has recently been revised 3(c) AWB 02-042 4(a) CAAP 42L-8(0)
5(b) 6(d) 7(c) AWB 14-003 8(a) 9(b) 10(a)
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
75
IFR OPERATIONS
Command instrument rating renewal – some more sample questions
These questions continue from those in the previous issue on completing a flight test
report form.
Questions 1 to 3 refer to the Brisbane (YBBN) ILS or LOC RWY 01 approach plate
(Dated 23.8.12).
1.Which of the following is a true statement concerning the visibility for
landing ‘straight in’ from the ILS?
a) It is the category I visibility available to all aircraft, providing HIAL and HIRL
are operative.
b) It is the category I visibility available for aircraft that are flown to DA using a flight
director or a coupled (LOC and GPS) autopilot.
These aircraft must also have serviceable failure warning systems for the primary AI and
heading reference indicator. The HIAL and HIRL must be operative.
c) It is the visibility for landing if the aircraft is not equipped with flight director or coupled
autopilot and failure warning flags for the primary AI and heading reference indicator.
d) It is the category II visibility only available to approved operators. All other operations
must use 1.2 km (with HIAL and HIRL operative) or 1.5 km if HIAL is not available.
2.Which of the following is a true statement concerning the ILS ‘straight in’
landing minima of 220 ft?
a) It is the minimum decision altitude (MDA), so an altimeter pressure error correction
(PEC) for the aircraft type or the standard 50 ft must be applied.
b) It is the minimum descent altitude and as such, no PEC is required.
c) It is the decision altitude (DA). An altimeter pressure error correction (PEC)
for the aircraft type, or the standard 50 ft, must be applied.
d) It is the descent altitude (DA). Since it is a precision approach, the PEC will
be required.
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CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Av quiz
3.What is the significance of the double asterisks against the alternate minima
(on Airservices plates) or ‘for filing as alternate’ on the aerodrome details
page (Jeppesen)?
a)The lower alternate minima is available for aircraft equipped with duplicated
ILS/VOR/Marker Beacon Receivers/ADF. Note that DME can replace one set of
marker beacons.
b)The lower alternate minima is only available to those aircraft capable of category I ILS.
c)The lower alternate minima is only available if the aerodrome has a forecast service
and ATC is in operation
d) Both a) and c) are correct.
4. You are inbound to Mildura (YMIA) along W293 from PROST. You copy the
AWIS, part of which reads ‘…wind 270/30, QNH 1005… cloud broken 500 ft,
visibility 3000 m…’
Your aircraft is equipped with ADF/VOR/DME and approach-approved GNSS. You are
endorsed and current on all NAV AID approaches.
Which of the following would be the most appropriate IMC procedure to establish cloud break?
a) Positive fix within 25 nm MSA, then descent to 2000 tracking to MIAEC for the RNAV
RWY 27 approach.
b) Continue tracking PROST to MIA for the DME or GPS arrival.
c) Positive fix within 25 nm MSA, then descend to 2000 tracking to join the 10 DME ARC
for the VOR RWY 27.
d) Continue tracking PROST to MIA, descending to LSALT of 2000 and from overhead
MIA VOR, conduct Sector 2 entry for the VOR RWY 27.
5. Your aircraft is tracking along W306 from Yarrowee (YWE) inbound to
Warracknabeal (WKB) on descent passing 6000 when you establish VMC.
Your ETA for YWKB is 0400Z with your GPS (TSO approved) showing 25 nm
WKB. Which of the following is correct concerning further descent?
a)You must maintain LSALT of 4700 until within the circling area for your category aircraft.
b) With a positive fix by GPS within 10 nm descend to MSA of 1700 and maintain until the
circling area for your category aircraft.
c) Visual descent is now possible maintaining VMC at height compatible to VFR to the
circuit area for YWKB.
d) Descend to 2100 as per the GPS arrival and then, after passing 7 GPS, descend to
1000 (no actual QNH) before circuit join within the circling area.
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
77
6. If the aircraft in question 5 above has an ETA YWKB of 1200Z, how will
this affect the descent procedure?
a)You must maintain LSALT OF 4700 until within the circling area for your
category aircraft.
b) With a positive fix by GPS within 10 nm descend to MSA of 1700 and maintain
until the circling area for your category aircraft.
c) Visual descent is now possible maintaining VMC at height compatible to VFR to
the circuit area for YWKB.
d) Descend to 2100 as per the GPS arrival and then, after passing 7 GPS, descend
to 1000 (no actual QNH) before circuit join within the circling area.
e) Both b) and d) are correct.
7. You are inbound to Hamilton (YHML) along W584 from Mildura (YMIA) in a
category B aircraft … with ETA YHML of 1245Z. The AWIS wind is 180/15.
You have been descending in accordance with the RNAV RWY 17 when
cloud break occurs at ‘HMLNF’ at 2500 ft. The runway lighting system
is clearly visible ahead. Which of the following is correct concerning
further descent?
a)You must continue descent only in accordance with the RNAV RWY 17 to the
landing minima.
b)You may continue a visual descent from 5 nm utilising the T-VASIS.
c)You must continue the RNAV RWY 17 procedure to within the circling area for
your category aircraft.
d)You may continue a visual descent utilising the T-VASIS, but only having established
the aircraft within the circling area.
Mildura airport| Wikipedia
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CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Av quiz
8. From what distance is it permissible to conduct a night visual approach to
RWY 18 at Avalon (YMAV) when tracking inbound via TEMPL (assume ATC
has given approach clearance).
a)
b)
c)
d)
5 nm only on the PAPI.
7 nm on the VASIS if utilising the ILS for back-up guidance.
10 nm utilising the ILS for guidance.
14 nm utilising the ILS for guidance.
9. You are on the final approach of the Moorabbin (YMMB) NDB-A approach at
5 nm GPS when you establish visual reference at the MDA of 620 ft (known
QNH). It is nighttime and you estimate the visibility at 3000 m. Your aircraft is
category B. When can you initiate further descent to set up for the landing?
a) Once within the circling area of 2.66 nm arcs off the runways joined by tangents.
b)Now, since you have in excess of the circling visibility, providing the approach end of the
runway is in sight.
c)Must maintain the MDA until ‘normal profile’ for the descent for landing, typically in this
case late base to final.
d) Within the final circling area, whilst maintaining the circling visibility and with the
approach end of the runway in sight. Also, descent initiated to achieve ‘normal profile’
i.e. late base to final in this case.
10.You have a comm. failure in IMC on departure, having been issued with (and
acknowledged) a radar vector and altitude restriction. You are not tracking
via a SID and you ascertain there are no terrain considerations at this time.
What are the time considerations for the vector and altitude before taking
further action?
a) Radar vector and altitude restriction for two minutes, then in accordance with flight
plan (if no ATC instructions received via voice NAV aids).
b) Radar vector for two minutes, altitude restriction for three minutes, then in accordance
with flight plan (if no ATC instructions received via voice NAV aids).
c) Proceed as per the flight plan immediately (if no ATC instructions received via voice
NAV aids).
d) Radar vector and altitude restriction for three minutes, then in accordance with flight
plan (if no ATC instructions received via voice NAV aids).
IFR answers
1(b) AIP ENR 1.5 – 31 PARA 4.7.3 b. A common misconception here is that the aircraft must have two such systems to qualify, as with special
ALTN minima. 2(c) AIP GEN 2.2 – 7 Definition AIP ENR 1.5 – 13 PARA 1.18.2 3(d) AIP ENR 1.5 – 34 PARA 6.2 4(a) YMIA approach plates.
Based on the AWIS, the RWY 27 RNAV is more likely to provide cloud break. 5(c) ETA 0400Z + 1000 (or 1100) = 1400 EST (1500ESST) thus by
day. AIP ENR 1.5 – 11 PARA 1.14 a. 6(e) ETA 1200Z + 1000 (or 1100) = 2200 EST (2300ESST) thus by night. AIP 1.5 – 12 PARA 1.14 b.
The GPS arrival can provide a more efficient enroute descent procedure in visual conditions as well as IMC. 7(b) ETA 1245Z + 1000 (or 1100)
= 2245 EST (2345 ESST) thus by night. AIP ENR 1.5 – 12 PARA .14b (5) 8(c) AIP ENR 1.5 – 12 PARA 1.14b (6) Note: Avalon RWY 18 has PAPI,
not VASIS. 9(d) AIP ENR 1.5 – 3 PARA 1.7.6 10(b) ERSA EMERG – 3. A good way to remember the times is to picture the letter ‘V’ for
Vector – 2 ‘strokes’, 2 minutes, and the letter ‘A’ for Altitude – 3 ‘strokes’, 3 minutes.
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
79
TOOL MANAGEMENT AND SAFETY
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track of its inventory by user, and
records which tools are removed
and replaced, and when.
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Web: www.snapontools.com.au/industrial Phone: 1800 811 480
80
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
One night over Toowoomba
One night over
Toowoomba
Name withheld by request
In the mid-1980s, relatively
early in my career, I was
employed as a bank freight
pilot, flying a Piper Seneca.
Eight sectors a day, three days
a week, had afforded me a
high degree of familiarity and
comfort with the aircraft and its
operation. As I began another
routine day, I had no idea how
that very adroitness would
almost lead to disaster.
After fuelling the Seneca and
giving it a quick pre-flight, I ran
the two Continental engines
to warm them in readiness
for a quick departure. While
supervising the loading of the
bank bags and some small
parcels, as well as a few
bundles of newspapers for the
country towns, I completed
the manual load sheet. By
6am I was taxiing for runway
04. Remaining on schedule
was of great importance
to the company, and after
completing engine run-ups
and magneto testing on the
run, Brisbane Tower cleared
me for take-off into a beautiful
spring morning.
Although filed under IFR, the
weather remained VMC for
the whole trip and, after four
uneventful sectors, I arrived in
Charleville at 9am. My routine
here always included a visit
to the flight service office for
a chat with the staff, and to
deliver them a copy of the
day's newspaper.
After lunch, and feeling well
rested, I was back in the flight
service office by 3pm to file
the plans for my return to
Brisbane.
South-east Queensland
remained fine and warm, and
after refuelling and loading,
I was on my way home. The
return routing was slightly
different from the morning.
First stop was Roma, before
making pick-ups in Dalby and
then Toowoomba.
The sun was just setting as
I completed the last of the
day's sixteen engine starts
and, slightly behind schedule,
quickly taxied the Seneca for
departure from runway 29.
Toowoomba sits on the edge
of the Great Dividing Range at
an elevation of just over 2000
feet, and with the outside air
temperature still at almost 25
degrees, the density altitude
was close to 3800 feet. With
the aeroplane full of freight,
the Seneca wasn't far off its
performance limit for the 1100
metre runway.
The Seneca’s landing lights
are mounted on the nose
gear and would normally be
switched off automatically
by a micro-switch on gear
retraction. On this particular
aircraft, however, that switch
was unserviceable, so lights
off had to be manually
selected as soon as the gear
was up, to avoid overheating
the lights’ filaments once
they were retracted from the
cooling airflow. I had just
completed that procedure
when, at a little over 200 feet,
the left engine abruptly failed.
After a brief pause generated
by the startle effect, my
training kicked in. A bootful of
right rudder kept the aircraft
straight and wings level. I did
my best to maintain the blue
line on the AS I. Mixture up,
pitch up, power up...gear up,
flap up. It was all just like my
instrument rating renewals,
albeit without someone sitting
beside me closing a throttle
lever. Dead leg, dead engine...
confirm and feather.
The Seneca struggled into the
night sky at little over 200 feet
per minute, and as I checked
clear left before starting the
turn for my return circuit, the
sight of the feathered propeller
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
81
To say I was preoccupied
during my homeward leg by
the stupidity of my actions
would be an understatement.
It would be many years before
I would be able to discuss this
self-inflicted incident with any
of my peers.
On closer reflection, I suppose
that the design of the electrical
panel played some role in my
error. The magneto and light
switches on the Seneca are
identical in size, shape, colour
and number, and are in very
similar positions. Only a small
spring held the guard over the
engine controls in place.
caught my eye for a moment.
‘Not something you see every
day’, I thought.
I was just about to key the
mike and make a Pan call
to Brisbane Flight Service to
inform them of my situation,
when I noticed something
very odd about the Seneca's
electrical panel at my left
elbow. The plastic cover
guarding the magneto
switches on the top row of the
panel was lying limply below
them (the spring holding the
cover in the guarded position
must have broken after the last
start), and the blood drained
from my face as I realised
the two switches for the left
engine were off. With the
magneto controls exposed, I
had confused them with the
landing light switches one
level below, and shut down
a perfectly good engine just
after lift-off.
Reselecting the magneto
switches to their correct
position, sliding the pitch levers
to full fine and the mixture to
rich, helped the engine to roar
back to life.
I re-established the Seneca
in a normal climb and gave
my departure report to Flight
Service.
However, it was mostly my
lax attitude to task that had
caused me to misidentify the
switches. I am certain that
this attitude was born out of
the constant repetition of the
same actions on a daily basis.
It is ironic, I guess, that while
repetition can make us highly
adept and comfortable with
the demands of flying, it can
also lead into territory where
we become over-confident
and complacent.
My career has progressed
onto larger, faster aircraft
but whenever I feel myself
becoming a little too familiar
with their operation I think
back to that close call in
Toowoomba.
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CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Mountain madness
Mountain madness
We were sitting absolutely still on the runway when
it began to rain. The captain was crying and I wanted
to throw up.
Name withheld by request
A few hours earlier I had been enjoying a perfect Anzac Day
poolside in Cairns. I was on reserve as a regional airline first
officer, but as we had no scheduled flights on public holidays,
I was certain my standby status was simply a formality. Then
the phone rang: a charter to Tabubil in Papua New Guinea
taking mine workers from Cairns, as their regular aircraft had
become unserviceable.
I was inexperienced in PNG operations, and felt somewhat
apprehensive. I knew Tabubil was a short, one-way, gravel
runway embedded in the beginning of a valley with a 12,000foot mountain range in very close proximity. Tabubil is set in
extremely dense jungle fed by one of the highest rainfalls in
the world. No wonder it has such a poor history of aircraft
safety – almost 50 lives lost in two decades.
From the pre-departure weather forecast, we knew there
would be passing showers and only one possible direction
for landing, which would see us conduct a straight-in GPSRNAV or 'cloudbreak procedure' (in PNG CAA terms).
We began our descent, flying over what we deemed our
alternate aerodrome. The town of Kiunga 30nm to the south
was CAVOK, with flat terrain, but we knew, if we diverted
there, that only drum Jet A-1 was available, and over-wing
refuelling of our turboprop was no easy feat.
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
With the cabin secure, the aircraft fully configured and the
captain flying, I advanced the propeller levers to full fine,
my duty at the final approach fix. Looking outside, we were
in VMC but on top of a thick layer of stratus cloud. I was
unsure if we'd even enter cloud before the minimum descent
altitude. We reached the MDA and then the missed approach
point without even entering cloud. We could see nothing of
the aerodrome. The go-around was
I immediately felt uncomfortable.
uneventful. At a safe altitude, we
Two missed approaches are enough
discussed our options. We had plenty
of fuel and Kiunga was available. We in my opinion. Moreover, while on
also discussed a second approach, the missed approach, I had heard a
as we knew the showers were moving Twin Otter taxi, backtrack and line
up on the reciprocal runway.
through fast.
We flew another missed approach and were again
manoeuvering safely on top of cloud visually. The 12,000feet monster at the end of the valley was shiny to look at as
it popped out of the cloud. After the prior discussion with the
captain I was comfortable that we'd then divert to Kiunga.
Instead he asked my opinion on manoeuvering visually, north
of our position to the south of the mountain range, to 'get a
closer look down the valley through the passing showers'.
I immediately felt uncomfortable. Two missed approaches
are enough in my opinion. Moreover, while on the missed
approach, I had heard a Twin Otter taxi, backtrack and line up
on the reciprocal runway. Manoeuvering further north we could
see passing gaps in the fast-moving stratus, with occasional
glimpses of the six lead-in strobes in the valley. What occurred
next left me frozen in shock. The captain disconnected
the autopilot and immediately put our turboprop in
a steep descent through a gap while yelling 'I'm visual!'
83
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CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Mountain madness
I could not believe what was happening. I felt betrayed and
cheated. We'd agreed a plan of action and this moment of
impulsiveness had intervened. The tension in the flight deck
increased instantly. The captain loudly called for full flap
and landing gear down while he pushed the plane into a
steep descent. Having been a skydive pilot, I thought my
days of steep, rushed descents were behind me. I then had
a horrifying realisation: the Twin Otter! I yelled at the captain:
'there's a Twin Otter taking off and we've told him we’re on a
missed approach!'
The captain was in a state of tunnel vision. He yelled at
me to 'tell them to get off the runway, we're landing!’ Five
minutes of sheer terror had begun. 'TRAFFIC TRAFFIC!' then
'CLIMB CLIMB, TCAS CLIMB' screamed our onboard Traffic
Collision Advisory System. I could see the target on my TCAS
indicator climbing and coming straight at us. 'This cannot be
happening' I remember thinking. ‘TCAS wants us to climb,
we have thick cloud above us; we are visual now, committed
to this narrow valley where the chart says circling prohibited!’
The captain reduced the descent rate and we became visual
with the Twin Otter. It was close. Very close. I will never forget
the look on its pilot’s face. Our steep profile was interrupted,
and now couldn't possibly land straight in. We were committed
to the valley, there was no plan B.
I've never been without a 'plan B'! We were visual but there
were walls of stratus cloud everywhere I looked. And, I knew
with certainty, large rock walls looming just behind the clouds.
The captain levelled out and began screaming
over and over again, 'I'm visual'. Overhead
the aerodrome, he put our turboprop into
a 60-degree left-hand turn. The Enhanced
Ground Proximity Warning System (EGPWS)
sounded its first of many warnings. ‘BANK
ANGLE! BANK ANGLE!'. Out of my window I could see
nothing but cloud. I thought we'd entered it.
I then had a horrifying
realisation: ... I yelled at the
captain: 'there's a Twin Otter
taking off and we've told him
we’re on a missed approach!'
In desperation, I did the only thing I could think of. I turned the
weather radar to terrain mode, fed directly from the EGPWS's
onboard GPS. There was close terrain, with glimpses of
yellow and red (terrain above).
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
85
Things turned quiet for a moment. We'd returned to wings
levels on a close, pseudo downwind when the captain began
another steep descent. The flight had become single-pilot
ops by this stage. We were now visual, although very high.
Another acute left-hand turn and the EGPWS came to life
once more. BANK ANGLE! BANK ANGLE!, followed by SINK
RATE! SINK RATE! We turned final, with an extremely high
descent rate. I remember screaming 'we are way too high!'
Intonations of SINK RATE! SINK RATE! PULL UP! PULL UP!
accompanied our very short final. At a few hundred feet we
were back, momentarily, on a normal profile. The captain
reduced the rate of descent and flared the aircraft and we
touched down very hard, followed by a bounce. Another
bounce, then full reverse thrust, and our aircraft showed off
its short field capabilities.
We were sitting absolutely still on the BANK ANGLE! BANK ANGLE!,
runway when it began to rain. I didn't followed by SINK RATE! SINK RATE!
want to say anything. The rain was We turned final, with an extremely
pelting down, like a theatre curtain after high descent rate. I remember
a command performance. I had begun screaming 'we are way too high!'
my after-landing scan when the captain
asked me to ‘say something!' I sat in silence as I mustered
the courage to look at him. He was crying. I said nothing. We
taxied to the terminal in silence. A chime from the intercom: the
flight attendant said the passengers wanted to congratulate
Ever had a
us on getting them on the ground safely. I felt sick to my core
close call?
– all I wanted to do was throw up.
Write to us about an
The passengers disembarked and the captain disappeared
aviation incident or
to the terminal for an hour. The flight attendant was really
accident that you have
shaken. She later told me she'd been rehearsing her impact
been involved in. If we
drill and commands as she thought – correctly – that we
publish your story, you
were in serious trouble.
will receive $500. Articles
should be between 450
We were lucky that day. No mission is worth those sorts of
and 1,400 words.
risks. Yes, over-wing refuelling post diversion would have
Submit your close call:
been a headache, but not nearly as big a headache as flying
fsa@casa.gov.au
into a mountainside. Crew resource management can swing
in an instant, so always be on the lookout!
86
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Up, down, round and round
Up, down, round and round – the haves and the wills
Name withheld by request
I am in the right seat of a Cessna Cutlass in the Canberra circuit, training
a private pilot toward his retractable undercarriage and constant speed
endorsements. We had been in the circuit for about thirty-five minutes
and he was coping pretty well for having less than an hour on the aircraft.
However, the circuit that afternoon was pretty busy, we had traffic to sight
and follow, and we had already been told on pretty much every circuit
to either tighten it up, or extend to allow for traffic. All this was of course
good training at any other time, but when my student was coming to grips
with several new techniques and procedures, it was just a little too much.
I was about to call it a day as we climbed out from a touch and go, until
I realised that John (not his real name) had forgotten to raise the gear.
Since he was coping with everything else and the circuit looked to have
finally cleared for a while, I let him continue − keeping a careful eye on his
actions − because I just knew what was going to happen next!
Sure enough, as we passed the upwind end of the runway on downwind,
John started his pre-landing checklist, and at the appropriate time, moved
the gear handle – only since it was already down, he now selected it up!
He completed the other tasks, including lowering one stage of flap, but
the tower controller then asked us to extend downwind yet again to allow
the departure of a Boeing. By the time we were cleared to turn base, we
were well away from the airport and John wisely elected to delay any
further flap extension until we were closer to the ideal glidepath. I was
still very much aware that we had no gear, and was hoping that the tower
controller didn’t spoil my surprise for John by alerting him to it.
On the normal approach path, John selected the second stage of flap,
and almost immediately we heard the gear horn, of course. This is where
the story takes an interesting turn – John assumed that it was the stall
warning horn, so he lowered the nose and applied a little power, but to
no avail. The horn dutifully kept blaring, but since he had only heard it
once before, it was just not sinking in. Since everything he was doing was
only making things worse, I told him to go around, select flaps to take-off
position and climb back into the circuit.
While all this was happening, I was expecting John to notice that the gear
was up and for the penny to drop, but he had one surprise left for me.
He grabbed the handle and lowered the gear (thinking he was raising it).
Of course the gear horn was now quiet, so John sat back and continued
to fly the circuit. Downwind, I told John to make a full stop and he called
tower to advise his intentions. Then came the checklist again, and I just
knew he would spot the gear this time ... but no! He again raised the gear
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
at the point in the checklist that calls for it to be lowered. My amusement
had now turned to frustration and I asked him to run the checks again
to ensure he was happy they were complete. Finally, he noticed that the
gear handle was in the up position! He was puzzled as he thought he had
missed that part of the checklist, or I was playing a trick of some sort. I
took over at this point and completed the landing as I wasn’t sure he was
thinking entirely straight any more.
We had a thorough debrief after the flight, and later shared a couple of
laughs and drinks at the bar – on him of course. He went on to complete
his training and become quite an accomplished pilot.
So what can we take away from this? Checklist procedures should be up
there at the forefront of our mind, at the very least! Fatigue will cause a
general slowing down of the mental processes, and IS a very real danger
– even if you’re not aware of being tired at the time. Also, task saturation –
when learning new procedures or coping with a busy circuit or radio – can
be a very dangerous and subtle foe. Finally, any deliberate inhibiting or
failing of a safety device such as a gear warning horn can be both illegal
and stupid, as well as very embarrassing! The end result is that metal
can easily be bent, and people hurt, or even killed, due to incomplete or
incorrect checklist procedures.
They say that there are those who HAVE, and there are those who WILL
(land gear up), but I prefer to think of it another way – what goes up
doesn’t necessarily come down!
87
CHECKLIST
PROCEDURES
FATIGUE
TASK
SATURATION
INHIBITING
SAFETY DEVICE
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CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Text here
Making safe
transport even
safer
Australia’s aviation industry is among the
safest in the world. Our strong reporting
culture and rigorous investigations mean that
when an accident or incident does happen,
we’re in a good position to prevent it from
happening again.
In fact, the information we receive from
occurrence reports and our investigation
findings allows the ATSB to monitor overall
trends in aviation safety. From these trends,
we can determine the main risk areas or
priorities currently facing Australian aviation.
To better inform the transport community
of these priority areas, the ATSB recently
released its Safety Watch initiative. Featured
on the ATSB website, Safety Watch highlights
the main safety concerns across the aviation,
maritime and rail industries. It also offers
suggestions on how to manage these
concerns along with links to safety resources.
Ultimately, Safety Watch aims to make
Australia’s safe transport systems even safer.
For aviation, we see opportunities for
improvement from general aviation through to
high capacity airlines. Some of the high risk
areas involve wirestrikes, low-level flying, fuel
management, handling of approach to land,
and data input errors.
We’ll be constantly monitoring Safety Watch
over the year and will remove or add safety
priorities as trends change or improvements
are made.
24 Hours
1800 020 616
I encourage you to check Safety Watch out
and welcome your thoughts and experiences
on these safety issues. If you have anything
you would like to add, please contribute to the
conversation by posting your comment on the
Chief Commissioner’s blog
www.atsb.gov.au/infocus.
Web
www.atsb.gov.au
Twitter
@ATSBinfo
Email
atsbinfo@atsb.gov.au
Martin Dolan
Chief Commissioner
Safety Watch
The ATSB’s website now includes a new resource,
Safety Watch, which contains information about safety
issues that the commission has identified as ‘priority
concerns’. The ATSB believes the aviation community
needs to pay extra attention to these matters.
The issues currently covered in Safety Watch include:
• Avoidable aviation accidents—GA pilots
continue to die in accidents that are mostly
avoidable.
• Handling of approach to land—There is a
worrying number of cases where stability is not
adequately assessed or uncommon manoeuvres
are mishandled.
• Performance calculations & data input
errors—Human error involving incorrect data
entry continues to cause concern. In some cases,
aircraft systems and operators’ flight management
procedures are not catching these errors.
• Safety in the vicinity of non–towered
aerodromes—Non-towered aerodromes can
pose a risk due to poor communication between
pilots, ineffective use of ‘see-and-avoid’ and failure
to follow common traffic advisory frequency and
other procedures.
• Robinson R44 fuel tanks—A significant number
of R44 helicopters are not fitted with bladdertype fuel tanks and other modifications detailed
in the manufacturer’s documentation that provide
improved resistance to post-impact fuel leaks and
enhanced survivability prospects in the event of an
accident.
• Reporting of accidents, incidents and
transport safety concerns—ATSB research has
revealed under-reporting of incidents.
Each page provides links to other resources that
provide useful information. These resources include
educational booklets, research articles, and accident
investigation reports that illustrate the dangers that
can arise from these safety issues. You can explore
Safety Watch on the ATSB website. 
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
89
Aviation Safety Bulletin
The ATSB has released its latest
bulletin of short investigation
reports. This edition of the Bulletin
highlights valuable safety lessons
for pilots, operators and safety
managers. Several investigations
from the Bulletin are featured below.
the crossfeed valves in accordance with
Boeing recommendations. The operator
also has a program in place to replace
existing crossfeed valves with a modified
version at scheduled maintenance
servicing. This program is currently under
review for acceleration.
Fuel imbalance
Are you fit to fly?
Investigation AO-2012-053
Investigation AO-2012-100
Virgin Australia Airlines is reviewing their
program to replace engine fuel feed
crossfeed valves after a fuel imbalance
on a flight from Gold Coast to Melbourne
led to a declaration of a PAN and a
diversion to Brisbane.
The partial incapacitation of a pilot has
shown how important it is for pilots
to assess their own wellbeing and
ability to fly, just as they check their
aircraft. In this case, the pilot and a flight
nurse were flying from Sydney to Port
Macquarie in a Raytheon B200 aircraft to
pick up a patient.
During climb, the crew observed that
both engines were being supplied only
from the right fuel tank, resulting in a fuel
quantity difference between the left and
right fuel tanks. The crew conducted the
fuel leak engine checklist. With centre
tank fuel available, the crew selected the
centre tank pumps on, which resulted in
the fuel imbalance stabilising.
Since the crew could not confirm fuel
from the left tank could be used once the
centre tank pumps were selected off, or
that no fuel tank fuel leak existed, they
diverted to Brisbane. The aircraft landed
safely.
An overhaul organisation inspected the
engine fuel feed crossfeed valve and
identified wear to the sealing materials
and Teflon within the valve body as
consistent with the existence of a leak
within the valve. However, the overhaul
organisation was unable to confirm
that the sealing material degradation
would explain a high volume internal fuel
leakage rate.
Virgin Australia Airlines had previously
established an inspection program for
After departing Sydney, the pilot began
to feel unwell, experiencing abdominal
pain and nausea. After donning his crew
oxygen mask, the pilot’s health improved
and he commenced a return to Sydney.
During the descent, the pilot removed
his oxygen mask and he began to feel
unwell again.
The aircraft landed at Sydney and after
shutdown the pilot became physically
ill. The pilot recovered from the illness
about one week later. It was found
that he most likely suffered viral
gastroenteritis.
The ongoing danger of
carburettor icing
Investigation AO-2012-091
Carburettor icing is a known problem
that can have serious safety implications
for aircraft. This has been demonstrated
most recently in an accident near
Miranda Downs in Queensland. On
6 July 2012, a Robinson R22 Beta was
conducting mustering operations when
the right skid struck a tree and collided
with terrain.
The operator’s investigation into the
accident—which examined GPS and
Bureau of Meteorology data— found that
the combination of temperature and dew
point indicated a moderate carburettor
icing risk at cruise power and a serious
icing risk at descent power.
Pilots are reminded to maintain
awareness of the weather conditions
that are conducive to carburettor ice
formation and closely monitor their
aircraft performance during times when
the risk exists.
The dangers of using
a phone while driving
airside
Investigation AO-2012-090
An incident at Mackay Airport has
highlighted the potential distraction
presented by portable communication
devices, especially in the dynamic airside
environment.
On 29 June 2012, a Piper PA-31 Navajo
aircraft, took off from runway 05 at
Mackay Airport. At that time, an Airport
Safety Officer (ASO) was conducting an
airfield runway and lighting inspection in
an airfield safety vehicle and moving in
a north-westerly direction along runway
32. Despite an earlier air traffic control
instruction to hold short of runway 05,
the ASO was distracted by a telephone
call and continued along runway 32,
crossing runway 05. The Piper PA-31
passed over the airfield safety vehicle by
an estimated vertical distance of
30 feet. 
These reports along with other
investigations are available on the
ATSB website.
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Deadline for R44 helicopter fuel tanks
The deadline is fast approaching for
R44 helicopter operators to replace
their all-aluminium fuel tanks with
the bladder-type tank.
In response to a number of R44
helicopter post accident fires, the
Robinson Helicopter Company has
produced a retrofit that replaces the R44
all-aluminium fuel tanks with bladdertype tanks. The bladder tanks provide
improved resistance to post-accident
fuel leaks due to their increased cut and
tear resistance and the ability to sustain
large deformation without rupture.
Two fatal R44 helicopter
accidents in Australia have
demonstrated the potential
danger of the all-aluminium
fuel tank.
The manufacturer has issued two
important Service Bulletins aimed at
reducing the risk of a potentially fatal
post-impact fire.
The first, SB-78B, requires that R44
helicopters with all-aluminium fuel tanks
be retrofitted with bladder-type tanks as
soon as practical, but not later than
30 April 2013.
The second, SB-82, aims to reduce the
chance of the rotor brake switch as a
possible ignition source in the event of a
fuel leak.
The ATSB strongly encourages
all operators and owners of
R44 helicopters fitted with allaluminium fuel tanks to consider
replacing these tanks with
bladder-type fuel tanks as detailed
in the manufacturer’s Service
Bulletin 78B as soon as possible.
More information on the R44 fuel tank
safety concern, along with details of
the two investigations, is available on
the ATSB web page
www.atsb.gov.au/safetywatch.
Wreckage of the R44 helicopter after crashing at Cessnock Aerodrome
Safety Management Systems
A new ATSB research report
examines the effectiveness of
safety management systems (SMS)
and provides important insights
for operators and organisations.
SMS refer to organisations having
a systematic approach to managing
safety, including organisational
structures, accountabilities, policies
and procedures. They generally
include common elements such as
explicit management commitment
to safety, appointment of key safety
personnel, hazard identification and
risk mitigation, safety investigations
and audit, and safety performance
monitoring.
This research is especially timely
because aviation, marine and
rail industries have all recently
incorporated safety management
systems into regulations and
operations as a required way
of managing safety. Although
Australia’s transport industries’
SMS approach is following world’sbest practice, there has been little
empirical evidence presented as
support for how the SMS approach
actually influences safety.
Dr Matthew Thomas undertook
a comprehensive search of the
literature that exists around SMS,
examining existing studies and
comparing their findings. The review
found that safety management
systems do appear to reduce
accidents and improve safety in
high-risk industries. At present,
however, there have only been a
small number of quality evaluations
and it is unclear as to whether
any individual elements of a SMS
have a stronger influence on safety
than other elements. At the same
time, it is clear that management
commitment and appropriate safety
communications do affect attitudes
to safety. Transport organisations
that provide an appropriate
investment and commitment to a
safety management system should
receive a positive return on safety.
The research report XR-2011-002 is
available on the ATSB website. 
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
91
Single-pilot flight operations must manage pilot fatigue
Investigation AO-2011-033
The investigation into the
collision with water off Horn
Island, Queensland highlights
the importance of pilots having
enough sleep before a flight and
for operators to manage potential
fatigue risks.
On 24 February 2011, the pilot of an Aero
Commander 500S commenced a freight
charter flight from Cairns to Horn Island
at 0445 under the instrument flight
rules. The aircraft arrived at Horn Island
at about 0720 and the pilot advised air
traffic control that he intended holding
east of the island due to low cloud and
rain. At 0750 he advised that he was
north of Horn Island and intending to
commence a visual approach. When
the aircraft did not arrive, a search was
commenced but the aircraft was not
found. It was eventually located on
10 October 2011 on the seabed about
26 km north west of the island.
The ATSB investigation found that
the aircraft had not broken up in flight
and that it had impacted the water
at relatively low speed and a near
wings-level attitude, consistent with it
being under control at impact. There is
insufficient evidence to determine why
the aircraft impacted the water, however,
Underwater wreckage of the Aero Commander 500S off Horn Island, Qld
several aspects of the flight increased
risk. The pilot had only four hours sleep
the night before the flight and the
operator did not have any procedures
or guidance in place to minimise the
fatigue risks of early starts. In addition,
the pilot, who was also the operator’s
chief pilot, had either not met the
recency requirements or did not have an
endorsement to conduct the types of
instrument approaches available at Horn
Island and other locations.
The operator ceased operations
following the accident and therefore did
not have the opportunity to improve its
processes. CASA has issued a notice
of proposed rule-making relating to
flight crew fatigue management. In
the case of single pilot public transport
operations, this included a proposal to
limit the duration of a flight duty period
and the number of late night flight duty
periods in certain circumstances. 
Keeping an eye on safety
SafetyWatch
AVIATION | MARINE | RAIL
www.atsb.gov.au/safetywatch
atsb.gov.au/safetywatch
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CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
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Learning from others
Strap up, helmet on:
two ways to make
helicopter flying safer
Managing partial power
loss after takeoff
Investigation AO-2011-108
A fatal accident involving a De Havilland
Tiger Moth at Maryborough Airport on
27 January 2012 illustrates several of
the points made in the ATSB’s research
report Managing partial power loss after
takeoff in single engine aircraft.
A recent fatal helicopter accident serves
as a reminder of the importance of
wearing a helmet and shoulder harness
restraints while flying in a helicopter.
The accident occurred on 26 August
2011, when the helicopter was
conducting sling load operations near
a small village, 183 km from Port Vila
in Vanuatu. The Civil Aviation Authority
of Vanuatu requested that the ATSB
conduct an investigation.
Sling loading involves the carrying of a
cargo at the end of a long cable or rope.
ATSB investigators found that as the
helicopter approached to land, the wire
rope attached to the helicopter’s cargo
hook contacted a tree. That contact
resulted in the rope fouling on the
main rotor blades, becoming entangled
and leading to the detachment of
segments of the rotor blades and the
tail boom. This rendered the helicopter
uncontrollable. The pilot died in the
accident and two passengers were
injured (one of them seriously).
The ATSB investigation also found that
none of the helicopter’s passengers
were wearing the installed shoulder
harness restraints or using flight
helmets, leaving them much more
vulnerable to injury.
The severity of contact injuries
in helicopter accidents can be
significantly reduced by the use of
shoulder harnesses and protective
flight helmets. A study of survivable
helicopter accident involving US army
aircraft concluded that by wearing a
good protective helmet, ‘helicopter
crewmembers can reduce their
chances of sustaining severe head
injuries in a serious but potentially
survivable crash by a factor of five.’ The
ATSB encourages pilots and operators
to use this equipment to make their
flying safer.
Investigation AO-2012-017
In this instance, immediately after
lift-off, the aircraft was observed to
have a partial, intermittent power loss.
The pilot continued the flight with the
aircraft maintaining altitude or climbing
slightly. At the upwind end of the
runway, the aircraft made a climbing
left turn before stalling and descending.
The aircraft impacted the ground and
was seriously damaged by the accident
forces and post-impact fire. Both
occupants died.
The ATSB investigation found that
the power loss was probably caused
by a partial blockage of the aircraft’s
fuel cock. Although sufficient runway
remained ahead to allow a safe landing,
the flight was continued under limited
power without gaining sufficient height
to clear trees beyond the runway.
Approaching the trees, the aircraft
climbed, lost airspeed, stalled and
collided with terrain. There would have
been a safer outcome had the pilot
immediately landed the aircraft straight
ahead.
Pilots are reminded that continued
power in such circumstances is
unpredictable and the risk can be
reduced by conducting a controlled
landing at the earliest opportunity.
Managing partial power loss after
takeoff in single engine aircraft is
available for free from the ATSB.
Watch out for wires
Investigation AO-2012-079
The ATSB’s investigation into a wirestrike
accident highlights the importance of
a proper reconnaissance when flying
in a wire environment and remaining
focused only on operational tasks.
On 12 June 2012, a Robinson R44
Raven 1 helicopter departed Moorabbin
Airport with one person on board to
conduct a private flight to a property at
Moolort, Victoria. During the flight, the
pilot decided to check on the progress
of a bore under construction. He landed
at the bore site and, after a short time
on the ground, decided to depart in the
same direction as his approach – parallel
to a main powerline.
As the helicopter transitioned from the
hover to forward flight, the pilot saw a
single strand powerline directly ahead.
There was no time to avoid the wire
and the helicopter struck the wire on
the middle of the main rotor mast. The
helicopter swung upwards on the wire
and the pilot remembered seeing the
sky before the wire broke, releasing the
helicopter.
The pilot had limited control and was
able to change the attitude to remain
relatively straight and level until the
helicopter landed heavily. The pilot
was not injured but the helicopter was
seriously damaged.
The pilot reported that he had been
focused on avoiding the main powerline
and had not seen the second powerline
during his scans of the area on arrival or
before departure.
The accident highlights the importance
of a proper reconnaissance when flying
in a wire environment and remaining
focused only on operational tasks. The
pilot’s reaction to the wirestrike, which
was to continue to fly the aircraft to the
ground, assisted him to land without
injury.
Wirestrikes are the third most prevalent
cause of fatal accidents in private flying
operations. The ATSB’s Avoidable
Accident booklet Wirestrikes involving
known wires: A manageable aerial
agriculture hazard provides a number
of strategies to help pilots manage the
on-going risk of wirestrikes.
These reports are available on the ATSB
website. 
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
93
REPCON BRIEFS
Australia’s voluntary confidential aviation reporting scheme
Concern regarding the
use of crew rest facilities
REPCON allows any person who has an aviation safety concern to report it to the ATSB
confidentially. All personal information regarding any individual (either the reporter or any
person referred to in the report) remains strictly confidential, unless permission is given by
the subject of the information.
The reporter expressed a safety concern
regarding the use of the crew rest area
by international flight crews from a
different airline.
The goals of the scheme are to increase awareness of safety issues and to encourage
safety action by those best placed to respond to safety concerns.
The reporter stated that during an
international flight, two off-duty pilots
from a different airline were given
the Flight Deck Emergency Code and
unsupervised access to the flight crew
rest compartment for the duration of
the flight. These pilots were travelling as
passengers on non-revenue tickets.
Reported problems with
PT-6A engines
The reporter expressed a safety concern
regarding the chip detector circuit in the
Pratt & Whitney PT6A-42 engine which
is used in the Hawker Beechcraft B200.
The reporter stated that if, following the
illumination of the chip detector warning
light, metal continues to build up on
the chip detector, the magnetic poles
may be earthed to the engine casing,
tripping the chip detector circuit breaker,
resulting in the chip detector warning
light extinguishing.
The reporter is concerned that the nonnormal procedure for a chip detector
warning light is to monitor engine
indications and if further abnormal engine
indications are received to shut down
the engine. If the chip detector light
then extinguishes, there is no guidance
in the Pilot Operating Handbook (POH)
regarding what action is required.
The reporter suggests that the nonnormal checklist should be amended to
include a procedure to follow when the
chip detector warning illuminates and
subsequently extinguishes. He suggests
the procedure should include checking
the circuit breaker, and if the circuit
breaker has popped, the pilot should be
made aware that an engine failure may
still be imminent.
The reporter is further concerned with a
scenario where the chip detector warning
light illuminates and then extinguishes
prior to a normal landing. If the next pilot
to fly the aircraft does not notice the
circuit breaker position, they may depart
without warning of a potential engine
failure, possibly on takeoff.
P&W response:
PWC has reviewed the subject REPCON
and wishes to offer the following
comments.
While P&WC provides the chip detector
and the maintenance criteria to be
followed in the event of chip detector
indication, the airframe provides the
circuitry and the operational instructions
in the event of indication, or loss of
indication. PWC would like to suggest
that this issue could be directed to
Hawker Beechcraft for comments and
resolution, as appropriate.
CASA response:
CASA has undertaken a review of its
Service Difficulty Reports database
to identify events of this nature over
the last five years. The collated data
identified 10 reports associated with
metal contamination and magnetic plug
service difficulties, with only two events
identifying the scenario where the chip
detector warning light illuminated, and
then extinguished.
CASA has contacted the operator and
maintenance organisation involved
and suggested that they should
engage the expertise of the Hawker
Beechcraft Company to achieve an
appropriate outcome for this issue.
CASA has requested a compilation of
the communication that has taken place
between all organisations involved
and will then analyse the information
to establish if the parties are taking
appropriate action to address the
safety concern. If not satisfied with
the response, CASA will initiate further
action with the operator, manufacturer
and governing authorities (FAA), as
deemed necessary.
Airline response
Our procedures require the Flight Crew
Rest Area to be treated with the same
level of security as the Flight Deck. This
occurrence was also reported via the
internal safety reporting system and
the following immediate actions were
initiated:
• all Crew have been reminded of their
obligations in regards to access to
Flight Crew/Cabin Crew rest areas
and the Flight Deck
• change of access code to the
respective doors communicated
• initiation of a review of procedures
for change of access code at regular
intervals. 
What may be reported with
REPCON?
Any matter may be reported if it
endangers, or could endanger the
safety of an aircraft.
Submission of a report known by the
reporter to be false or misleading is
an offence under section 137.1 of the
Criminal Code.
How can I report to REPCON?
Telephone: 1800 020 505
Email: repcon@atsb.gov.au
Mail: Freepost 600
PO Box 600, Civic Square ACT 2608
Online:
www.atsb.gov.au/voluntary.aspx
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ATC
notes
365 days and
counting for ADS-B
Airservices continues to urge airlines, and specifically corporate
jet operators, to fit their aircraft with Automatic Dependant
Surveillance Broadcast (ADS-B) technology ahead of a mandated
fitment deadline in December.
O
n 12 December 2013, the
satellite-based technology
enabling aircraft to be accurately
tracked by air traffic controllers and
other pilots without the need for
conventional radar, will be required
for flight in Australian airspace at and
above 29,000 feet (FL290).
Responsible for providing air traffic
surveillance services for Australia’s
56 million square kilometres of
airspace, Airservices has been a
world leader in the development and
implementation of ADS-B technology.
Currently, Australia’s ADS-B network
is supported by 29 duplicated
ground stations nationwide plus
14 ADS-B capable multilateration
sites in Tasmania and 16 sites in the
Sydney basin.
Around 60 per cent of the Australian
domestic airline fleet and 73 per cent
of all flights at or above FL290 within
Australian airspace have been fitted
with ADS-B so far.
Airservices biggest concern is for
corporate jet operators. Whilst some
have equipped, this industry sector has
not equipped as quickly as others.
Airservices urges corporate jet
operators to ensure their aircraft
have appropriately fitted equipment
before December.
More information on ADS-B and future
mandates beyond December 2013 can
be found at www.airservicesaustralia.
com/projects/ads-b
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
De-mystifying air traffic services
Airservices Pilot Information Nights
T
an Airservices representative (often with
an ATC or flying background and in some
cases both) delivering presentations on
critical safety and operational issues. This
is followed by a visit to the simulator and
ATC operations room to see the air traffic
control traffic management system and
what a controller sees on their monitor.
Pilots also have the opportunity to ask
questions and raise issues of concern to
the pilot community.
aking the mystery out of air
traffic control is what Airservices
Pilot Information Nights are all
about. In just a few short hours, pilots
can learn about the air traffic system
and understand how their activities,
decisions and operations can impact on
it. The free sessions are targeted at the
general aviation community, particularly
student pilots, to promote safe flying and
encourage pilots and air traffic services
employees to engage and communicate
with each other.
Pilot information nights do not include
visits to the tower at any of the locations.
Hosted in Melbourne, Sydney and
Brisbane, the sessions commence with
When are they held?
Pilot Information Nights occur in:
Sydney:
1st Tuesday of every month
Brisbane:
Tuesday 5 March
Tuesday 2 July
Tuesday 5 November
Melbourne:
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Brisbane also offers the option of conducting
a dedicated session tailored for your group.
2nd Wednesday of every month
To register please email your preferred location, date/s and names of attendees
to pilotinfonight@airservicesaustralia.com
Early registration is encouraged as minimum numbers apply and places are limited.
95
96
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
International accidents
International accidents/incidents 28 September – 11 November 2012
Date
28 September
Description
Aircraft
Dornier 228-202
Location
0.5km E of KathmanduTribhuvan Airport, Nepal
Fatalities
19
Passenger plane (first flight 1987) destroyed when it crashed shortly
after take-off, killing all on board. Unconfirmed rumours say that the
aircraft struck a vulture and turned around to return to the airport, but
stalled, hit the ground, and burst into flames.
Damage
Destroyed
Date
7 October
Description
Aircraft
Antonov 12BP
Location
40km SW of Omdurman,
Khartoum, Sudan
Military transport plane developed engine problems en route and
crashed as the crew attempted an emergency landing.
Fatalities
15
Damage
Written off
Date
7 October
Description
Aircraft
Britten-Norman BN-2A-26
Location
Antigua International
Airport, Antigua
Fatalities
3
Passenger plane (first flight 1969) sustained substantial damage
after crashing on take-off and coming down in the grass next to the
runway in light rain associated with a thunderstorm. The pilot and two
of the three passengers were killed.
Damage
Written off
Date
14 October
Description
Aircraft
Boeing 737-8KN
Location
Antalya Airport, Turkey
Fatalities
0
Passenger plane (first flight 2009) sustained substantial fire damage
to its cockpit during push-back from the gate. The captain ordered
an emergency evacuation via the slides. Twenty-seven passengers
were hospitalised, two with serious injuries.
Damage
Substantial
Date
19 October
Description
Aircraft
Antonov 12B
Location
Shindand Air Base,
Afghanistan
Transport aircraft (first flight 1971) contracted by the U.S. military
crashed and was destroyed, with its cargo of 2132 kilos of
inbound mail.
Fatalities
0
Damage
Written off
Date
25 October
Description
Aircraft
Cessna 208B
Location
Yola Airport, Nigeria
Fatalities
0
Taraba State Government aircraft (first flight 2009) sustained
substantial damage when it crashed on approach. All six people
aboard (including the Taraba State Governor) were found alive, with
various degrees of injuries.
Damage
Written off
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
97
Date
28 October
Description
Aircraft
Beechcraft 1900D
Location
Bir Kalait, Chad
Fatalities
0
Chad Government aircraft (first flight 2000) ‘missed the runway on
landing’, causing the undercarriage to collapse and the propeller
blades to separate, damaging the side of the fuselage. Chad’s
President, and the other occupants of the aircraft, survived.
Damage
Substantial
Date
30 October
Description
Aircraft
Let L-410UVP
Location
Butembo Airport, Congo
Passenger aircraft (first flight 1979) damaged in a runway excursion
on landing.
Fatalities
0
Damage
Substantial
Date
6 November
Description
Aircraft
Cessna 208B
Location
3.3 km SW of Witchita
Airport, Kansas, U.S.A.
Fatalities
1
Pilot of the Super Cargomaster freight aircraft (first flight 1991)
initiated a return to the airport, after climbing to about 4000 feet, but
had to make a forced landing and crashed into trees. The pilot was
killed on impact.
Damage
Written off
Date
9 November
Description
Aircraft
CASA C-295M
Location
Lozère, France
Fatalities
6
Transport plane (first flight 2005) operated by the Algerian Air Force
came down on a hillside in an uninhabited area and burst into flames,
killing everyone on board.
Damage
Destroyed
Date
11 November
Description
Aircraft
Cessna 525B CJ3
Location
São-Paulo Airport, Brazil
Fatalities
0
Damage
Written off
Corporate jet (first flight 2008) overran the runway on landing,
bounced down a slope and crashed into a perimeter fence. Pilot
seriously injured, co-pilot and passenger suffered minor injuries.
The wind direction had apparently changed by 140 degrees over
the course of the previous hour.
International accidents
Compiled from information supplied by the Aviation Safety Network (see www.aviation-safety.net/database/)
and reproduced with permission. While every effort is made to ensure accuracy, neither the Aviation Safety
Network nor Flight Safety Australia make any representations about its accuracy, as information is based on
preliminary reports only. For further information refer to final reports of the relevant official aircraft accident
investigation organisation. Information on injuries is not always available.
98
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Australian accidents
Australian accidents/incidents 1 October – 23 November 2012
Date
1 October
Description
Aircraft
De Havilland DH-84
Location
Gympie (ALA), 235° T 33km, Qld
Injury
Fatal
Damage
Unknown
During the cruise, the pilot reported the aircraft had entered
cloud and requested ATC assistance. Communication with
the aircraft was subsequently lost. A search located the
wreckage of the aircraft and found all the occupants had
died. Investigation continuing.
Date
3 October
Description
Aircraft
Robinson R22 BETA
Location
Halls Creek Aerodrome,
SW M 150km, WA
Helicopter rotor hit the side of a canyon. The pilot was fatally
injured and the helicopter was substantially damaged.
Investigation continuing.
Injury
Fatal
Damage
Substantial
Date
11 October
Description
Aircraft
Robinson R44
Location
Cairns Aerodrome,
303° M 38km, Qld
Injury
Nil
During the initial climb, the pilot received a clutch warning
and the helicopter lost power. The pilot conducted a forced
landing and the helicopter sustained substantial damage.
Investigation continuing.
Damage
Substantial
Date
14 October
Description
Aircraft
Diamond (HOAK) HK36R
Location
Moorabbin Aerodrome, 162° M
15km, Vic
During the approach, the battery failed and the engine
stopped. The pilot conducted a forced landing and the motor
glider nosed over and came to rest upside down.
Injury
Minor
Damage
Substantial
Date
16 October
Description
Aircraft
Cessna 210N
Location
Thylungra (ALA), Qld
Injury
Nil
During the landing flare, the aircraft struck a kangaroo and
the pilot conducted a go-around. During the subsequent
landing, the nose landing gear collapsed and the aircraft was
substantially damaged.
Damage
Substantial
Date
19 October
Description
Aircraft
Fokker B.V. F28 MK 0100
Location
Nifty Aerodrome, WA
Injury
Nil
During the final approach, it was reported that the aircraft
encountered windshear and subsequently made a hard
landing. Investigation continuing.
Damage
Substantial
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
99
Date
22 October
Description
Aircraft
Bell 206B (III)
Location
Gympie (ALA), Qld
During auto-rotation training, the helicopter landed hard and
sustained substantial damage.
Injury
Nil
Damage
Substantial
Date
25 October
Description
Aircraft
Guimbal Cabri G2
Location
Bankstown Aerodrome, NSW
During low level training, the helicopter had a hard landing.
Investigation continuing.
Injury
Nil
Damage
Substantial
Date
26 October
Description
Aircraft
Piper PA-39
Location
Innamincka Township (ALA), SA
During the landing roll, the aircraft overran the runway and
came to rest in a ditch. Investigation continuing.
Injury
Nil
Damage
Substantial
Date
27 October
Description
Aircraft
Robinson R22 BETA
Location
Napier Downs Station (ALA), WA
Injury
Nil
After landing, the pilot got out of the helicopter, leaving the
engine running. The helicopter became airborne, crashed,
and was destroyed.
Damage
Destroyed
Date
29 October
Description
Aircraft
Cessna 172N
Location
Bendigo Aerodrome, NNE M
15km, Vic
Injury
Fatal
Aircraft reported to have struck a wire on approach, crashed
and burst into flames. One person on board killed and
the pilot and a passenger seriously injured. Investigation
continuing.
Damage
Destroyed
Date
31 October
Description
Aircraft
Robinson R22 BETA
Location
Innamincka (ALA), 328° T 89km
(Innamincka Station), SA
During mustering, the helicopter collided with water and
sank. Investigation continuing.
Injury
Nil
Damage
Destroyed
100
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Australian accidents
Date
3 November
Description
Aircraft
Amateur-built P-51 Mustang
Location
Toowoomba Aerodrome,
E M 15km, Qld
It was reported that the engine began running roughly before
the aircraft impacted terrain. The aircraft was destroyed by a
post-impact fire and the pilot was killed.
Injury
Fatal
Damage
Destroyed
Date
3 November
Description
Aircraft
De Havilland DH-82A
Location
Jandakot Aerodrome,
S M 16km, WA
During the landing, the aircraft nosed over and came to rest
upside down.
Injury
Nil
Damage
Substantial
Date
6 November
Description
Aircraft
Piper PA34-200
Location
Jandakot Aerodrome, WA
During approach, the crew failed to lower the landing gear,
resulting in an unintentional wheels-up landing.
Injury
Nil
Damage
Substantial
Date
7 November
Description
Aircraft
Cessna 172N
Location
Kagaru (ALA), 180° M 5km, Qld
Aircraft reported to have collided with terrain. Investigation
continuing.
Injury
Minor
Damage
Substantial
Date
9 November
Description
Aircraft
SOCATA TB-20
Location
Lismore (ALA), 185° T 3km, NSW
Injury
Fatal
The aircraft was seen to bank left and impact the ground.
The aircraft was destroyed by fire and the two persons on
board were fatally injured. The investigation is continuing.
Damage
Destroyed
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
101
Date
12 November
Description
Aircraft
Beech A36
Location
Marymia (ALA), 340° T 46km
(Kumarina Roadhouse), WA
Injury
Nil
During the initial climb, a door opened and the aircraft
returned to land. The pilot inadvertently landed the aircraft
with the landing gear retracted. The investigation is
continuing.
Damage
Substantial
Date
15 November
Description
Aircraft
Amateur-built Searey
Aircraft collided with terrain and the pilot was killed.
Location
Weipa Aerodrome,
N M 141km, Qld
Injury
Fatal
Damage
Destroyed
Date
18 November
Description
Aircraft
Glasflugel Hornet
Location
near Orange Aerodrome, NSW
During the landing roll, the aircraft ground looped, resulting
in substantial damage.
Injury
Nil
Damage
Substantial
Date
21 November
Description
Aircraft
Cirrus SR22
Location
Gilgandra (ALA), 180° M 7km,
NSW
During cruise, the engine failed and the pilot conducted
a forced landing. Both occupants suffered minor injuries.
Investigation continuing.
Injury
Minor
Damage
Substantial
Date
23 November
Description
Aircraft
Piper PA32-260
Location
Jandakot Aerodrome, WA
Aircraft landed short of the runway and collided with terrain.
Investigation continuing.
Injury
Minor
Damage
Substantial
Australian accidents
Compiled by the Australian Transport Safety Bureau (ATSB). Disclaimer – information on accidents is the result
of a cooperative effort between the ATSB and the Australian aviation industry. Data quality and consistency
depend on the efforts of industry where no follow-up action is undertaken by the ATSB. The ATSB accepts
no liability for any loss or damage suffered by any person or corporation resulting from the use of these data.
Please note that descriptions are based on preliminary reports, and should not be interpreted as findings by
the ATSB. The data do not include sports aviation accidents.
102
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Flight bytes
See Avalon free!
Aerospace student professionals are being
offered free tickets to attend the 2013 Avalon
Airshow as accredited trade visitors.
Any Australian undergraduate or postgraduate
university or TAFE student undertaking a tertiary
course in aerospace engineering, aviation
sciences or technology, and with a keen
interest in pursuing a career in aviation, is
eligible to apply.
The International Civil Aviation Organization
(ICAO) and the Flight Safety Foundation (FSF)
have signed a new agreement formalising their
plans to cooperatively promote and advance
the sharing of aviation safety information and
metrics worldwide.
The new collaborative initiative supports ICAO
Safety Management System (SMS) guidance
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Applications close on 18 February 2013.
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FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
that calls for increased monitoring, analysis and
reporting of aviation safety results.
The ICAO-FSF Memorandum of Cooperation
will see the two bodies working more closely
to enhance global compliance with ICAO
Standards and Recommended Practices
(SARPs) and related guidance material. Joint
activities between the organisations in the
areas of data sharing and analysis, training
and technical assistance will facilitate the
harmonisation of proactive and predictive safety
metrics and the promotion of a just safety
culture globally.
103
Animal strikes rising
The number of reported collisions between
Australian passenger planes and birds and bats
has more than doubled in the past decade,
despite airports employing extreme avoidance
tactics – from fireworks to imitation hawk kites.
A report by the Australian Transport Safety
Bureau (ATSB) found the number of strikes
increased from 400 to 980 a year in large
ICAO and the FSF will shortly begin convening
regular regional forums to share results
on emerging safety issues and facilitate
collaboration on mitigation strategies. Both
organisations are already consulting with
a number of States on upcoming demonstration
projects. Source: www.icao.int
The new online learning and event management
registration system will go live in the new year.
For further information see the CASA website
education page, click here.
104
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Flight bytes
passenger aircraft between 2002 and 2011,
and 1450 animal collisions with Australian
aircraft have already been reported this year.
The ATSB’s research investigation and data
analysis manager, Stuart Godley, said bird and
bat strikes were one of the most common safety
hazards reported. ‘While it is uncommon for bird
strike to cause any harm to crew or passengers,
some do result in damage [to aircraft] and
some have had serious consequences such
as forced landings and broken windscreens’,
he said.
The head of the Australian Centre for Wildlife
Genomics, Rebecca Johnson, whose team
uses DNA analysis to identify animals struck by
planes, said the impact that flying animals had
on planes was extraordinary. ‘The fan blades
in [some] engines are the highest-quality alloy
and something like an ibis can tear those’,
said Dr Johnson, whose laboratory receives
about five tissue, blood or feather samples
from unrecognisable animals a week. ‘When
you have two things travelling in opposite
directions towards each other, the speed and
the concentration of mass colliding in one
small area explains why they can do so much
damage.’
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FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
105
A bird strike consultant, Phil Shaw, said while
the total number of collisions had increased
along with a rise in flights, the strike rate – the
number of collisions per aircraft movement –
had also grown.
frequently. The Australian Museum's DNA
facilities, used to identify which species were
most commonly involved in plane collisions, had
helped airports to implement species-specific
management programs, Dr Johnson said.
The rise was due to many factors, Shaw said,
including the growth of regional airports that did
not have the resources to manage wildlife, as
well as modern bigger and quieter aircraft being
able to sneak up on birds.
What’s Tina got to do with it?
Airports, with their ponds, creeks and grassy
vegetation, had also become little oases for
birds in urban environments.
Airlines must report all strikes and near misses,
but airports were mainly responsible for
reducing animal hazards. Godley said it was
hard to tell whether bird strikes were increasing,
or if pilots were reporting minor incidents more
S
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Gloucestershire Airport in England has found
nothing beats rock’n’roll for bird control. The
airport’s bird control team found Tina Turner is
simply the best for keeping birds at bay.
Head of operations, Darren Lewington, told
British newspapers the airport had discovered
the wildlife-dispersing abilities of the sultry
septuagenarian songstress by accident.
Turner’s high-volume vocals worked even
better than the distress calls that airport birdscarers normally used.
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106
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Flight bytes
‘When our bird distress noises weren't working
properly, they turned the tape player on, and
that day it was Tina Turner who scared the
birds away.’
A member of the mustard family, carinata is
inedible – it is foul-tasting and a laxative, so it
can't be used in food, says ARA, but it can be
grown on fallow land in hotter, drier climates.
Turner’s albums have now been added to
the airport’s repertoire of anti-bird techniques,
which includes distress calls, pyrotechnics
and lures.
ARA says ReadiJet differs from other biofuels
produced by the Fischer-Tropsch process
because it contains the cycloparaffins and
aromatics that are present in petroleum-based
jet fuel. This allows it to be used unblended.
Jet flies on biofuel
Flights using partly plant-derived biofuel blends
are a relatively common aviation news story, but
Canadian researchers have gone further, flying
a jet on 100 per cent biofuel.
ARA hopes to get approval for its fuel to be
used in aircraft by the end of 2013. For the
Ottawa test flight, an NRC Lockheed T-33 flew
behind the Falcon to measure the biofuel’s
airborne emissions.
The hour-long flight over Ottawa used biofuel
produced from carinata, an industrial oilseed
crop, supplied by Canadian company Agrisoma
Biosciences.
www.ainonline.com
In October, Canada's National Research Council
(NRC) flew a Dassault Falcon 20 bizjet burning
100 per cent unblended biofuel in its two GE
CF700-2D2 engines. The fuel, called ReadiJet,
has been developed by Applied Research
Associates (ARA) and Chevron Lummus Global,
with funding support from the U.S. Air Force
Research Laboratory.
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
Bureau releases draft TAF review
for industry comment
In response to requests from the aviation
industry, the Bureau of Meteorology has
undertaken a review into the provision of
Aerodrome Forecasts (TAFs). The purpose of
this review is to assess regulatory obligations,
explore the needs of the aviation industry, and
make recommendations relating to the provision
and categorisation of TAFs, including guidelines
for the introduction, modification and cancellation
of forecasts. This includes the provision of
TAFs for locations funded separately from the
Meteorological Service Charge-funded service
and the definition of minimum observational
requirements to support the production and
ongoing monitoring of a TAF during its period
of validity.
The Bureau has completed a draft report,
including 15 recommendations. The draft
report and a questions and answers document
can be accessed at:
www.bom.gov.au/aviation/taf-review
The purpose of the draft report is to seek
formal feedback from the aviation industry on
the proposed recommendations and request
updated movement and passenger numbers
where the data held by the Bureau is found
to be inaccurate. The Bureau welcomes any
comments or suggestions from interested
parties as part of the review, and commits
to a comprehensive consultation process
prior to the implementation of any significant
changes to existing products or services.
The review will remain open for comment until
30th March 2013. Following feedback, the
Bureau will finalise recommendations and then
develop an implementation plan, with phased
implementation of agreed recommendations
commencing in late 2013.
Unmanned advances
Unmanned aerial systems (UAS) continue
to experiment with automatic dependent
surveillance-broadcast (ADS-B), which holds
the promise of allowing them to operate more
closely and safely around other air traffic.
In October, General Atomics Aeronautical
Systems announced a successful test of
ADS-B on a Predator-series aircraft.
The prototype’s first successful flight test
occurred in August off the Florida coast. During
the test, the aircraft’s ADS-B in transponder
detected other ADS-B-equipped aircraft in the
vicinity and showed them on a display in the
ground control station. At the same time, the
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107
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108
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Flight bytes
ADS-B out transponder notified other aircraft
and ATC of the aircraft’s location and velocity.
www.uasvision.com
Meanwhile, the German armed forces, the
Bundeswehr, announced it had completed
50 successful sorties of its LUNA tactical
unmanned aircraft system, using an ADS-B
transponder, over Afghanistan.
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How big is your (electronic) bag?
CASA has amended the Civil Aviation Orders
covering the use of electronic flight bags in
commercial operations. The amendments,
based on the latest international standards,
came into effect in November 2012.
The new regulations do not set out which
devices should be used as electronic flight
bags. Instead they allow pilots and operators to
choose devices most suited to their operations.
But there are some important general points.
One of them is that pilots should choose the
right sized electronic flight bag for their aircraft.
The recommended minimum size is A5 - 210 x
148mm (which rules out the recently released
Apple iPad Mini). This is because a device being
used as an electronic flight bag needs to be able
to display information in a comparable way to
the paper aeronautical charts and documents
it is replacing. Devices should be large enough
to allow images to be shown without excessive
scrolling. Smart phones, for example, are too
small. At the same time pilots need to think
about the device most suited to their aircraft.
While a laptop might be appropriate in a large
aircraft, it may be cumbersome and difficult to
operate in a smaller aircraft.
Power sources and battery life also need to be
considered, as well as air flow around devices
to maintain cooling. A new Civil Aviation Advisory
Publication provides guidance to commercial
operators and private pilots about the use of
electronic flight bags. It can be found at
www.casa.gov.au/efb
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
109
Ageing aircraft paper draws
comment
CASA has received 79 responses to its recent
Discussion Paper 1205 that was released
for public comment from 12 September –
7 November 2012 inclusive.
Overall, the responses were very positive
with respect to CASA’s initiatives. This was
particularly so in respect to the potential benefits
that type clubs offer can offer registered
operators of ageing aircraft, the introduction
of e-learning for ageing aircraft issues, and
the prototype matrix tool. In fact, increased
ageing aircraft education across the whole
industry, from registered operators to LAMEs to
authorised persons and industry delegates was
a common theme.
There was also considerable support for
the review of current minimum maintenance
requirements for aircraft most affected by
ageing issues, as well as support for the
implementation of continuing airworthiness
initiatives such as the Cessna SIDs.
Another common theme was that of making
technical and supporting data available to
industry where possible to assist registered
owners with their airworthiness obligations.
‘I am very pleased with the both the level
of response and the profile of the various
responders to the discussion paper’ said
Pieter van Dijk, the project manager of CASA’s
Ageing Aircraft Management Plan.
‘It seems most people really took the time to
absorb the material contained in the discussion
paper, and made considered responses
accordingly.’
Once all responses have been appropriately
analysed and considered, CASA will finalise its
intentions for the future management of ageing
aircraft in Australia.
Further updates on CASA’s Ageing Aircraft
Management Plan will be made available
on the CASA website www.casa.gov.au/
ageingaircraft, including continued access
to the ageing aircraft online e-learning course,
as well as the prototype matrix tool, until the
end of March 2013.
Online Human Factors training
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For more informaon, visit www.hs.com.au
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The smarter way
110
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Next issue
Next issue
UPCOMING EVENT
March–April 2013
Avalon – or the Australian International
Human factors and the engineer – what you
need to know before picking up a spanner
The exit row – why having a little more leg
room brings responsibility
‘I’m sorry, Pete’ – how organisational failure,
system design and one pilot’s error killed
109 people.
And … more close calls
Airshow and Defence Exposition – is a
great place to see the latest aircraft and
be inspired by the glamour of aviation. It’s
also a place to learn. CASA’s presence at
Avalon is focused on serving Australian
aviation, with subject matter experts on
hand to answer queries on regulatory,
technical and operational matters. It’s a
one-stop shop for answers to your nagging
aviation questions.
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
111
A V A L O N 2 0 1 3
AuStRAl iA N i Nt e RNAt i oNAl AiR SHow AND AeR oSPACe & DeF eN Ce exP oSitioN
Visit the CASA stand in Hall 1 to talk to our aviation subject
matter experts (SMEs). SMEs will be available to answer
your questions on:
Tuesday 26 Feb
» Maintenance regulations
» Remotely piloted aircraft
» Safety management systems
» Flight testing enquiries
Wednesday 27 Feb
» Propulsion – rotary wing, piston engines & GA
» Fatigue
» Maintenance regulations
» Remotely piloted aircraft
» Safety management systems
» Flight testing enquiries
Friday 1 Mar
» Fatigue
» Human factors in maintenance
» PBN & new technology
» Ageing aircraft
» Dangerous goods
» Sport aviation
» Future technology
Sat 2 Mar / Sun 3 Mar
» Ageing aircraft
» Dangerous goods
» Future technology
» Sport aviation
» CASA graduate program
Thursday 28 Feb
» Propulsion – rotary wing, piston engines & GA
» Human factors in maintenance
PLUS: CASA’s Aviation Safety Advisers
» Remotely piloted aircraft
will be on the stand daily to assist with
» Maintenance regulations
your general aviation safety enquiries.
» Safety management systems
» PBN & new technology
» Fatigue
www.casa.gov.au | 131 757 | |
» Flight testing enquiries
112
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
Calendar
ACT/NEW SOUTH WALES
Ballina 4 Feb
Canberra 21 Jan, 18 Feb
Coffs Harbour 4 Feb
Forbes 4 Feb
Nowra 11 Feb
Sydney 4 Feb
Temora 4 Feb
Wollongong 11 Feb
26 February – 3 March 2013
Avalon International Airshow
www.airshow.com.au
AvSafety seminars – coming to your area soon!
For some years CASA has been holding very successful aviation
safety seminars for the wider aviation community. These were
run by CASA aviation safety advisers (ASAs) at all major aviation
hubs, often in conjunction with local aero clubs or organisations.
In 2013 there will be a change of focus from seminars to site
visits by ASAs, who will be visiting organisations to discuss
the forthcoming aviation regulatory changes. They will travel
throughout Australia, and organisations or individuals are
welcome to contact their local ASA to arrange an appointment
time. The approximate travel schedule for each region in
January/February is shown below, and details for the rest of
the year can be found on the AvSafety seminars and workshop
page at www.casa.gov.au/avsafety
ASAs are also available for visits within capital city environs
(within approximately two hours drive of the centre of a
capital city).
Aero clubs and other aviation organisations are also welcome to
run aviation safety seminars, with ASAs presenting on selected
topics. However, CASA will not be financially supporting these
events. If you would like to run a seminar with ASA attendance,
please click the AvSafety request form and complete the details.
Every effort will be made to accommodate your requests,
but this will obviously be easier to do if your proposed date
coincides with the schedule below.
NORTHERN TERRITORY
Darwin 11 Feb
QUEENSLAND
Gold Coast 18 Feb
Mackay 4 Feb
Townsville 4 Feb
SOUTH AUSTRALIA
Mt Gambier 5 Feb
Naracoorte 5 Feb
Parafield 29 Jan
VICTORIA
Albury 11 Feb
Ballarat 4 Feb
Melbourne 4 Feb
Shepparton 11 Feb
Wangaratta 11 Feb
Yarrawonga 11 Feb
WESTERN AUSTRALIA
Jandakot 4 Feb
Please note: some CASA seminar dates may change. Please go to www.casa.gov.au/avsafety for the most current information.
CASA events
Other organisations’ events
FLIGHT SAFETY AUSTRALIA
Issue 90 January–February 2013
INTERNATIONAL
26 – 28 March
International Cabin Safety Conference,
Richmond, British Columbia
www.ldmaxaviation.com/Cabin_Safety/Spring_
International_Cabin_Safety_Conference
23 – 25 April
International Accident Investigation
(IAI) Forum, Singapore Aviation Academy
www.isasi.org/
19 – 22 August
International Society of Air Safety
Investigators (ISASI) Annual Seminar,
Vancouver, British Columbia
www.isasi.org/
UPCOMING EVENTS
21 – 26 March
The Australian Bonanza Society Beechcraft
Pilot Proficiency Program (BPPP) and Service
Clinic with Thomas P. Turner – Cowra, NSW.
Beechcraft owners and non-ABS members
are most welcome to attend.
www.abs.org.au
3 – 5 June
Aerial Agricultural Association of
Australia Convention, Surfers Paradise
www.aerialag.com.au/
15 – 17 Oct
Safeskies, Canberra
www.safeskiesaustralia.org/
Director of Aviation Safety, CASA | John F McCormick
Acting Manager Safety Promotion | Margo Marchbank
Acting Editor, Flight Safety Australia | Robert Wilson
Deputy Editor, Flight Safety Australia | Joanna Pagan
Designer, Flight Safety Australia | Fiona Scheidel
ADVERTISING SALES
Phone 131 757 | Email fsa@casa.gov.au
CORRESPONDENCE
Flight Safety Australia GPO Box 2005 Canberra ACT 2601
Phone 131 757 | Fax 02 6217 1950 | Email fsa@casa.gov.au
Web www.casa.gov.au/fsa
CHANGED YOUR ADDRESS
If you have an aviation reference number (ARN) and want to
update your contact details, go to http://casa.gov.au/change
For address change enquiries, call CASA on 1300 737 032.
DISTRIBUTION
Bi-monthly to aviation licence holders, cabin crew and industry
personnel in Australia and internationally.
CONTRIBUTIONS
Stories and photos are welcome. Please discuss your ideas
with editorial staff before submission. Note that CASA cannot
accept responsibility for unsolicited material. All efforts are made
to ensure that the correct copyright notice accompanies each
published photograph. If you believe any to be in error, please
notify us at fsa@casa.gov.au
NOTICE ON ADVERTISING
Advertising appearing in Flight Safety Australia does not imply
endorsement by the Civil Aviation Safety Authority.
Warning: This educational publication does not replace ERSA,
AIP, airworthiness regulatory documents, manufacturers’ advice,
or NOTAMs. Operational information in Flight Safety Australia
should only be used in conjunction with current operational
documents. Information contained herein is subject to change.
The views expressed in this publication are those of the authors,
and do not necessarily represent the views of the Civil Aviation
Safety Authority.
© Copyright 2013, Civil Aviation Safety Authority Australia.
Copyright for the ATSB and ATC supplements rests with the
Australian Transport Safety Bureau and Airservices Australia
respectively—these supplements are written, edited and designed
independently of CASA. All requests for permission
to reproduce any articles should be directed to FSA editorial
(see correspondence details above).
ISSN 1325-5002.
To have your event listed here, email the details
to fsa@casa.gov.au Copy is subject to editing.
Cover design: Fiona Scheidel
113
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114
CONTENTS | ARTICLES | AIRWORTHINESS | REGULARS
FLIGHT SAFETY AUSTRALIA
AUSTRALIAN INTERNATIONAL
AIRSHOW
115
AND AEROSPACE & DEFENCE EXPOSITION
AVALON2013
Issue 90 January–February 2013
26 FEBRUARY - 3 MARCH 2013
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