CONTENTS
Features
ISSUE NO. 70, SEP-OCT 2009
8
MANAGER, SAFETY COMMUNICATIONS &
MARKETING
Gail Sambidge-Mitchell
EDITOR, FLIGHT SAFETY AUSTRALIA
Margo Marchbank
ADVERTISING SALES
P: 131 757 or E: fsa@casa.gov.au
CORRESPONDENCE
Flight Safety Australia
GPO Box 2005 Canberra ACT 2601
P: 131 757 F: 02 6217 1950
E: fsa@casa.gov.au
W: www.casa.gov.au
CHANGED YOUR ADDRESS?
To change your address online, go to
http://casa.gov.au/change
For address-change enquiries, call CASA on
1300 737 032
DISTRIBUTION
Bi-monthly to 87,000 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
‘HEMS diagnosis’
Helicopter emergency medical services – USA and Australia .
DIRECTOR OF AVIATION SAFETY, CASA
John McCormick
20 ‘Harnessing safety’
Industry risk profiles: the Australian Parachute Federation and sport aviation.
24
‘Loading safely’
Ground safety part 2 looks at unit load devices, or ULDs.
28 ‘TAWS for thought’
Don’t ignore that alert.
29 ‘Victa Airtourer feedback on …
May-June’s ‘High-G manoeuvring’ article.
31
‘All you wanted to know about TNS 32’
DHC chief engineer, Mark Miller, on the revised technical news sheet for the Moth.
42 ‘Error management workshops ’
A round-up of Tony Kern’s Australia-wide workshop series.
58 ‘Boeing 737 stalls during an ILS approach’
Macarthur Job on a recent UK incident.
63 ‘GAAP changes’
New rules for GAAP zones.
Regulars
DESIGN & PRODUCTION
Spectrum Graphics – www.sg.com.au
PRINTING
IPMG (Independent Print Media Group)
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 2009, Civil Aviation Safety
Authority Australia.
Copyright for the ATSB and ATC supplements
rests with the ATSB and Airservices
Australia respectively– these supplements
are written, edited and designed
independently of CASA. All requests
for permission to reproduce any articles
should be directed to FSA editorial (see
correspondence details above).
Registered–Print Post: 381667-00644.
ISSN 1325-5002.
COVER: Polair NVG training.
Photograph © Margo Marchbank
2 AirMail
4 Flight Bytes –aviation safety news
16
ATC Notes – news from Airservices Australia
18
Accident reports – International
18
Accident reports – Australian
31
Airworthiness pull-out section
33 SDRs
38 Directives
44 Close call
45 Freightful flight
47 Sky dive
49 Swamped
52 ATSB supplement
66 Av Quiz
71 Quiz answers
70 Calendar
A IR M A IL
PAR AVION
BEVAN MARSHALL EMAILED
I am a retired LAME and CPL bush
pilot. I read each issue of your
publication with much interest
and was concerned about two letters
from fellow pilots in Issue 69.
FSA SEP–OCT09
2
during a Western Australian warm
summer period as well; I would
frequently demonstrate this to ab
initio pilots to make them aware of
the phenomenon.
Your publication has published many
fine articles on carby icing over the
years. Also refer to the American
FAA’s:
special
airworthiness
information bulletin [SAIB] CE-0935, Carburettor Icing Prevention 30
June 2009.)
The second letter from a ‘low-hour
pilot’ (Issue 69) in his words, was
relevant to short field takeoff using
full flap application on the takeoff
roll. In my opinion ‘full flap’ is
‘drag flap’, and if he/she keeps this
practice up as a bush pilot, he/she
may end up in the trees at the end of
the bush airstrip.
Yet I still hear some pilots suggest
that icing will not occur when the
ambient temperature is above
freezing. Or, if you have to apply
carby heat, don’t pull it completely
out; they suggest half-way because of
the power reduction experienced.
ED: pilots should do what the pilot’s
operating handbook (POH), and/or
the aircraft flight manual (AFM) says
for that particular aircraft (unless
that information has been officially
superseded by the manufacturer or
CASA).
I have personally experienced
visible ice build up on a Continental
0-470 carburettor aluminium alloy
induction yoke whilst the engine
was running at low power. This was
LINDSAY AMOR EMAILED
Lindsay had been re-reading
an article from last year on
controlled flight into terrain
(CFIT), prompting him to submit
the following thoughts.
1. It is time that aviation around
the world settles on just one
standard, instead of confusing and
contradictory use of measurement
paradigms (metric and imperial and
even American standards). Logically,
it should be the metric standard:
distance and heights in metres and
kilometres, weights in grams and
kilograms, and liquids in litres.
There have been numerous accidents
and incidents caused by confusion from
different measurement standards.
2. The phonetic alphabet is old and
needs updating to reflect modern
understanding of phonetics, then
appropriate words selected for a
new phonetic code. Words would
be selected for ease of use and
understanding and in consideration
of
various
countries’
cultural
sensitivities.
3. It is time that cabin instrumentation
is standardised for each aircraft
Where is your
aircraft right now?
Track your aircraft in real-time with spidertracks,
the world’s leading portable aircraft tracking system.
+ No installation required,
simply plug it in and start
tracking
+ No software to install, view
all of your tracks at
www.spidertracks.com
+ Rentals available from as
little as $80 per month plus
ongoing costs
+ Track your aircraft,
manage your fleet, protect
your people, invest in your
business
+ Book your FREE no
obligation demonstration
today. Call 1800 461 776
or email
demo@spidertracks.com.au
P 1800 461 776 E info@spidertracks.co.nz www.spidertracks.com
type, this will over time simplify the operation, training
and reduce possibilities of confusion and therefore
reduce the possibilities of accidents.
Standard operating procedures for the particular airline (I
was employed by nine) should include crew comparisons/
discussions of all significant factors.
4. Reduce the amount of jargon, archaic terms and the
use of letters instead of full words. This sort of usage is a
throw-back to the early military days of aviation and has a
sort of elitism that one finds in medicine and botany and
so forth, but is a source of confusion in aviation which has
brought about operational incidents in the past. Let me
give just one little example. ‘QNH’ when printed is three
letters, but when said it’s ‘Que En Aitch’ 3 words, so where
is the saving? And its meaning? ‘Question nil height’; an
old term from the days of Morse code, which is not even
used now. How many know its real meaning or origins?
This Tullamarine incident would not have happened
if a professional flight engineer had been in the crew.
Such professionals always made their own calculations
and comparisons.
The other area that has a lot of jargon is the weather
reports. In the days of Morse code and limited information
transferral and storage; it made sense to have the weather
in abbreviated codes. But not now, if you need to look
up a book to decipher the code then that code should be
banished to the archives.
It would be good to raise some of the issues in your
magazine for general debate.
Wishing happy landings to the investigators.
ED: Keep those emails and letters coming in. We value
your feedback, and while selfishly perhaps, it’s nice to
have the positive ‘bouquets’, we need the brickbats too,
so that we can continue to improve the magazine.
Airworthiness
Consultancy
Services
Providing quality services for certification,
manufacturing & maintenance requirements.
Independent auditing to ISO, AS or regulatory
standards.
As a one-time DCA Airways surveyor and 28-year PIC
in international airline flying (and with 24,000 plus pilot
hours), I feel it important to raise several issues:
Specialising in Quality Management Systems
for Part 21 manufacturing, maintenance &
MITCOM.
For many years it has been standard airline practice to
apply ‘limited EPR’ on take-offs, that is, to use less than
full jet thrust on take-off if atmospheric conditions and
runway length meet certain conditions. I disagree. Having
made thousands of take-offs (1943-1993), I consider this
to be the most critical in any routine flight. Maximum
thrust permitted by engine manufacturers should be
applied until the aircraft attains minimum circling altitude
for that particular runway.
John Niarchos
Grad Dip Aircraft Eng Mgt, LAME
T/F: 61 3 9885 8662
M: 0449 768 449
E: johnacs@bigpond.com
ABN 1942 358 1785
AIR MAIL
ROBERT BIRCH WROTE REGARDING
THE ‘TULLAMARINE TAIL SCRAPE’
INVESTIGATION
3
NEW CASA BOARD
Transport
minister,
Anthony
Albanese, announced members of
the new CASA board on 29 June.
According to the minister’s media
release: ‘The appointments flow from
the landmark legislation that passed
through the parliament in May
creating a new five member expert
board for CASA, and establishing the
ATSB as a separate statutory agency
with a full time chief commissioner
and two part-time commissioners.
FSA SEP–OCT09
4
The intellectual calibre and diverse
experiences of the individuals
being
appointed
underscores
the determination of the Rudd
Labor Government to preserve
public confidence in the safety
and reliability of air travel. While
Australia has an enviable safety
record, we cannot take past success
for granted,’ said the minister.
The new CASA Board comprises:
Dr Allan Hawke (chair), David Gray
(deputy chair), Trevor Danos and
Helen Gillies, with CASA’s CEO and
Director of Aviation Safety, John
McCormick, as an ex-officio member
of the board. The first CASA board
meeting took place in mid-July.
At the same time, Martin Dolan
became
the
new
Australian
Transport Safety Bureau (ATSB)
chief commissioner, supported by
Noel Hart in the position of parttime commissioner, with the second
part-time position yet to be fi lled.
Muchamad Sholehuddin, Agustinus
Budi Hartono, Sigit Sudarmadji
and Udi Tito Priyatna attended a
course in Brisbane, led by CASA’s
Michael Horneman and David Voss.
Michael and David conducted a
variety of workshops, including the
one pictured opposite, where the
inspectors conducted an investigation
following an accident.
AUSTRALIAN-INDONESIAN
COOPERATION
The joint Australia-Indonesia
education and mentoring program
for Indonesian aviation continued
with six Indonesian Directorate
General Civil Aviation (DGCA)
inspectors travelling to Australia in
July as part of CASA’s foreign agency
program. Capt. Megi Hudi Helmiadi,
Capt. Anderson Adrin Pinson,
Michael Horneman & David Voss (right)
State of the Art, Two Place, Touring and Training Aircraft – Certified IFR (FAR Part
23)
• Safety – robust modular design with incredible visibility
• Performance – advanced aerodynamics with high manoeuverability
• Comfort – 48” wide cockpit with huge baggage space
• Utility – Useful load after full fuel 192 kg
• Simplicity – FADEC Engine with digital engine monitoring display
• Economy – 132 knots cruise at 23 litres per hour, up to 500 nm range plus
reserves
• Affordability – low purchase price and low operating costs
Book a demonstration
flight now!
Call 0419 355 303
Contact Nigel Hutchinson–Brooks
Liberty Aircraft Company Pty Ltd A.C.N. 118 727 889
Tel 03 5662 5658 Fax 03 5662 5179
Email nigelhb@libertyaircraft.com
Details at www.libertyaircraft.com
This program is part of Australia’s
commitment to helping to improve
aviation safety in Indonesia and
is building stronger connections
between Australian and Indonesian
government
agencies
through
‘people-to-people’ links.
EU LIFTS BAN ON GARUDA
fourth overall in the championship
after his British rival had a worse
race on the challenging course set
up just 20 metres above the Detroit
River that runs between Canada
and the U.S. city of Detroit. He has
19 championship points from three
races – only 14 behind Arch and 13
behind Bonhomme in second.
MATT HALL NOW FOURTH
Matt Hall, who was interviewed in
March-April’s Flight Safety feature:
‘The war on error’, has climbed to
fourth place overall in the Red Bull
Air Race World Championship. Hall,
a former RAAF fighter pilot, and a
Red Bull rookie, had a challenging
final run in Windsor, hitting two
pylons and ending up falling back to
seventh place. But he was still able
to move ahead of Nigel Lamb into
5
The offending pylon – bottom left
Stop press
After the Budapest race on 20 August, Matt
Hall has dropped to fifth place overall, with
two races left to go in the season.
FLIGHT BYTES
The European Union has removed
a ban on four Indonesian airlines,
including the national carrier
Garuda, from flying its air space
in recognition of improved safety
standards. The ban was imposed in
2007 after a slew of fatal accidents,
including the Garuda crash in
Yogyakarta, which killed 21 people,
including five Australians travelling
to a media event held by the then
foreign affairs minister, Alexander
Downer. ‘Significant improvements
and accomplishments of the
Indonesian civil aviation authority
are recognised in the area of safety,’
the EU said. Garuda said it was
looking to resume flights to Europe
next year.
Sydney Morning Herald 16 July p12
STRONG LINE-UP
FOR SAFESKIES
Organisers of the ninth biennial
SafeSkies aviation safety conference,
to be held during 6-8 October, 2009
in Canberra, have assembled a strong
line-up of speakers who will address
the conference theme of ‘Managing
aviation safety in a changing
environment’.
FSA SEP–OCT09
6
According to President of SafeSkies,
Peter Lloyd, the calibre of the
speakers, who include Captain
Bertrand de Courville (pictured
right) head of safety for Air France,
‘emphasise how timely the theme
of our conference is. We are very
pleased that Capt de Courville is able
to contribute to our conference at a
time when aviation safety issues are
under new scrutiny following recent
tragic crashes.’ Capt de Courville is
co-author of a human factors training
course devoted to professional pilots,
and has been actively supporting
safety information sharing for many
years, all around the world, through
a number of conferences and articles,
as well as through specific safety
initiative together with Airbus and
Boeing. He was also a contributor and
supporter of the ICAO human factors
program led by Daniel Maurino
during the 1990s.
Chairman of SafeSkies, David
Forsyth, who will welcome the 400
attendees expected for the event,
outlined some of the other speakers
who will address the conference.
‘Along with Capt de Courville, we have
respected aviation safety specialist,
Dr Rob Lee, who will talk about the
necessity, in these turbulent times, to
have integrated safety management
systems in place. Dr Paul Dempsey,
an aviation law academic from
Montreal’s Magill University, and
Nancy Graham, the head of ICAO’s
Air Navigation Bureau, will give an
international perspective on the
theme,’ he explained.
Professor Dempsey (pictured on
page 7) has a stellar academic
and public affairs career: he was a
Fulbright Scholar, was awarded the
Transportation Lawyers Association
Distinguished Service Award, and
was designated the University of
Denver’s ‘outstanding scholar’. He
has published 20 books and ninety
law review and academic journal
articles, and scores of newspaper
and news magazine editorials. He has
testified before the transportation
committees of the U.S. Senate, the
U.S. House of Representatives, the
Canadian Senate, and the state
legislatures of Colorado, Michigan
and Texas. There would be few
countries internationally where he
has not lectured, across Europe,
North and South America, the AsiaPacific region, and now in Australia.
Nancy Graham assumed her current
position in April, and oversees much of
the work undertaken in the development
of ICAO’s technical standards and
recommended practices (SARPs) critical to the safety of the international
air transport infrastructure.
Sir Roy McNulty, the recently-retired
former Chairman of the UK Civil
Aviation Authority will bring another
international perspective, and years
of aviation regulation experience, to
his address entitled ‘Managing safety
in difficult or business environments’.
Domestic issues in these challenging
economic times for the industry will
also receive a strong focus. Qantas
CEO, Alan Joyce, will give the Sir
Reginald Ansett Memorial Lecture
prior to the conference dinner; and
Tiger Airways’ MD, Shelley Roberts,
will speak on ‘Safety management in
a low-cost carrier’, while the ‘Safety
management challenges of a regional
RPT carrier’ will be the topic for
Jim Davis, MD of Regional Express
Airlines’ (Rex).
The Aviation Policy Group (APG),
comprising the heads of the
government instrumentalities: Mike
Mrdak, secretary of the Dept of
Infrastructure, Transport, Regional
Development and Local Government;
Air Marshal Mark Binskin, Chief of
Air Force; John McCormick, Director
Aviation Safety, CASA; and Greg
Russell, CEO, Airservices Australia,
will explain the group’s role in facing
the current aviation safety challenges.
The APG, David Forsyth explains, plays
a unique role. ‘To have this working
relationship between the key players
in aviation safety makes Australia the
envy of many countries, and facilitates
the co-ordination of the key agencies.’
The conference is now almost at
capacity, so those wishing to attend
should confirm their booking by
registering online at
www.safeskies.org.au or
www.conlog.com.au/safeskies/
registration.html,
or by downloading the form.
Full registration is $880, with a
discounted registration of $770 for
groups of 10 or more/corporate, or
GAPAN members.
For more information, phone the
conference organisers:
7
02 6281 6624, or email
conference@conlog.com.au
SAFESKIES
In tthe wake of last year’s American
hel
helicopter emergency medical services
(HE
(HEMS) safety record, Flight Safety
di Margo Marchbank, looks at
editor,
industry responses to the statistics.
FSA SEP–OCT09
8
H
EMS
diagnos
s
The accident and fatality rate in the American HEMS sector over
recent times has prompted a series of investigations, am
mong
them a US National Transportation Safety Board (NTSB) public
hearing earlier this year. Speaking at that hearing, Dr Ira Blumen,
of the Chicago Aeromedical Network, quoted in the March 2009,
AeroSafety World, said ‘a detailed analysis found that 146 HEMS
accidents, including 50 fatal accidents, occurred between 1998
and 2008. Of the 430 people in the accident helicopters, 131 were
killed, including 111 crewmembers, 16 patients and four others’.
The article goes on to say that 2008 was ‘the most deadly year on
record for HEMS in the United States, with 13 crashes, nine of them
fatal, and 29 fatalities’.
It was against this background that Australian company, Aerosafe
Risk Management, was commissioned to undertake an assessment
of the American HEMS industry. Flight Safety spoke to Kimberley
Turner, Aerosafe CEO, in Sydney at the company’s Australian
headquarters. The story began in 2005, when Kimberley Turner presented a case
study of the Australian HEMS Aviation Safety Network (ASN) at the 2005 International
Helicopter Safety Team meeting in Montreal. The Chairman of the Association of Air
Medical Services, hearing about the ASN, pressed her to speak at a medical conference
in Austin Texas, which Kimberley says, was ‘amazing. There it’s a medical industry
which happens to “do” aviation, whereas in Australia, it’s an aviation industry which
happens to do medical work. It’s a huge difference.’ The ‘leading-practice example
down-under of how to overcome the barriers of competition, and
unite in safety’, according to Kimberley, led to a lot of interest in the
ASN, with American HEMS operators wanting to join. ‘At this time’,
she says, ‘safety management systems were not in the vocabulary in
the US’, whereas Australia was ‘probably three to five years into the
process’. The North American Aviation Safety Network was launched
in May 2007 at the Australian Embassy in Washington DC.
A year later, in May 2008, on the basis of the work Aerosafe had
been doing with the ASN, they were approached to undertake an
industry risk profile of American HEMS. There had been, Kimberley
says, a lot of analysis to that date, looking at operational and training
issues, but nothing which took a ‘holistic view, which got to the heart
of the systemic issues’. Using the methodology which the company
had already applied to good effect in Australia and New Zealand,
Aerosafe consulted widely with organisations such as the Federal
Aviation Administration; the NTSB; the Joint Health Care Commission;
the American Association of Air Medical Services; the Helicopter
Association International; the Flight Safety Foundation; and HEMS
operators. After broad consultation on the draft, they released the
HEMS Industry Risk Profile (IRP) in April 2009. Despite comments
from some detractors that ‘we don’t think this report will get traction’,
since April there have been over 50,000 downloads of the report from
the Flight Safety Foundation website (www.flightsafety.org).
9
HEMS DIAGNOSIS
Previous HEMS safety improvements, such as the NTSB’s ‘Most
Wanted’ had suggested:
Conducting all flights with medical personnel on board in
accordance with Federal Aviation Regulation Part 135 – charter
aircraft operation – with its tighter operating restrictions on weather
and visibility
Installing terrain awareness and warning systems (TAWS) on all
EMS aircraft
Formalised procedures for dispatch and flight-following, including
current weather information.
However, the IRP was the first HEMS study to examine ‘latent and
systemic’ issues in the current HEMS structure, in order to
o first,
identify factors with the potential to introduce operational or safety
risks, and then to address them.
The report, Kimberley explains, provides a ‘focal poi
oint for the
American industry to get behind the scenes, and revisi
sit
how the structures are designed, and their impact on
n
how things are done. A lot of work has been done, but
b
maybe these efforts haven’t been linked back to
o the
cause of the risk’. The profile was developed usi
sing the
process in the International Standards Organization
ion draft
d
standard on risk management (ISO31000), (which in turn
urn
is based on the Australian-developed standard). ‘Risk managemen
ement,’
Kimberley explains, ‘is a confronting field. You have to be mature in
n
‘the most deadly year on record for HEMS in
the United States, with 13 crashes, nine of
them fatal, and 29 fatalities’.
Implementing programs to evaluate the safety risks of each flight,
and
being willing to identify risks, and prepared to acknowledge the real
cause, and your role in inducing or removing risk.’ Consequently, there
was some industry resistance to the ‘warts and all’ findings outlined
in the profile.
FSA SEP–OCT09
10
The process was very comprehensive: 161 HEMS stakeholders were
identified in the initial and review stages, including 74 FAA-approved
Part 135 HEMS operators. According to the National Association of State
EMS Officials, there was ‘slow but steady growth’ in HEMS
operations in the United States from the 1970s, but rapid
growth from 2000 to today—from 400 EMS helicopters in
2000 to the present approximately 850. Perhaps the key
driver behind this phenomenal growth was the new formula
for reimbursing operators set by the Centers for Medicare
and Medicaid Services in 2000, where operators are paid
on flight volume, a move which encouraged the entry of
private, for-profit HEMS operators. Thus HEMS operators
in the US now include the community-based, not-for-profit
model seen in Australia;
hospital-owned
services;
private operators; and large
enterprises,
commercial
such as one public company
operating a fleet of over
300 aircraft, listed on the
American stock exchange.
The IRP report identified 26
distinct risks, categorising
eight of these as ‘very high’. Three ranked at the top of the
‘very high’ were: the lack of a well-defined national EMS
structure; the problematic nature of the ‘current medical
reimbursement model (primary payer model)’; and the
‘complexity, non-alignment and lack of clarity around
the roles and scope of federal, state and county agencies
involved in oversight of the HEMS industry.’ A report issued
by the Australian Transport Safety Bureau (ATSB) following
the Bell 407 air ambulance accident, which claimed three
lives in Queensland in 2003, reinforces the last finding. In
the Queensland case, responsibility for safety oversight was divided
between the Queensland Department of Emergency Services Aviation
Services Unit, Central Queensland Helicopter Rescue Ltd and the
operator. The ATSB report noted that ‘safety systems are strongest
when one organisation has overall responsibility’.
The US ‘primary payer’ model for Medicare reimbursement, the IRP
report says, ‘fosters the proliferation of new programs that operate
in rural areas and that incur the lowest operational overhead,’ to the
potential detriment of services in urban and suburban areas. This
commercial, ‘task-by-task’ imperative can also lead to ‘EMS shopping’
where a client can call several competing operators, and eventually
find one willing to undertake a task which others have deemed to be
too risky, because of adverse weather conditions, for example. The
H
report also describes how this reimbursement model can also
limit the uptake of technological advances such as night vision
goggles (NVGs), helicopter terrain awareness warning systems
(H-TAWS), or the use of more sophisticated twin-engine, IFR
aircraft.
During May to mid-July 2009, ‘the full
spectrum of industry stakeholders’ were
when a helicopter
invited to ‘work through the HEMS IRP’
occurs,
in order to develop individual submissions
ples the risk of
trip
outlining the risk treatment strategies they
were already undertaking, or were willing
plann
nin
ng
to commit to; and during August a risk reduction p
conference attended by representatives of all stak
kehol
olld
deer
er
groups developed a HEMS industry risk reduction actiion plaan
n..
This plan was due for release as Flight Safety went to print
p ntt.
with industry definition and contracts’,
Kimberley argues, ‘so that then puts
more emphasis on the operating
systems and safety management
systems. Australia’s medical helicopter
system is much more mature [than in
the United States].’
Ohlsson,
Greg
more than
chief of checking
and training at the
fatalities,
community-based
CareFlight service,
agrees. IIn Australia, ‘we are lucky in
that we have first-world clients, and
first-world-providers.’
EMS crash
darkness
As in the United States, Australia’s HEMS operations began in the
1970s, with the first service established in Sydney in 1973. There is
now a network of operators in all states and territories – these are a
mix of community-based, government and commercially-contracted
operators. However, as distinct from the US, all contracts are organised
at a state level, generally though the respective departments of health,
in association with the state ambulance services. By mapping at a
state level, Kimberley says, ’you’ve got more visibility of what the
needs are. The placement of aircraft is mapped out: so in Queensland,
for example, the coastal areas are served by HEMS, and the inland
by the Royal Flying Doctor Service, and other fi xed-wing providers.’
That doesn’t happen in the US – ‘there are no contracts, and if you
see a commercial opportunity, there are no real barriers to starting
up business’.
‘Over there, it’s the medical industry which happens to be in aviation.’
But here, the doctors and paramedics are nearly all employed by or
contracted to health departments, or the ambulance service, and the
contracts come back to a central point. ‘We have a good balance between
aviation and medical.’ In the United States, she explains, aviation is
regulated at a federal level [by the FAA], but the medical component is
administered at the state level – with hospitals regulated, and doctors
and equipment licensed. ‘Australia has done a good job at the back end,
That’s not
n
to say, however, that
Australiaa can afford to be complacent,
which is why tthe Australian HEMS industry
has seen a conttinuing focus on safety and risk
management aand governance, undertaken
both by membe
members within the framework of the
Aviation Safety Network and by other HEMS
operators. One risk identified in a number of
studies is the ‘contribution of darkness and
bad weather to the likelihood of helicopter
EMS crashes’. A study published in the Annals
of Emergency Medicine, (April 2006) found that
‘when a helicopter EMS crash occurs, darkness
more than triples the risk of fatalities, and
bad weather increases the risk eight-fold’. The
study goes on to say, ‘To reduce the likelihood
of crashes and deaths in night flights, many
have argued for night vision goggles (NVGs)
and helicopters equipped for night vision
flight.’ In a joint statement to the National
Transportation Safety Board hearing earlier
this year, three HEMS industry associations
asked the NTSB to consider a number of
recommendations, including ‘a requirement
that all night EMS flights be conducted either
with NVGs or another form of enhanced
vision system, or under instrument flight
rules’. Similar recommendations were made
in Australia following the Queensland HEMS
accidents, which resulted in first a CASA
trial, and then approval for the use of NVGs
in helicopter EMS.
‘It was, very deliberately,’ Charles Lenarcic, a
CASA avionics specialist working on the NVG
project explains, ‘a measured process. The
11
HEMS DIAGNOSIS
The HEMS situation in Australia, Kimberley Turner explai
e
inss,
is ‘quite different. There is no socialised medicine in the US,
hei
heir
and there are no state-based contracts as you have in Australia. The
business model is completely different, with a reall patchwork of
governance arrangements and licensing. Now just because the mode
d l
is different doesn’t mean it’s necessarily more risky, but there are so
many gaps in accountabilities. Although there are a lot of standards
and accreditation requirements, they are not centralised in the one
spot. ‘If you are paid on patient transport volume, what better way is
there to induce risk?’ she asks. Services tend to be provided where it is
profitable to do so, and there may be a tendency to deploy less capable
aircraft, because they are more commercially viable.
intent behind the regulations was to create a consistent environment,
to set standards [encompassing] equipment, flight crew training and
operational methodology across Australia. There were no “ifs, buts
or maybes”. Night vision technology is’, he continues, ‘restricted
technology, available only to accredited users and approved
organisations. There was a great team, with both CASA and industry
involved’, Charles says, ‘Yvette Lutze and John Beasy headed the
project team, supported by Dale South and Matthew Wallace who
have a range of civil and defence helicopter experience. The team
was oversighted by John Grima from CASA.’ Most of Australia’s EMS
and law enforcement operators participated in the trial, including
CareFlight NSW, Rotor-lift Aviation, EMQHR, the Victorian, Western
Australian and NSW Police Air Wings, Westpac Rescue Helicopter
Service (WRHS), CHC Helicopters and Australian Helicopters, to
name a few.
FSA SEP–OCT09
12
The operators have now had about two years’ utilisation of
NVGs, since the CAO came into effect in 2007. Flight Safety
spoke to a number of operators for an update on their
experiences with NVGs: CareFlight; the Hunter/ New England/
North West Westpac Rescue Helicopter Service, and the NSW
Police Air Wing, currently undergoing NVG
training for their search and rescue operations.
They are all careful to point out that first and
foremost, NVGs do not turn night into day; as
the CareFlight training manual states: ‘NVG
flight uses night-flying techniques with a vision aid – NOT
day techniques with a reduced field of view’. It is easy to
focus on the night vision goggles as the most-visible part of
a night vision imaging system (NVIS), but as recognised in
CASA’s regulations, an NVIS comprises four equally important
elements. There are the NVGs themselves [goggles, battery pack,
helmet attachment]; the cockpit lighting system; crew and training;
and operational procedures.
Currently, the only NVGs approved for civil HEMS use in Australia are
American manufactured models, which are subject to the stringent
International Trade in Arms Regulation (ITAR) control administered
by the US State Department. However, according to Charles Lenarcic,
‘whilst the US have been world leaders in this technology to date, the
Europeans are rapidly developing comparable technology. The ANVIS
9 are the best goggles you can get out of the States at the moment’,
he says, ‘whereas their more capable models, with significantly
improved performance are not available in Australia due to the ITAR
restrictions.’
Mike de Winton, an ex-military helicopter pilot, has been in charge
of the implementation of NVGs at the Westpac Rescue Helicopter
Service (WRHS) headquartered in Newcastle, in NSW’s Hunter
Valley region, but is off duty after a night shift when Flight Safety
visits. So it is Kevin Ratcliffe, (pictured above left) another highlyexperienced former UK military helicopter pilot, now flying for the
Service, who gives a background on the Service’s implementation
of NVGs. The WRHS has he explains, ‘probably used the NVGs on a
hundred or so missions. The NVGs are not expanding the envelope
of what we do, just enabling us to do it more safely.’ There was a
detailed process necessary to set up the NVIS for the Service.
People tend to think simply of the goggles, but appropriate cockpit
lighting is vitally important. ‘Most instruments are internally lit, with
dimmers set up in banks, but all that lighting has to be off,’ Kevin
says, ‘because it’s not compatible with NVGs.’ To make illumination
of the entire area suitable, each of the Service’s three aircraft, the
Bell 412 (the primary response aircraft) and the two BK-117s had to
have the cockpit lighting disassembled to sort out the wiring. Then
‘compatible brow lighting on the instrument coaming, and elsewhere
in the cockpit was installed, so that there is even illumination down
on all the instruments of interest, radios etc There was a certain
amount of trial and error,’ Kevin explains, but the ‘result is very even
illumination’. This in turn has to be approved under the regulations.
This experience reinforces the
importance of training, of currency,
and a raft of human factors issues
in using NVGs. When Flight Safety
visited the CareFlight base in the
Westmead Hospital precinct in
Sydney’s west, chief of check and
13
HEMS DIAGNOSIS
‘So we’ve done the recce’ he continues, ‘we’ve said “here’s
the plan”. We’ll go in on the goggles, and position ourselves.
Here I have to go off the goggles and do the hoisting with
the searchlights and the NiteSun will be illuminating the area.
But we had a bit of a drama with the hoist and the aircraft
electricals; one of the generators dropped offline. I couldn’t
NVGs do not turn night into day
He details a number of the missions undertaken so far using NVGS,
and the understanding required when using the goggles. ‘I was on
a mission up to Hat Head.’ (A national park on NSW’s mid north
coast). The 412 was tasked to retrieve a [bush] walker from
a slope on the ocean side. ‘There was a certain amount of
weather – cloud above us. We went up on the goggles, which
gave us a darn good appreciation of the conditions on the
way, well before we got there. On approach we were talking
to the guys on the ground, and could see the lights on their
reflective jackets. We went around a couple of times to set
ourselves up. At this stage, as an organisation, we have set
operational constraints on what we can do on goggles, while
we’re still getting things bedded
down. Taking a risk management
approach, we’re not doing any
low-level searches; over water
operations; or hoisting, for
example, on goggles, while we
build up operational experience
with them in more benign
mission environments.’
reset the generator, so I decided I was not
really happy, and went away to somewhere a
bit safer, away from the hover. The last thing
I wanted was to have the other generator
drop off, and lose all my lights, working at
relatively low level near the cliff. We sorted
ourselves out, and came back on goggles
around the headland on the seaward side “wham” straight into showers we never saw
coming. The light reflected off the rain makes
the goggles virtually useless, from medium
showers upwards. We had briefed up on an
escape route, slightly north, but slightly out to
sea, over water, convenient and safe. I reverted
to instruments on an agreed safe heading, and
I got Pete, my crewman, to stay on goggles
and tell me when we were out of the showers.
It was a great learning experience, because
it showed just how abruptly you can go from
aided flight which is working for you, to having
to revert (to instruments).’
Crew resource management (CRM) becomes especially critical in
NVG operations. CareFlight did CRM training in Sweden, former
CareFlight crewmen instructor Jeremy (Jerm) Cutelli explains,
‘because the Swedes offer the best course. They have a brilliant
LOFT session in a full-motion simulator.’
FSA SEP–OCT09
14
Both the Westpac Rescue Helicopter Service and CareFlight
operate contracts for the NSW Ambulance Service, and
full implementation of NVGs only came about after NSW
Ambulance was fully satisfied that the safety benefit of the
technology outweighed any potential risk. Both operators
use the goggles in less populated areas, the WRHS especially
in their New England-North-West operations, and CareFlight
in the Northern Territory, as well as SAR IN NSW since April
2008. However, CareFlight have only
had full NSW Ambulance approval
to use the goggles in their Sydney
Basin and Central Coast HEMS since
the end of April 2009. They are in
the final stages of conducting the
head injury research trial (HIRT) in
metropolitan Sydney, and have faced some challenges in
gaining approval to use the goggles in this environment, but
as Greg Ohlsson explains, ‘It’s all about how you manage
the risk’. CareFlight also contracts to the Northern Territory,
where their NVGs have been used mostly to date. One of
the first incidents where the NVGs demonstrated their
usefulness was in the retrieval of an 18-month-old boy with
respiratory problems in the Katherine area. Using the NVGs,
Greg was able to fly safely at the lower altitude necessary to ensure
the baby boy’s breathing.
CareFlight has also been conducting NVG training for the NSW Police
(Aviation Support Branch), also members of the Aviation Safety
Network. The Police Air Wing (Polair) implemented a venture/change
risk management plan for the introduction of NVGs to manage this
key area of operational change. At Polair, there has been involvement
from the top down. Commander Ian Bown, who has completed the
ground course, says ‘It was good to see what’s going on, and the
impact your decisions have, as well as appreciating their (the NVGs’)
limitations.’ ‘The NVGs fit well into Polair operations’, he explains,
and describes the case of a search for a person lost in Sydney’s
Royal National Park. ‘Using the goggles, the crew identified the
person by the light of their mobile phone, and saved an hour or two
of flight time.’ The goggles are also useful , he says, in identifying
emergency landing areas such as golf courses, and ‘we can maintain
a search after last light, because even small light sources make
them visible: a mobile phone or a camp fire’.
Given that the NSW Police conducted 140
searches for missing persons over the past
12 months, and such searches represent
16 per cent of their activity, the NVGs are
likely to play an increasingly important role
in Polair operations. Although according to
Commander Ian Bown, Polair ‘hasn’t found a
downside yet’ to using the goggles, Inspector
Phil Gornall, Polair’s chief pilot says ‘NVGs
require a significant level of discipline, and
crew have to be competent in a wide range
of areas, relying heavily on team member
interdependence.’
Pic courtesy of 92 TIF Combat Camera Section
training, Greg Ohlsson was conducting NVG training.
CareFlight’s training package emphasises both the advantages
and disadvantages of the technology, and the importance of
knowing, understanding and operating within the limitations
of NVGs.
From the top: the same scene viewed by day, at night
and through NVGs.
ADVANTAGES Disadvanta
N
NVGS
Advantages
Di d
Disadvantages
t g
No disadvantages compared to NVFR, beyond costs
of acquisition.
If compared to day VMC
Enha
En
hanc
ha
nced
nc
ed visu
ual acuity at night
Visual acuity not equal to day
See the horizon & terrain
Reduced field of view
Ob
bse
serr ve in-fligght meteorological conditions
Depth perception/distance estimation
Identify obstacles and in-flight hazards
Requires aircraft compatibility
High-level of crew coordination
Increased situational awareness
Potential for increased fatigue
High concentration & workload
Potential for overconfidence & complacency
Visual acuity increase tempts you
Situational awareness increase tempts you
Weather more easily seen – mostly!
Source: CareFlight training manual
‘Closing the loop’ Linda Werfelman
AeroSafety World
d March 2009 p14-18
‘Systemic ills’ Linda Werfelman
AeroSafety World
d May 2009 p 12-17
Night Vision Goggles in Civil Helicopter Operations
April 2005
Australian Transport Safety Bureau Aviation Research Report –
available online @ www.atsb.gov.au
‘The view ahead’ - Dr Boyd Falconer & Melanie Todd
Flight Safety Australia May-June 2007 p 36-37. Available online
@ www.casa.gov.au
‘EMS helicopter crashes: what influences
fatal outcomes?’
Annals of Emergency Medicine Vol 47 No.4 April 2006
‘What is the right helicopter for our medical
scene response?’
Blair J Mumford: Injury Journal December 2002
‘Safety of emergency medical service helicopters’
Medical Journal of Australia January 2005, p12-19
‘Fatal night flight’
Flight Safety Australia May-June 2005 p34-37, adaptation of
ATSB report 200304282, available online @ www.atsb.gov.au
Helicopter Emergency Medical Services: Industry
Risk Profile.
Aerosafe Risk Management April 2009. Available online @
www.flightsafety.org or hardcopies can be ordered from the
Foundation of Air Medical Research & Education, Virginia,
USA: www.fareonline.org
HEMS DIAGNOSIS
For more information
15
!"#Notes
Aerodrome
safety for
airside drivers
16
F
FSA SEP–OCT09
or the uninitiated, driving a vehicle airside can be extremely
hazardous. Serious incidents like runway incursions involving
tugs, catering vans and other vehicles can occur. Fortunately
these types of incidents can be prevented.
Here are a few tips to help you increase your safety and situational
awareness at the aerodrome:
t obtain a clearance to enter a runway
t comply with Air Traffic Control (ATC) instructions and
clearances
t comply with published aerodrome procedures
t use standard phraseology
t accurately report your vehicle’s position to ATC
t be extra cautious –
- in reduced visibility (e.g. night, smog, rain or storm)
- when using a runway where taxiways intersect with another
runway
t look for possible landing aircraft in the area before entering or
crossing a runway – even if ATC has given you a clearance.
Planning your aerodrome operations
Before you take to the roads it’s important to plan your airside
movements. Always have a current aerodrome chart or diagram
available and familiarise yourself with what visual aids on the
aerodrome mean including markings, signs and lights.
At all times be aware of where you are and what (planes, vehicles
etc.) is around you. Minimise ‘heads down’ activities while driving
and use vehicle lights to show your location, ensuring the rotating
beacon is on when driving on aprons, taxiways and runways.
Gaining clearance from Air Traffic
Control
When receiving clearance for your aerodrome operations always
communicate clearly and concisely, stating your position when you
first contact any tower or ground controller, regardless of whether
you have stated this before to a different controller.
Write down any clearances or instructions, especially if detailed or
complex. Read all instructions back clearly, being sure to include
your call-sign. If you are unsure of an issued instruction, be sure to
clarify with ATC as soon as possible and let them know if you are
unable to comply with their instructions.
It’s also important to listen out for other vehicles or aircraft with a
call-sign that sounds like yours to ensure there is no confusion.
TIP: If you are unsure of your location on the aerodrome,
make sure you are clear of any runway and STOP. Speak to
ATC about your situation and ask for progressive clearances
or instructions, or seek help from other ground personnel (e.g.
aerodrome safety officer) immediately.
For more information
To find out more refer to our booklet: Runway Safety – An Airside
Driver’s Guide to Safe Surface Operations at Controlled Aerodromes
on our website at www.airservicesaustralia.com
For a hard copy of the booklet or for more information on how
Airservices is improving safety for airside drivers contact Fiona
Lawton, Safety Programs and Promotions Manager, at
safety.promotions@airservicesaustralia.com
Above: Airservices AusFIC employees processing critical flight
information and facilitating pilot information requests.
Tailor-make your flight: Specific
Pre-flight Information Bulletins
Airservices’ Specific Pre-flight Information Bulletins (SPFIB) allows
pilots to retrieve MET (meteorological) and NOTAM (Notice to
Airmen) information relating to the departure, destination and en route
locations of their flight and its planned altitude.
Default data from the bulletin can also be transferred to a flight
notification so pilots do not need to re-enter default information.
Any Air Traffic Services (ATS) route shown on a chart is pre-stored
along with its NOTAM and weather requirements. These ATS routes
are available as stored routes to select from when creating the SPFIB,
enabling easy configuration of the required bulletin. If needed, any
off-track NAVAID (Navigational Aid) information may be requested
through the use of ‘additional locations’.
Similarly, FIR (Flight Information Region) NOTAM, PRD (Prohibited,
Restricted or Danger) NOTAM and ARFOR (Area Forecast) relating to
an ‘ad hoc’ route are not automatically included in the bulletin and need
to be noted under additional information requirements.
Each bulletin created generates a NAIPS SPFIB Reference Number that
can be used to easily access and update the bulletin immediately before
flight or in-flight when using FLIGHTWATCH.
Pilots can ask for the bulletin to be stored and retrieve it as a flight file
with a description of the route using turning points (called ‘ad hoc’) or
up to ten planned stages of a flight.
WARNING: An ATC instruction to operate on taxiways or
other areas of the aerodrome is NOT a clearance to cross a
runway holding position, to enter, or to operate on a runway
– unless you are specifically cleared to do so. (Note: A runway
holding position is always set back from the sealed surface of a
runway. It’s never aligned with edge of the sealed surface).
More information on these bulletins may be found:
t in ERSA at GEN-PF-2 and GEN-FIS-3;
t by visiting Pilot Briefing Services on Airservices website, or
t by contacting the Airservices Australia Help Desk on 1800 801 960.
ATC NOTES
The bulletin is free and can be requested through the Briefing Office or
directly from Pilot Briefing Services on Airservices website. It includes
Head Office (Australia General) NOTAM information and for flights
above 10,000ft AGL, a wind and temperature profile.
17
Date
Aircraft
Location
Fatalities
Damage
Description
08 Jun
Antonov
32
West Siang district, India
13
Destroyed
The Antonov 32 was dropping army supplies when it went
missing in a mountainous area near Rinchi village. The
wreckage was found two days later.
09 Jun
Antonov 2
Kadamdzhayskom,
Kyrgyzstan
0
Substantial
The Antonov 2 crashed following engine problems.
13 Jun
Antonov 2
Primorsko-Ahtarsk, Russia
0
Destroyed
The Antonov 2 struck powerlines when spraying crops.
14 Jun
Dornier
328-110
Tanahmerah Airport,
Indonesia
0
Substantial
The Dornier 328-110 was substantially damaged when it ran
off the side of the runway after landing.
20 Jun
Antonov 2
Pologi, Ukraine
0
Written off
The Antonov 2 caught fire during a refuelling operation.
25 Jun
Xian
MA60
Caticlan-Malay Airport,
Philippines
0
Substantial
The Xian MA60 landed with a tailwind too far down the
runway and overshot the runway end coming to rest at a
drainage ditch. The airport was closed for several hours.
29 Jun
DHC-6
Twin Otter
300
Wamena, Indonesia
3
Missing
The DHC-6 Twin Otter 300 flew into the side of a mountain
9600ft above sea level during a domestic cargo flight from
Dekai to Wamena.
30 Jun
Airbus
A310-324
Mitsamiouli, Comoros
152
Destroyed
The Airbus crashed into the sea while on approach.
13 Jul
Boeing
737-3H4
Charleston, West Virginia
0
Substantial
The Boeing 737-300 experienced rapid decompression
while en route and the crew declared an emergency and
landed. On examination a hole approximately 43 x 20 cm
was discovered in the top of the fuselage.
18
15 Jul
Tupolev
154M
Qazvin, Iran
168
Destroyed
The Tupolev struck terrain 16 minutes after takeoff. The
aircraft was in normal operation at 34,000ft when it
suddenly turned 270 degrees and entered a rapid descent to
14,000ft. The Tupolev exploded on impact, creating a 10m
deep crater.
FSA SEP–OCT09
International Accidents/Incidents 08 June 2009 - 11 August 2009
19 Jul
BAe 3212
Jetstream
32
Metropolitano airport,
Venezuela
0
Substantial
The British Aerospace suffered structural damage on landing.
24 Jul
Ilyushin
62M
Mashhad-Shahid Hashemi
Nejad Airport, Iran
16
Written off
The Ilyushin flew too fast during the approach and landing.
The usual landing speed for an Il-62 would have been
between 145-165 mph, this landed at a speed of 197 mph.
The airplane went off the runway, colliding with a wall
more than 1100m from the runway.
02 Aug
DHC-6
Twin Otter
300
Between Jayapura and
Okibil, Indonesia
?
Missing
The DHC-6 Twin Otter was reported missing when it failed
to arrive after a domestic flight. It took off at 10:15 - contact
was lost at 10:28.
04 Aug
ATR-72212A
Koh Samui Airport Thailand
1
Written off
A Bangkok Airways ATR-72 skidded off the runway at Koh
Samui, colliding with the airport control tower building.
11 Aug
DHC-6
Twin Otter
300
near Kokoda Airport,
Papua New Guinea
13
Destroyed
Flight CG 4684 departed Port Moresby-Jackson Field (POM)
at 10:53. The airplane flew into the side of a tree-covered
mountain at an altitude of 5500 feet (1676 metres) after
aborting the first attempt to land at Kokoda.
Notes: compiled from information supplied by the Aviation Safety Network (see www. aviation-safety.net/database/) and reproduced with permission. While every effort is made to ensure accuracy,
neither the Aviation Safety Network nor Flight Safety Australia make any representations about its accuracy, as information is based on preliminary reports only. For further information refer to final reports
of the relevant official aircraft accident investigation organisation. Information on injuries is unavailable.
Australian Accidents/Incidents 08 June 2009 - 30 July 2009
Date
Aircraft
Location
Injuries
Damage
Description
08 Jun
Robinson
R44
near Laura (ALA), QLD
Nil
Serious
A fire broke out at the rear of the helicopter, after it landed
in short dry grass. When the pilot attempted to take off
to move away from the fire, the engine failed. The fire
advanced very quickly, destroying the unoccupied helicopter.
10 Jun
Bell 206B (II) Dreamworld (HLS), QLD
Jetranger
Serious
Serious
During final approach, the engine failed. The aircraft impacted
the ground and rolled over. The investigation is continuing.
Australian Accidents/Incidents 08 June 2009 - 30 July 2009
Date
Aircraft
Location
17 Jun
Robinson
R22 Beta
21 Jun
Injuries
Description
Kowanyama Aerodrome, S M Fatal
37km, QLD
Minor
After landing, the pilot exited the helicopter with the
engine running. While walking back to the helicopter, the
pilot was struck in the head by the main rotor blades and
was fatally injured.
Robinson
R22 Alpha
Darwin Aerodrome, SW M
93km, NT
Minor
Serious
The helicopter collided with terrain during a low-level
manoeuvre, and was destroyed. The passenger sustained
minor injuries.
23 Jun
Bell 206B
Jetranger
near Albury Aerodrome,
NSW
Minor
Serious
It was reported that during spraying operations, the
helicopter struck power lines and subsequently collided
with terrain.
25 Jun
Robinson
R22
Paraburdoo Aerodrome, 280°
M 120km, WA
Fatal
Serious
The helicopter was reported missing. Searching aircraft
sighted wreckage which was later confirmed as the
missing helicopter. The investigation is continuing.
29 Jun
Piper PA31P-350/A2
Mojave
Bankstown Aerodrome,
NSW
Nil
Serious
As the aircraft landed, it encountered rotor wash
turbulence from the preceding helicopter. The aircraft
was seriously damaged when the left wing struck
the ground.
30 Jun
Amateurbuilt
Express CT
Old Bar (ALA), NSW
Nil
Serious
During initial climb from runway 35, the engine lost power
and the pilot landed on the remaining runway. The aircraft
ran off the end of the runway and collided with shrubs.
02 Jul
Robinson
R22 Beta
Gold Coast Aerodrome, QLD
Fatal
Serious
While conducting circuits, the helicopter collided with
terrain. The solo pilot was fatally injured.
05 Jul
Piper
PA-28-235
Pathfinder
near Mansfield (ALA), VIC
Minor
Serious
During approach to Mansfield ALA, the engine failed.
The aircraft landed heavily in a paddock, striking a
creek bank during the bounce. The three occupants
received minor injuries.
06 Jul
Amateurbuilt VANS
RV-6
Dubbo Aerodrome, NSW
Nil
Serious
During the initial climb, the aircraft lost power. The pilot
conducted a forced landing in a nearby paddock. Upon
landing, the aircraft flipped, sustaining serious damage.
07 Jul
Cessna
182G
Skylane
Sunrise Dam Aerodrome,
074° M 81Km, WA
Nil
Serious
During cruise, the aircraft’s engine failed. The pilot
conducted a forced landing on a nearby bush track. The
pilot and three passengers were not injured.
08 Jul
Cessna
A188B/A1
AgTruck
Hobart Aerodrome, 285° M
78km, TAS
Nil
Serious
During spraying operations, the aircraft’s engine failed
and the pilot conducted a forced landing.
10 Jul
Beech 76
Duchess
Bunbury (ALA), QLD
Nil
Serious
During a go-around from a practice asymmetric landing
on runway 25, the aircraft yawed right, left the runway
then impacted the ground in a flat attitude.
10 Jul
Cessna
337A Super
Skymaster
Hillston (ALA), 090° M 10km,
NSW
Nil
Serious
During the cruise, both engines were starved of fuel when
the pilot changed tanks from the auxiliary to the main
tanks. Both engines could not be restarted and the pilot
conducted a wheels up forced landing beside a highway.
19 Jul
Mooney
M20E
Balmoral (VFR), N M 13km,
VIC
Nil
Serious
During cruise, the engine lost partial power and the pilot
conducted a wheels-up landing in a paddock, resulting in
damage to the propeller, engine and fuselage.
20 Jul
Amateurbuilt Sabre
Wedderburn (ALA), NSW
Nil
Serious
During the initial climb, the engine failed. The pilot
conducted a forced landing resulting in serious damage
to the aircraft.
21 Jul
Robinson
R44
Theodore (ALA), 225° M
8km, QLD
Nil
Serious
A grass fire developed after landing in a grass paddock,
seriously damaging the helicopter.
30 Jul
Cessna
U206F
Broome Aerodrome, NE M
19km, WA
Minor
Serious
During the cruise, the engine failed and the pilot
conducted a forced landing in scrubland. During the
landing roll, the aircraft collided with bushes and
sustained serious damage.
Text courtesy of the Australian Transport Safety Bureau (ATSB). Disclaimer – information on accidents is the result of a co-operative effort between the ATSB and the Australian aviation industry. Data
quality and consistency depend on the efforts of industry where no follow-up action is undertaken by the ATSB. The ATSB accepts no liability for any loss or damage suffered by any person or corporation resulting
from the use of these data. Please note that descriptions are based on preliminary reports, and should not be interpreted as findings by the ATSB. The data do not include sports aviation accidents.
19
ACCIDENT REPORT
Damage
FSA SEP–OCT09
20
G
N
I
S
S
E
N
R
HA
SAFET Y
As flagged in the July-August
issue, Flight Safety takes
a look behind the scenes
at the work CASA and
the Australian Parachute
Federation (APF) have been
doing on safety oversight and
industry governance.
Many people associate
with
parachuting
adventurous risk takers
who are looking for
a thrill. As CEO of
the APF, Brad Turner,
explains, while there are
some venerable skydivers, the
biggest proportion of parachutists are
those aged 18 to 35. Brad has extensive experience: he’s been in the
industry for 28 years, a chief instructor for 18 of these, has 11,000
jumps to his credit, owned an aircraft, and was on the APF board for
ten years before becoming CEO last year. This experience has been
invaluable, because since taking office, he and the board have been
closely involved in the joint efforts of CASA and the APF in safety
oversight and industry governance arrangements. He understands the
operators’ point of view, as well as the board’s role in governance.
A brief overview of the Australian parachute industry
There are approximately 64 registered member clubs of the APF, with
some 290,000 jumps performed each year and approximately 80,000
once-only tandem jumps. Of the 64 registered operators, some provide
once-only tandem jump activities exclusively.
The APF came into being in 1960 to represent recreational parachutists,
and the sport increased in popularity throughout that decade, with
organised competitions encouraging new styles and disciplines of
parachuting. In these early years of the sport, there were no specific
regulations governing parachuting and the APF was formed to
ddeveloped rules and procedures for the industry.
In 1986, the APF became a self-administered organisation under
CASA, continuing to grow under this arrangement. Throughout these
years, parachuting continued to evolve. New technologies such as the
development of the cruciform design and self-inflating ‘ram-air’ airfoils,
and the development of tandem jumping equipment, have introduced
new and different techniques. But what impact have these changes
had on the parachute industry and the way it is administered?
The APF is the primary body responsible for the administration of the
parachute industry with the APF comprising three tiers: the board and
executive; the area councils; and the drop zone (DZ) operations.
The APF executive level consists of the board of directors and the
executive management team, made up of the chief executive officer
(CEO) and a number of technical directors. Each of these directors
is responsible for specific areas, such as safety, instructors, riggers,
competitions, judges and aircraft operations. A technical officer and
an operations manager also support the office of the CEO.
review; and a survey of parachute industry
operators, were just some of the means
used to gather information on all these
key elements.
The eight APF area councils, associations recognised by the APF as
affiliated councils of the APF, represent each state and territory. Each
council is responsible for appointing an area safety officer (ASO), who
carries out compliance audits on their local area council members.
CASA wanted a means of base-lining the level of governance and
organisation capability of each of the self-administration organisations,
and decided to undertake an industry risk profile (IRP) of the sector. An
IRP presents a clear picture of the key risks facing a nominated sector
within an industry at a given point in time. It defines the industry
context; identifies risks: what impact they have and their rating;
proposes high-level treatment strategies, and evaluates and ranks
residual risk. An IRP provides a platform for developing a detailed
risk reduction plan, including an outline of the agreed risk reduction
measures, a timeline for implementation of the risk reduction
measures, and accountabilities – who is responsible for what.
CASA decided that an IRP was the perfect vehicle to gauge the capabilities
of the various self-administration organisations, and then to use the
resulting risk reduction plan to inform the subsequent deed of agreement
between CASA and the self- administration organisation. In August 2008,
CASA and Aerosafe Risk Management, a company with Australian and
international experience in developing IRPs, began the process of working
with the Australian Parachute Federation on an IRP.
The industry risk profi le worked on the industry sector model
developed by Aerosafe Risk Management. The model includes key
elements such as: the oversight model; the compliance regime;
the assurance model; the operator profile; activity profi le; aircraft
capability profi le; the environment in which the industry operates;
the passengers and participants; industry systems; and the
safety profi le. Workshops and individual interviews with
key stakeholders, including APF board members and APF
executive office holders; a comprehensive documentation
This data-driven approach meant that the APF
and appropriate parachute industry stakeholders
had the opportunity to provide input into
developing the industry risk profile. Not only
was the involvement of the parachute industry
critical in developing the profile – in identifying
the key risks – but it was also instrumental in
then identifying appropriate treatment options
available to reduce those identified risks. Once
the data was collected and the risks identified,
treatment options were developed. This was
achieved through further workshops with both
APF stakeholders and CASA, and resulted in a
set of activities CASA and the APF could work
on together to implement.
Emerging industry risks
In the ten months since the 2008 IRP, the APF
has continued to work closely with CASA and
Aerosafe to achieve a significant reduction
of their industry risk profile. In fact, to
quantify, in this time, the APF, has been
able to reduce their industry risk
exposure levels by 23.7 per cent.
2 9 0,0 0 0
jumps
per formed e
ach year and
approximate
ly 8 0,0 0 0
on
ce-only tand
e
m jumps.
21
HARNESSING SAFETY
CASA’s self-administration model for sports and recreational aviation
works on the theory that those who participate in these particularly
specialised activities are the ones who better understand their own
industry. As Brad Turner explains, ‘We’re the best ones to control the
industry, but if we are going to do it, we have to show we can control it.’
The self-administration model does not abdicate CASA’s responsibility
to ensure industry compliance. So with this in mind, CASA looked for
a means of assuring that each of these sports aviation industry sectors
had the appropriate governance and organisational capabilities so that
they could provide this assurance.
Developing an industry risk profi le has allowed the APF and CASA
to work closely together to achieve their common goal: reducing
the perceived risk for the parachute industry sector. Consultation
is part and parcel of developing an industry risk profi le, and has
fostered a stronger relationship between the APF and CASA with
increased openness and improvements in communication on both
sides. ‘We’re enjoying our new relationship with CASA,’ Brad Turner
says. We can sit around the table and talk, and arrive at a mutually
rewarding outcome.’
APF has invested heavily in new
software as part of an ongoing
IT project, with a new database
that will provide immediate and
accurate information across the
industry
FSA SEP–OCT09
22
The APF is also reviewing every piece of documentation. ‘We’ve
overhauled our operations regulations,’ Brad explains, ‘they’ve grown
from 56 to 86 pages’. Also under review are the constitution and
instructor manuals. ‘We’ve been able to see some inconsistencies
in our processes, and recognise where the shortfalls are.’ Although
he acknowledges ‘it’s a huge job,’ he says most of it will be complete
by Christmas.
www.dreamstime.com
An important part of the process, Brad Turner explains, is to
identify the information required by the regulator to lower the
risk profi le. The APF has invested heavily in new software as part
of an ongoing IT project, with a new database that will provide
immediate and accurate information across the industry. ‘We do
follow data and trends,’ Brad says, but their new IT due in place by
the end of the year, ‘will make a huge difference to all our regions
– with the capacity to supply even more accurate data.’
Leading the way for self-administration organisations
The APF led the way, demonstrating that by identifying risks, and
implementing treatment strategies, self-administration associations
could improve their governance, and reduce risks. The other nine
self-administration organisations which make up the recreational
and sport aviation industry sector have now, along with CASA,
been through the process of developing an IRP specific to their
industry sector. Each IRP has identified key activities that the
self-administration organisations and CASA can work together to
implement over the next 12 months with the ultimate goal of reducing
the overall risk exposure of the sport aviation industry sector.
Sport aviation consists of approximately 39,000 participants using
more than 9000 aircraft, with broad and varied activities, including
the APF’s 290,000 parachute jumps made each year. Aircraft coming
under the sport aviation category include single-seat gyroplanes,
model aircraft, paragliders and warbirds.
of organisational competence to administer
this work on CASA’s behalf. This process has
delivered on that expectation and holds the
parachute industry in a good light. The forum
will be an annual event, with the next to take
place in July 2010.
And in November-December’s Flight Safety,
we’ll take a look at some of the data from the
other nine recreational and sports aviation
organisations’ industry risk profiles.
Ed: An apology to Australian Parachute
Federation’s CEO, Brad Turner. In the article ‘Can’t
walk. Can fly’ in the July-August issue, the APF’s
Susan Bostock was incorrectly given the title.
Representatives from the sport aviation industry met in Canberra
with CASA in early July to discuss this new framework for selfadministration organisations, and all embraced the new risk-based
oversight approach to sport aviation. Greg Vaughan, General Manager
Regulatory Implementation, said he was very pleased with the outcome
of the IRP process. ‘Achieving a 23 per cent risk reduction in less than
12 months with the parachute industry shows this innovative, riskbased approach works. It’s a good news story. Profiling risk in this way
provides a platform for ongoing improvement of governance, oversight
and industry reporting. Not only does this give us great confidence,
but it also provides the industry, the regulator and the community
with a roadmap for further risk reduction,’ he concluded.
John McCormick, CASA’s Director of Aviation Safety, opened the
inaugural Sport Aviation Safety Forum on 8 July this year, where
he highlighted the importance of self-administration organisations
such as the APF being able to demonstrate they have a high level
BOB TAIT’S AVIATION THEORY SCHOOL
Has New Premises at Redcliffe Aerodrome - Queensland
Full-time BAK and PPL courses now available! Check out our web page at www.bobtait.com.au
BAK & PPL
All CPL subjects plus IREX
Courses available full-time or by home study
PO Box 2018 Redcliffe North QLD 4020
P:07 3204 0965
F:07 3204 1902
W:www.bobtait.com.au
E:bobtait@bobtait.com.au
HARNESSING SAFETY
www.dreamstime.com
23
David Voss takes a look at a sometimes
neglected issue; one with potentially serious
implications for safety.
LOADING SAFELY
FSA SEP–OCT09
24
In any given calendar year there are millions of aircraft flights
worldwide, ranging from joy flights, to passenger operations and
cargo-only operations.
With advances in technology and the pressure for more effective
utilisation of ‘cargo-hold space’ many operators are flying aircraft
designed to uplift ‘unit load devices’ (commonly referred to as ULDs,
containers or bins).
With this increasing use, there are hundreds of reported occurrences
worldwide each year in which ULDs have been:
Incorrectly loaded into cargo hold positions.
Not locked into position by the aircraft’s ‘cargo hold locks’. These
cargo hold locks are located on the floor of an aircraft, and secure
the ULD into position to prevent it from moving at any stage of
flight or taxi.
Uplifted when unserviceable.
The cause of damage to aircraft fuselage/skin, where unsecured
ULDs have moved during stages of flight.
‘A single ULD may uplift anything from a single
piece of freight... to perishables, aircraft spares
or several tonnes of cargo or baggage.’
Most wide-bodied aircraft, and increasingly some narrow bodies,
are able to use this system of aluminium containers. These ULDs,
which vary in size and dimension, are used for the transportation
and uplift of passenger baggage and cargo, which is then loaded into
the aircraft hold by specialised hydraulic lift equipment. The ULDs
are then manoeuvred manually to a final position on board by use
of a roller floor, before being finally secured in position. A single
ULD may uplift anything from a single piece of freight (for example,
a single dangerous goods item), to perishables, aircraft spares or
several tonnes of cargo or baggage. Loaded ULDs must either be
weighed, or the number of baggage items per container must be
within a specified range and the prevailing standard baggage unit
weights applied.
ULD CASE STUDIES
Case study 1
In November 2008, on a Perth Boeing 717 flight, freight was loaded
into the incorrect bay and the cargo nets were not secured prior to
departure. Subsequently, during descent, the freight shifted, resulting
in the autopilot having difficulty holding the required descent speed.
Case study 2
In October 1997, a ULD was found to be unrestrained on a Boeing 767
flight from Australia to New Zealand. The ULD weighed 1530 kilograms
and had been free to travel nine metres.
In November 1997, a Boeing 767-300 was travelling from New Zealand
to Australia. During the descent, the crew heard ‘loud rumblings and
bangs coming from the cargo hold’. When ramp staff opened the
forward cargo hold, they found two ULDs weighing a total of 2015kgs,
which were unrestrained and free to move about three metres during
the flight. There were no injuries, or damage to the aircraft, but both
ULDs were substantially damaged.
Case study 4
On January 7 1998, cargo handlers opened the cargo hold of a Boeing
767 after the aircraft arrived in Australia following a flight from New
Zealand. Cargo handlers discovered three ULDs that had been free to
move two metres during the flight.
Case study 5
On January 10 1998, a Boeing 767 arriving in New Zealand from
the United States, and was found to contain a jet engine on a pallet,
weighing a total of 2268 kgs. The pallet had been free to move two
metres during flight.
WHY DID THESE INCIDENTS HAPPEN?
Several studies conducted worldwide into these types of occurrences,
have identified a number of causal factors:
The increasing number of containerised aircraft in use worldwide
A rapidly changing technological environment
25
LOADING SAFELY
Case study 3
‘The ULD weighed 1530 kilograms and had been free to travel nine metres’
Below are some of these reported incidents where unrestrained ULDs
have been loaded onto passenger aircraft. These reports have been
de-identified and are case studies which highlight the risks involved
in loading ULDs into aircraft holds without ensuring the locking
mechanisms are secure. In each of these incidents the freight, in some
cases weighing several thousand kilograms, moved, with potentially
disastrous consequences.
Workforce turnover, and a lack of skilled or adequately trained staff
Human factors – such as fatigue, communication and multiple
tasking: the person who commenced the loading task didn’t
complete the task, (for example, shift change, moved on to
another aircraft), communication breakdown, lack of company or
supervisory oversight
Deficiencies in training: insufficient, ineffective training for staff
Organisational/commercial pressure – short aircraft turn-around
times and under-staffing
Poor lighting conditions on ramp or within aircraft holds
Poor weather
Procedures – ineffective, unworkable, or outdated standard
operating procedures
Lack of a ‘just culture’
Non-existent or poor safety management system within the groundhandling organisation.
FSA SEP–OCT09
26
WHAT ARE THE CONSEQUENCES?
Thankfully, the case studies described above, which are only a small
sample, did not result in serious accidents. However, incorrectly
loaded ULDs have the potential to cause severe hull damage, or even
loss of life. They represent a large mass, upwards of 2500kgs, which
if allowed to move unrestrained in the hold, can seriously affect the
centre of gravity.
Unrestrained ULDs can lead to the following:
Weight shift (centre of gravity [CG]) during rotation, taxi, climb
or descent
Nose-up pitch, nose-down pitch, loss of aircraft stability, loss of
control, airframe shudders and vibrations/shakes
Aircraft finding itself in ‘an undesired state’
Excess fuel burn
Incorrect landing/take-off configuration
Incorrectly trimmed aircraft
Aircraft limitations exceeded
Hull/frame/floor/gear stress
Cargo hold skin damage and stress
ULD damage
Cargo/baggage damage
Complete hull loss
What happens if the certified limits as defined in the ‘CG’ envelope
are exceeded?
Aircraft flight characteristics will be adversely affected whenever
the aircraft loading limits are exceeded. For example, as the centre
of gravity limit moves aft, the aircraft will become less stable. If the
centre of gravity is too far aft, the aircraft may be difficult to control,
and, in serious cases, uncontrollable.
On the ground, if
the centre of gravity
shifts aft of the main
undercarriage, the aircraft
can tip up and a tail strike
can result. This will invariably
damage the aircraft.
If the centre of gravity position is forward of
the forward limit, there will be a decrease
in elevator control authority. At some point,
elevator control might become insufficient
to perform required manoeuvres, such as
rotating to take off, or to flare during landing
Exceeding the maximum weights as
specified in the aircraft flight manual can
result in serous airframe damage. The cargo
deck and the cargo locking mechanisms
all have structural limits – exceeding these
limits will cause damage and could result in
unrestrained cargo. Exceeding the maximum
landing weight of the aircraft could result in
structural damage, failure of the airframe, or
landing gear collapse.
Exceeding the maximum take-off weight will
affect the flight performance characteristics.
The take-off ground roll distance is increased
and the climb performance is reduced. (This
was demonstrated vividly in the March 2009
accident at Melbourne Airport, where an
Airbus A340-500’s tail struck the runway
and a number of airport landing aids came
into contact with the aircraft. An incorrect
weight had been inadvertently entered into
the laptop when completing the take-off
performance calculation prior to departure.
The performance calculations were based on
a take-off weight that was 100 tonnes below
the actual take-off weight of the aircraft.
ATSB report 30 April 2009.) While a crew
can sometimes get away with an overweight
take-off, the margins of safety reduce rapidly
when an engine failure occurs, or the runway
is short, or the density altitude high.
MITIGATING THESE RISKS
An organisation with a healthy and robust
safety management system (SMS) has the
means to implement strategies to minimise
risks arising from the increasing use of ULDs.
An effective SMS, where a healthy
safety culture is present, will provide a
framework for
Ensuring an effective safety reporting
process exists for incident reporting
Analysing and investigating incident/
occurrence reports, conducting risk
analysis on processes and procedures, and
root cause analysis on accident/incident
data collated from reporting systems
Examining all incident or occurrence
reports and mitigating. Ensuring the
‘investigation loop’ is closed, and an
outcome is achieved
Identifying trends in incoming reported
incidents
Training and educating staff: through
newsletters, bulletins, workshops and
meetings
Providing adequate and acceptable level of
training and recurrent training for aircraft
loading personnel
The International Air Transport Association (IATA) has convened
a series of working groups; their cargo working group has a panel
focusing on ULDs. That panel’s plans and activities following the
2009 World Cargo Symposium are:
Create a ULD care charter and start introducing this to industry
Interaction and increased involvement in airport activities related
to ULDs – ISAGO audit protocols re ULD content, and airport
authority’s guidelines on basic ULD infrastructure. Reassess the
ULD content of the standard ground handling agreement
Reformat and enhance the ULD technical manual
Overhaul the ULD type codes – structure and control of the codes
And, in the future:
ULD technical manual in electronic format
Develop damage limitations for non-certified ULDs
Obtain outstanding aircraft contours for inclusion in the ULD
technical manual
27
Develop container-handling guidelines.
ULD Type Code
IATA uses three letter codes (in upper case letters) to describe key
characteristics of ULDs. Examples are AKE, DPN and RKE. Each of
the three letter code positions describes particular characteristics
of the ULD.
Position 1
The Position 1 letter describes the container as:
1. certified as to airworthiness or non-certified
2. structural unit or non-structural
Position 2
The Position 2 letter describes the base dimensions of the container.
Position 3
incorrectly loaded ULDs have the
potential to cause severe hull
damage, or even loss of life.
The Position 3 letter describes the container’s contour, forklift
capability, and in the case of pallets and nets, the restraint
system into which the unit is classified. The Position 3 codes are
extremely complex.
Position
Character Type
Description
1
Alphabetic
ULD category
2
Alphabetic
Base dimensions
3
Alphabetic
Contour or compatibility
4, 5, 6, 7, 8
Numeric
Serial number
9, 10
Alpha-numeric
Owner/registrant
For full details, see IATA’s ULD technical manual.
www.iata.org/workgroups/uldp.htm
LOADING SAFELY
Reviewing / adjusting / cha nging /
implementing or adopting SOPs, as well
as additional safety checks, cross-checks
and check lists where necessary.
INTERNATIONAL AIR TRANSPORT
ASSOCIATION’S ULD PANEL
TAWS
for thought
TAWS (terrain awareness and warning system)
was developed with the aim of preventing
controlled flight into terrain.
It does this by ‘looking ahead’ of the aircraft using a pre-programmed
terrain database, and warns the pilot/crew of any approaching impact
with the ground, giving enough time to take appropriate action.
It alerts audibly and visually if there is an approaching impact.
FSA SEP–OCT09
28
Before flying an aircraft equipped with TAWS, you must ensure that
you clearly understand the configuration of the aircraft and TAWS,
and the settings of both are correct.
You should have read the manuals for both the aircraft and TAWS in
order to understand how terrain-alerting functions operate and how
they are affected by aircraft configuration.
SAFETY FIRST
If you receive an alert do not ignore it, pull up and go around. Check all
configurations, and if the alert is false, then report it to the equipment
manufacturer and complete an air safety incident report (ASIR) with
the ATSB.
Terrain databases are now included in all new GPS equipment;
however, do not assume that the terrain data is 100 per cent accurate.
There is currently no requirement for terrain data to be verified; an
issue currently being addressed by ICAO.
Class B TAWS is defi ned by the U.S.
FAA as
Providing (at a minimum) alerts in the
following circumstances:
Reduced required terrain clearance
Imminent terrain impact
Premature descent
Excessive rates of descent
Negative climb rate or altitude loss
after take-off
Descent of the airplane to 500 feet
above the terrain or nearest runway
elevation (voice callout ‘Five Hundred’)
during a non-precision approach.
Optional: Class B TAWS installation
may provide a terrain awareness
display that shows either the
surrounding terrain or obstacles
relative to the airplane, or both.
Class A TAWS includes all the above
requirements, and adds the following
additional three alerts and display
requirements of:
Excessive closure rate to terrain
Flight into terrain when not in
landing configuration
Excessive downward deviation from
an ILS glideslope.
Required: Class A TAWS installations
must provide a terrain awareness
display that shows either the
surrounding terrain or obstacles
relative to the airplane, or both.
Photo: courtesy Phil Vabre
Some balance
for the Airtourer
29
A LETTER FROM DOUG STOTT & STU HILSBERG
The Airtourer has never suffered the type of failures depicted in
the drawing and it’s disappointing to see the type used in such a
careless manner, simply to provide a dramatic visual impact for
what otherwise was an important article.
approach, with the support of the designer, the
late Dr Henry Millicer, to the then regulator,
resulting in a review of the previous figure of
12,000 hours.
The actual AD makes the following points:
Time flying competition type aerobatic
manoeuvres need to be factored by 20 for
structural life purposes.
Training or pleasure aerobatics, flown
occasionally, do not attract the factor of 20.
The intent of the article was to point out that some aerobatic aircraft
need the actual aerobatic time recorded as it may have an implication
on the fatigue life, the Airtourer being one.
Information available to the writers suggests
that the number of airframes to which this AD
applies is now minimal.
Immediately below the sketch of the breaking Airtourer the article
commenced with a story of CASA grounding an aircraft because a
previous operator had failed to log aerobatic time. It would not be
unreasonable for a reader to believe that the aircraft referred to
was an Airtourer. We have not heard of an Airtourer being treated
in this manner.
A significant concern to many Airtourer
owners is that as a direct result of this poorly
presented article, the airworthiness of the
type may be questioned by industry members,
LAMEs and prospective purchasers, and
unless corrected, the value of the type may
even be degraded.
Later in the article it incorrectly states: ‘Victa Airtourers have a
requirement to replace wing and tailplane structure after 17,200
hours.’ These requirements are included in AD/VAT/41 Amdt 1 which
describes the components requiring replacement*. Ed: *‘The wing
main spar lower cap and the wing front attachment spigot fittings; and
the tailplane rear spar assembly and the tailplane to fuselage attachment
fittings’. The AD is applicable to ALL models, both Victa and AESL,
not just Victa. The current fatigue life in that AD was the result of an
The Airtourer is a significant part of Australian
aviation history. Many owners now have their
aircraft in showroom condition and make a
great effort in maintaining its airworthiness
in what at times are difficult situations,
especially given that the type is now often
older than many of those responsible for its
continued serviceability.
AIRTOURER
Flight Safety
Australia magazine were surprised to see the article in the May-June
edition: ‘High-G Manoeuvring’ headed by a sketch of an Airtourer with
a wing separating. Just to emphasise the Airtourer connection, the
next page included a photo of an Airtourer, (although the photo had
been printed back to front).
We are sure that there is an expectation by owners and members of all
breed groups that those within the regulator responsible for such things
would utilise the experience within these groups. This experience and
knowledge is there for the asking, when and if the need arises. As the
years progress, this is especially so as much of the corporate history
and experience once held within the regulator and the industry at
large is lost.
There is also an expectation within the industry that articles appearing
in Flight Safety Australia are researched to the highest level using all
available sources and that both articles and associated drawings and
photos convey the required message clearly and accurately. We could
be forgiven for believing that CASA, being the Airtourer’s state of original
type certification, would demonstrate a more intimate knowledge of one
of Australia’s own products.
30
Doug Stott is a long-time Airtourer pilot/owner
and a co-founder of the Airtourer Association.
He is a professional pilot, safety manager and
auditor. Stu Hilsberg is a retired commercial
pilot, former Airtourer owner, airworthiness
coordinator and auditor.
This experience and
knowledge is there for
the asking
Photo: courtesy Phil Vabre
There are currently quite a number of clubs of aircraft owner/pilots,
now often referred as ‘breed groups’. More than anyone else, the
members of these groups have significant knowledge of their type,
both operational and airworthiness. The Airtourer is no exception,
being strongly represented by the Airtourer Association.
Sadly, it is the writers’ belief that on this occasion that did not occur. We
appreciate the space being made available to provide some balance.
FSA SEP–OCT09
Authors
This article is the opinion of the authors, Doug Stott and Stu
Hilsberg, and not necessarily that of any club or association they
may be members of.
S
E
R
V
I
C
E
S
Jamie Johnston and Kevin McMurtrie are back in control
at Johnston Aviation Services. We are offering the valueadded training, professionalism, expertise and high levels of
service that our students have come to expect of us.
-
Leaders in M/E command instrument ratings,
2 testing officers on staff (Jamie and Kevin),
PPL and CPL courses
Instructor ratings
Initial issue & renewal - all grades of instructor
ratings
- Accommodation provided
Multi-Engine Command Instrument Rating Course
4 week course
Training on Beechcraft Baron
Includes GNSS RNAV
$13,990
For further information and pricing please contact us
Phone: (02) 6584 0484
Email: info@johnstonaviation.com.au
Web: www.johnstonaviation.com.au
Our Reputation is your Guarantee
Many had hoped that an early relaxation of TNS No 32 would appear
as if by magic. At the other extreme, only too well aware that we
de Havilland lunatics had literally taken over the asylum, the Civil
Aviation Authority, BAE Systems and our product liability insurers were
undoubtedly on the lookout for any incaution in discharge of these newfound responsibilities. All that could be done initially was to analyse
BAE’s bulging TNS No 32 files and to continue gathering worldwide
B
opinion and data from successive structural inspections. It was only by
op
2008 that our thoughts had crystallised sufficiently - and the regulatory
20
planets aligned suitably - to enable meaningful progress to be made.
As subscribers to DHSL’s Continuing Airworthiness Service will know,
we celebrated Christmas 2008 by publishing a completely revised
TNS No 32. This document at Issue 3 is infinitely more rigorous in its
guidance and yet, paradoxically, it should be much easier to live with.
Let me explain!
THE ORIGIN OF TNS 32
Photos courtesy de Havilland Support
Suppo
The late 1990s were not a time of any great credit for our movement. In
succession came the failure of a misplaced Tiger Moth datum bolt and
fracture of a fuselage tie-rod – leading to the discovery of a UK Tiger flying
with NO tie-rods at all! Then an accident in England implicated the fuel cock
linkage, original type safety harnesses, and aileron controls. At a time when
the then BAe was being notably more proactive in flight safety matters,
these events gave rise to new Technical News Sheets and to associated
CAA Airworthiness Directives which were mirrored around the world.
After a still worse occurrence, the mid-air break-up of Tiger Moth VH-TMK
in WA on 28 February 1998, the stage was set for draconian action.
31
AIRWORTHINESS
Owne
Ow
n rsh
ne
hip of elderly
ly w
woode
den
en aeroplanes has
ofte
en be
been likened
e (and
ed
d not entirely in jest) to a
game
e of ‘p
passs the pa
p rcel’. Perhaps the analogy
m ght be
mi
e appli
a ied
e similarly to type certificate
ho
olders! Whe
en the music stopped and BAE
Systems
Syst
sttems tran
transferred
ansfferred DH responsibilities to de
an
Havilland Support Ltd in 2001, not the least
of our inherited hot topics was the future of
Technical News Sheet CT (Moth) No 32. If you are a Moth owner, you
will need no reminding that this TNS requires searching and repetitive
inspections of the wooden structure.
PULL-OUT SECTION
Mark Miller, chief engineer
with de Havilland Support in
the UK, gives some background
on the revised technical news
sheet for the Moth.
ALL YOU WANTED TO KNOW ABOUT TNS 32 .... CONT.
PULL-OUT SECTION
How close the entire fleet of all Moth types came to an immediate
grounding is another story. Only some informed diplomacy by the
de Havilland Moth Club Technical Support Group, in concert with
the good influence of Lyn Forster as a local advisor trusted by BAe,
enabled the Moths to continue flying pending findings from the
VH-TMK investigation.
FSA SEP–OCT09
32
The quid pro quo was acceptance of Technical News Sheet CT(Moth)
No 32, mandated in the UK by CAA AD 002-03-98. At Issue 1 the
TNS prohibited aerobatics and spinning while the implications of the
Australian accident were being considered. Who could forget those
yellow sticky labels, mandated even for the straight and level Moths?
REINSTATEMENT OF AEROBATICS
AND SPINNING
To their great credit, the Australian Bureau of Air Safety Investigation,
as it then was, co-operated with Bob Bennett at BAe back in the UK to
share their findings on an almost day-by-day basis. Long before the
VH-TMK report was published in July 1999, it was known that the right
upper wing front spar had failed during a probable high ‘g’ pullout
from an egg-shaped loop. Violent slat deployment was a possible but
uncertain contributory factor. It came to light that the wooden wing
structure was in poor condition with a disbonded spar front doubler,
fungal decay, probable pre-existing compression shakes from earlier
accidents, and bolt holes in the wing spars impregnated with rust to
the point of weakening the surrounding timber.
This set of deficiencies sounded to the de HMC Technical Support
Group very much like the proverbial ‘accident waiting to happen’. But
in seeking the reinstatement of aerobatic and spinning clearances,
the unspoken BAe and CAA question was unanswerable – just how
many more structural time bombs might be ticking out there? The
only viable option on the table was to submit the entire fleet to
detailed inspection … and so BAe developed Issue 2 of TNS CT(Moth)
No 32. The title of ‘Flight Limitations’ remained (although the aim
was removal of limitations!) and the TNS continued to be mandated
in the UK by CAA AD 002-03-98, and by CASA under
nder designations
designation
ons
specific to each Moth variant. [CASA at least described the AD more
accurately as ‘Flight Limitations and Structural Insp
pection’]
TNS No 32, Issue 2, required a detailed visual i nss pe
pecc t io
o n of t he
interior of the flying surfaces and to this end an arrr
rray
ay
y o f in
insp
spec
sp
e ti
ec
t ion
n
rings was prescribed for the wings, tail unit an d co
o nt
n ro
rols
ls o f all
Moths. Enhanced drain hole provisions were alsso spec
eciff ie
ec
ied (f
(for
or
some types with more zeal than justification! ) and a o n e-o
-o
-off
o ff
ff
removal of sample bolts in spar root joints was reequired t o ch
c ecc k
for rust in the holes.
Memorably, the TNS also included a sizeable sheaff of now
w outtda
d ted
teed
photocopies containing advice on wooden structures in general. Bullk
notwithstanding, TNS No 32, Issue 2 enforced an o
overdue ‘wake--up
p
call’ on a number of very suspect airframes, allowed the resumptio
on
of aerobatics, and yielded some excellent informatio
on from the field.
The main objection to TNS No 32 has always
been its denial of discretion over the scope of
three-yearly repeat inspections. Maybe the
effort required to make good all 92 fabriccovered inspection holes in a Tiger Moth was
skewing the finite available maintenance
effort too far in the direction of structures?
Nor did TNS No 32 address the need for reinspection of wooden members as and when
mishaps occur.
THE OVERDUE REVIEW
Since 2001, we have taken every opportunity
to view Moths undergoing restoration or
TNS No 32 inspections in Europe, the types
ranging from DH60 to DH94. Even better,
on a visit to family in Australia in 2007 I was
chauffeured by Roy Fox to canvass Ray and
Lance’s opinions at Luskintyre, by Des Porter
to meet Greg and Nick at Murwillumbah, and
had a good look at Mark Carr’s Moth Minor in
progress at Sandora Aviation. I also re-read the
incredibly useful Australian submissions made
in the BAe days by Laurie Brown, Glen Caple
and Mike Stacy. The key findings of what was a
long investigation
on are
re readily summarised:
Poo
oorr co
c nd
ndit
itio
ion
n fe
feat
atur
ures
es oft
f en
en pre
re-date the
curren
en
nt fa
fabr
bric
ic
R at
a e of c ha
han
nge of
o c ondition
n can be
negl
ne
glig
gl
i ib
ig
ible
lee
Com
mpr
p esssi
sion
on
n ffai
a lures ar
ai
aree co
comm
m on
mm
n aft
fter
er
sp
par o
ove
verl
ve
r oa
rl
oad
d
S gg
Su
g es
esti
t ng
ti
g iin
n tu
turn
r tha
rn
h t:
Morre guid
gu
uid
idan
ance is ne
an
eed
eded
ed
d on in
insp
sp
pec
ection
be
efo
fore
rre
e recov
ov
ver
Dep
pth of ro
r ut
utin
iin
ne insp
in
nsp
spec
e tion
ec
o can be subjecct
to
o discret
ettio
on
R ig
gor
orou
o s sp
ou
par ins
nspe
pee ctt io
on af
afte
terr in
te
nci
c dents
is e ssential.
SELECTED SERVICE DIFFICULTY REPORTS
1 June 2009 – 31 July 2009
AIRCRAFT ABOVE 5700KG
Airbus A330202 Co-pilot’s windshield heater
terminal fire. Ref 510008563
First officer’s No.1 window fire, caused by
windshield heat system. Initial investigation found
windshield heater terminal damaged, with evidence
of high temperature and thermal degradation.
Investigation continuing.
BAC 146100 Landing gear emergency systems
cable seized. Ref 510008800
Landing gear emergency uplock release mechanism
operating cable fork-end seized at cable to link
interface preventing RH main landing gear from
locking in the ‘up’ position.
BAC 146200 APU seized. Ref 510008573
APU seized. Sparks and smoke from tailpipe.
Investigation found turbine wheel off alignment and
inlet plenum support struts (4off) all cracked under
stress conditions of seizure action.
P/No: 4501690A. TSN: 19,715 hours/24,339 cycles.
TSO: 15,622 hours/17,015 cycles.
Boeing 737476 Cabin pressure controller failed.
Ref 510008551
Cabin pressure controller faulty. Investigation
continuing. P/No: 7638102. (4 similar occurrences)
Boeing 737476 Engine anti-ice valve failed.
Ref 510008516
No.1 engine anti-ice valve failed to open.
P/No: 1726257. TSN: 42,665 hours. TSO: 6,190 hours.
(7 similar occurrences)
Boeing 737476 Galley oven faulty. Ref 510008602
Rear galley oven faulty. Toxic smell when oven turned
on.TSN: 33,583 hours. TSO: 12,932 hours. (20 similar
occurrences)
Boeing 737476 Pressurisation controller faulty.
Ref 510008597
Pressurisation system outflow valve faulty.
Valve failed to close. Investigation found faulty
pressurisation controller.
P/No: 7638102. TSN: 57,368 hours. TSO: 18,161 hours.
Boeing 737476 Pneumatic sense tubes loose.
Ref 510008612
Pressurisation system high stage valve pneumatic sense
tubes (3off) loose at regulator. Investigation continuing.
TSN: 48,417 hours. TSO: 7,423 hours.
Boeing 73776N Engine oil pressure sensor line
disconnected. Ref 510008787
No.1 engine oil pressure sensor line disconnected. Oil
leak. P/No: 3400218020.
Boeing 7377BX Co-pilot’s elevator and rudder
cables rubbing. Ref 510008842 (photo below)
Co-pilot’s elevator and rudder control cables rubbing
on cable guard hi-lock heads. Cable guards located
at Stn 947.5. Investigations found the cable tensions
low. Elevator cable tension 70lbs (normal tension
approximately 115lbs) and rudder cable tension 80lbs
(normal tension approximately 140lbs). Investigation
only found wear on the hi-locks with no wear evident
on the control cables. (1 similar occurrence)
Beech 1900C Wing aileron balance weight
clips cracked. Ref 510008776
RH aileron balance weight inboard two clips cracked.
Found during inspection iaw SB 27-3928.
P/No: 101130001191. TSN: 21,401 hours/28,443
cycles. (3 similar occurrences)
Boeing 737376 Aileron PCU control rod clevis
cracked. Ref 510008855
Aileron power control unit (PCU) control rod clevis
cracked from threaded area to clevis head. Crack
length 19.05mm (0.75in). P/No: 69407272.
Boeing 737376 Rear pressure bulkhead
corroded. Ref 510008749
Rear pressure bulkhead corroded on inner face of ‘C’
section of the lower horizontal flange and vertical web.
Boeing 7377Q8 Nose landing gear axle failed.
Ref 510008813
RH nose landing gear axle failed. Investigation
continuing.
P/No: 162A11202. TSN: 25,208 hours/18,355
cycles. TSO: 2,494 hours/1,751 cycles.
Boeing 737838 Aircraft refuel manifold check
valve failed. Ref 510008689
Refuel manifold check valve failed. Failed valve
flapper half found in centre tank outboard of No.1
rib panel LH side.
P/No: 2670137101. (2 similar occurrences)
Boeing 737838 APU compressor contaminated.
Ref 510008736
APU load compressor contaminated with oil.
Investigation continuing.
P/No: 38007021. (3 similar occurrences)
Boeing 737838 Engine cowl anti-ice valve
faulty. Ref 510008756
LH engine cowl anti-ice valve failed.
P/No: 32156184. TSN: 11,906 hours. TSO: 11,906
hours. (7 similar occurrences)
Boeing 73786N DEU faulty. Ref 510008549
No.2 display electronics unit (DEU) failed.
Investigation found multiple internal defects.
P/No: 4081600930. (4 similar occurrences)
Boeing 7378BK Cabin burning smell.
Ref 510008824
Burning smell in forward cabin. Smell classified
as‘sulphur like’. Investigation continuing. (4 similar
occurrences)
Boeing 7378FE Spoiler interlock cable broken.
Ref 510008814
Spoiler interlock cable broken. Investigation continuing.
(12 similar occurrences)
Boeing 747438 Air conditioning system – odour
in cockpit. Ref 510008555
Odour in cockpit and flight deck. Suspect No.2 air
conditioning pack. Investigation continuing.
(3 similar occurrences)
Boeing 747438 Door handle loose.
Ref 510008745
No5 LH door handle moved during flight.
Aircraftwas flying in light turbulence.
Investigation continuing.
Boeing 747438 Flight deck toilet solenoid
failed. Ref 510008742
Flight deck toilet solenoid failed. Water overflow
soaked floor and leaked through ceiling into
A/B zone on main deck. Investigation continuing.
Boeing 7377BX Wing/body overheat detector
unserviceable. Ref 510008775
Wing/body overheat detector unserviceable.
Investigation continuing.
P/No: 3571279. (6 similar occurrences)
Boeing 7474H6 Hydraulic pressure hose
ruptured. Ref 510008611
No4 hydraulic system pressure hose ruptured. Loss
of hydraulic fluid.
P/No: AS115100192. (1 similar occurrence)
Boeing 767336 Flap inboard hinge arm
attachment bolt sheared. Ref 510008492
RH inboard main flap inboard hinge arm attachment
bolt sheared. Investigation continuing.
33
AIRWORTHINESS
BAC 146300 Flap system failed. Ref 510008656
(photo below)
No.3 RH moveable flap hanging down, with damage to
fixed fairing. Operating spring strut rods found sheared
and fairing only retained at forward attachment pivot
pins. Investigation found that the rear adjustment barrel
nut had separated from the adjuster bolt allowing the
internal mechanism to foul and cause operating rods to
shear. Investigation revealed that adjuster bolt unwound
out of the barrel nut due to the adjuster bolt lock plate
tangs not engaging with the bolt head. Rather thick
sealant application at lock plate/fairing interface had
caused the lock plate to stand off and tang failure to
effectively lock the bolt. (2 similar occurrences)
Boeing 737476 AOA sensor faulty.
Ref 510008833
LH angle of attack (AOA) sensor faulty causing
autopilot to disengage. \P/No: 861CAS3. TSN: 47,151
hours. TSO: 47,151 hours.
Boeing 7377Q8 Cockpit window frame cracked.
Ref 510008643
No.1 cockpit window frame cracked.
P/No: 141A48401.
PULL-OUT SECTION
Airbus A380842 Aircraft fuel tank
contaminated. Ref 510008815
Microbiological contamination of fuel tanks found
during scheduled inspection.(4 similar occurrences)
Boeing 737476 Air conditioning system outflow
valve faulty. Ref 510008644
Cabin pressurisation problems. Outflow valve, part
number 711003-3, and LH temperature control
valve replaced. P/No: 7110033. TSN: 53,104 hours.
TSO: 90 hours. (2 similar occurrences)
Boeing 767338ER Captain’s window burn
marks. Ref 510008841
Captain’s No.1 window contained six burn marks at
bottom of window. Burn marks grew progressively
during flight. (4 similar occurrences)
PULL-OUT SECTION
Boeing 767338ER Emergency exit signs failed
comparator test. Ref 510008530
Self-illuminating emergency exit signs (8off) failed
comparator test.
P/No: CANDB451.
FSA SEP–OCT09
34
Boeing 767338ER Main wheel bearing failed
bearing. Ref 510008691
No.1 main wheel inboard bearing collapsed allowing
wheel to rub on brake assembly. No.1 wheel axle also
damaged beyond limits. Investigation continuing.
P/No: 161T113011.
Boeing 767338ER Passenger entertainment
system seat box sparking/smoking.
Ref 510008761
Passenger entertainment system seat box and
harness located beneath seat 40AB sparking and
smoking. Investigation continuing.
Bombardier DHC8102 NLG steering manifold
check-valve split. Ref 510008797
Nose landing-gear steering manifold check-valve
split. Suspect manufacturing fault. Loss of No.2
hydraulic system fluid.
P/No: DSC1906.
Bombardier DHC8202 TSCU suspect faulty.
Ref510008622
LH engine low power. Suspect faulty torque signal
condition unit (TSCU). Investigation continuing.
(2 similar occurrences)
Bombardier DHC8315 Cabin – oil fumes.
Ref 510008636
Oil fumes in cabin. Investigation continuing.
(1 similar occurrence)
British Aerospace BAE1251000 Windshield
shattered. Ref 510008661
RH windshield shattered during landing.
Investigation continuing.
P/No: PO31008GKN. TSN: 286 hours/200
cycles/200 landings.
Embraer EMB120 Hydraulic pump pressure line
worn and damaged. Ref 510008600
LH hydraulic pump pressure line located in LH nacelle
worn and leaking. Investigation found a broken
electrical bonding lead had worn a hole in the pipe.
Loss of hydraulic fluid.
P/No: 12039829011. TSN: 35,693 hours/37,907
cycles.
Embraer ERJ170100 Flap rod sheared.
Ref 510008698
LH aft flap upper rods (2off) sheared.
P/No: 17103779901.
Fokker F28MK0100 Autoflight systems
transducer suspect faulty. Ref 510008792
Intermittent sluggish auto-throttle followed by
failure of auto-throttle to disconnect. Investigation
found that the dynamic rods which contain the micro
switches to release the auto-throttle were out of
limits. Further the RH power lever angle transmitter
(PLA) was also out of limits. Investigation continuing.
Fokker F28MK0100 MLG retraction actuator rod
end sheared. Ref 510008808
RH main landing gear retraction actuator rod end
sheared off. Investigation found the rod end had
been installed 180 degrees out which allowed the
grease nipple to contact the attachment casting and
shear off.
P/No: 415005. TSO: 4,501 hours/2,388 cycles.
Saab SF340B ACM seized – suspect failed
bearing. Ref 510008550
LH air cycle machine (ACM) seized. Suspect bearing
failure. P/No: 7769106. TSO: 2,598 hours/2,745
cycles. (1 similar occurrence)
Saab SF340B Navigation data systems
transponder faulty. Ref 510008718
Anomalous transponder behaviour following
introduction of AMSTAR radar.
(5 similar occurrences)
AIRCRAFT BELOW 5700KG
Beech 200 Cargo door sill cracked.
Ref 510008773
Cargo door sill cracked at door latches cut-outs.
P/No: 1014301571. TSN: 9,458 hours/11,382cycles/73
months.
Beech 200 Flap flex drive shaft unserviceable.
Ref 510008809
RH inboard flap flexible drive-shaft unserviceable,
leading to burning out of flap motor.
P/No: 1013800002.
Beech 200 Landing gear door link plate
incorrect part. Ref 510008760
LH main landing-gear door-link plate replaced by
block of metal, preventing correct door adjustment.
The fitment of the aluminium block could not be
traced, nor could any reason be found for fitment. The
aircraft is fitted with Raisbeck high floatation landing
gear doors fitted in the USA.
P/No: 8137083.
Beech 300 Pilot’s windshield inner-ply
shattered. Ref 510008828
Pilot’s windshield inner-ply shattered.
P/No: 10138402521. TSN: 4,132 hours/2,231cycles/94
months.
Beech 58 Alternator cables chafed.
Ref 510008664
LH and RH alternator power cables chafed in area
where they pass over the top of the wing and through
the nacelle firewall behind the engines.
Beech B200C Passenger door inner skin
cracked. Ref 510008856
Passenger door inner skin cracked. Cracks emanate
from position where door cable stay bracket attaches
to the skin.
P/No: 1014301031. TSN: 24,840 hours/25,484
cycles/25,484 landings. (1 similar occurrence)
Cessna 152 NLG steering pushrod broken.
Ref 510008821
Nose landing gear steering system LH push-rod broken.
P/No: 05430223.
Cessna 208 Flap actuator bracket damaged.
Ref 510008628
Flap actuator support bracket part no 2611144-1 torn
and cutting through electrical wire to flap actuator
causing short circuit. P/No: 26111441. TSN: 20,912
landings. (1 similar occurrence)
Cessna 404 Aileron control pulley FOD.
Ref 510008590
Autopilot system suspect faulty. Controls jamming
during flight. Initial control inspection could find no
faults. Further investigation found a small stone
wedged under the LH aileron control pulley. Autopilot
system found to be serviceable.
Cessna 404 Alternator drive coupling rubber
separated. Ref 510008686
LH alternator drive coupling rubber separated from
inner half.
P/No: LC53675N. TSO: 1,700 hours.
Cessna 404 Wing structure systems spar
debonded. Ref 510008730
LH and RH wing rear spars disbonded. LH spar
disbonded in two areas and RH spar disbonded
in three areas. Found during inspection iaw AD/
Cessna400/103.
Cessna 550 Brake anti-skid system motor
failed. Ref 510008534
Brake anti-skid system motor failed. Low pressure
switch part no 9912163-1 also failed which prevented
warning of motor failure.
P/No: MP50B1. TSN: 8,753 hours/9,178 cycles/9,178
landings/120 months.
Child S2CPITTS Rudder pedal bent and
jamming. Ref 510008712
LH rudder pedal located in front cockpit bent and
jamming on fuselage truss/vertical member.
P/No: 25310004. TSN: 650 hours.
Cirrus SR22 Wing flap brackets severely
corroded. Ref 510008617
LH and RH wing flap attachment brackets (6off)
severely corroded.
P/No: 16814001. TSN: 461 hours/72 months.
Gippsland GA8 Landing gear axle broken.
Ref 510008608
RH main landing gear axle broken at weld. Possible
evidence of inclusion in weld. RH main landing gear
wheel, brake and axle missing.
P/No: GA832101311. TSN: 4,178 hours.
Pilatus PC12 Flap cable seized. Ref 510008672
Trailing edge flap interconnect cable seized in
the ‘flap down’ position keeping the interconnect
engaged and causing the autopilot circuit breaker
to pop.
P/No: 5271012194. TSN: 6,355 hours.
Piper PA28151 Aircraft general systems
corroded. Ref 510008579
‘Significant to severe’ corrosion found on various
structural parts. Both rear spar fittings on the wing
and on the spar carry-through corroded. Fin forward
spar attachment corroded. Severe corrosion on left
rear under-floor hat section part no 76115-00. Fin
left-hand skin, part no 63398-00 corroded. Stabilator
trim barrel, part no 65246-00, and screw, part no
63530-00, badly worn.
TSN: 8,444 hours. (3 similar occurrences)
Piper PA31350 NLG steering plate to gear
trunnion bolts broken. Ref 510008759
Nose landing gear steering plate to nose gear
trunnion attachment bolts (2off3) broken.
Investigation found bolts had been cracked in thread
before failing due to overload.
P/No: AN3H7A.
Piper PA44180 Battery swollen/distorted.
Ref 510008483 (photo below)
Battery unserviceable (flat). Investigation found
battery swollen and distorted with very little acid
possibly due to leakage through filler caps.
P/No: G35. TSN: 1,245 hours/18 months.
Agusta Westland AW139 Roof beam cap angle
cracked. Ref 510008782
RH roof beam cap angle cracked. Angle located at
WL 2470 BL 550.
P/No: 3P5338A12051. TSN: 893 hours. (1 similar
occurrence)
Agusta Westland AW139 Tail rotor control rod
cracked and corroded. Ref 510008682
Tail rotor control rod cracked longitudinally adjacent
to rod end fitting. Tube contained five cracks.
P/No: 3E6722A00535. TSN: 893 hours. (1 similar
occurrence)
Swearingen SA227DC Fuselage ‘belly’ skin
cracked. Ref 510008752
Fuselage belly skin cracked at inboard end. Found
following removal of panel 610.
Swearingen SA227DC Landing gear hydraulic
line holed. Ref 510008674
Landing gear down hydraulic line leaking from pin
hole. Loss of hydraulic fluid.
P/No: 2781006143. (1 similar occurrence)
Swearingen SA227DC Windshield electrical
terminal short circuit. Ref 510008705
Windshield electrical terminal short circuiting to
aircraft structure. Correct insulating boot was fitted.
Windshield was replaced on previous day due to failed
windshield heating. Heating connection is difficult
to connect and inspect following window fitment.
ROTORCRAFT
Agusta-Bell 412 Rescue hoist electric motor
suspect faulty. Ref 510008546
Rescue hoist electric motor suspect faulty. Sparks
seen in area of motor.
Robinson R22BETA Engine/transmission
coupling drive belt failed. Ref 510008757
Engine to transmission forward drive belt failed.
Damage caused to actuator, oil cooler and cooling
baffle.
P/No: A1902. TSN: 66 hours. (24 similar occurrences)
Robinson R22BETA Engine/transmission clutch
shaft seal dislodged. Ref 510008524
Engine/transmission clutch shaft leaking.
Investigation found forward clutch seal dislodged.
Further investigation found metal in the clutch
assembly.
TSN: 1,162 hours/24 months. (1 similar occurrence)
Robinson R22BETA Main rotor blade debonded.
Ref 510008732 (photo below)
Main rotor blade debonded at tip. Nil evidence of
corrosion and no paint missing.
P/No: A0164. TSN: 87 hours/33 months. (11 similar
occurrences)
Continental GTSIO520M Engine cylinder
cracked. Ref 510008503
RH engine No 2, No 4 and No 5 cylinders cracked
from injector ports to spark plug holes. Cracks
confirmed using dye penetrant method.
TSO: 1,477 hours/25 months. (19 similar occurrences)
Continental IO520C Engine counterweight
incorrectly fi tted. Ref 510008748
Crankshaft counterweight circlip incorrectly fitted.
Counterweight separated from crankshaft and exited
through the crankcase.
P/No: 639195. TSO: 1,669 hours. (1 similar
occurrence)
Engine exhaust system cracked. Ref 510008630
Exhaust cracked and muffler cores degraded.z
P/No: 86299008. TSN: 3,215 hours. TSO: 2,900 hours.
Robinson R22BETA Tail rotor control bellcrank
bolt rubbing. Ref 510008727 (photo below)
Tail rotor pitch control bellcrank lower bolt rubbing
on upper fan-shroud. Shroud deeply scored and
pal nut damaged. Problem also found on two other
helicopters in fleet.
Agusta Westland AW139 Landing gear system
control panel suspect faulty. Ref 510008851
RH main landing gear did not indicate ‘down’
following landing gear extension. Visual and ground
staff inspection found gear to be down. Investigation
could not duplicate the fault and all micro switches
were found to be correctly adjusted. Landing
gear control panel replaced as a precaution. Nil
recurrence of defect since.
Agusta Westland AW139 Longeron cracked
through fastener holes. Ref 510008780
Upper LH longeron cracked through fastener holes.
Longeron is located adjacent to tail boom attachment
bulkhead.
P/No: 365306A07751. TSN: 893 hours.
PISTON ENGINES
Lycoming IGSO480A1E6 Engine cylinder piston
ring seized. Ref 510008688
LH engine oil consumption excessive. Investigation
found No 6 cylinder oil control ring seized in piston
ring groove. Further investigation found corrosion on
all cylinder walls.
TSO: 741 hours.
Lycoming IO540AC1A5 Engine fuel pump low
pressure. Ref 510008848
Engine-driven fuel pump low pressure. At full power,
the pump delivered 10psi. Investigation also found
oil leaking from the vent fitting on the pump. P/No:
LW15473. TSN: 586 hours. (8 similar occurrences)
Lycoming IO540AE1A5 Magneto drive coupling
incorrect. Ref 510008728
RH magneto fitted with incorrect drive coupling.
Coupling fitted was for an O540F1B5 engine. Suspect
incorrect coupling fitted to two or possibly three
other aircraft.
P/No: 7300073636. TSN: 585 hours.
Robinson R44 Engine muffler failed.
Ref 510008751
Muffler failed at tailpipe connection due to heat
distortion and cracking.
P/No: C16932. (11 similar occurrences)
Lycoming LTIO540J2BD Engine cylinder
cracked. Ref 510008836
RH engine No 6 cylinder cracked from upper spark
plug bore recess extending to inlet valve seat.
P/No: LW12966. TSN: 910 hours/28 months. (6 similar
occurrences)
35
AIRWORTHINESS
Swearingen SA227DC Landing gear system
pipe split. Ref 510008488
Landing gear ‘up’ rigid pipe located in RH wheel well
split on 90 degree bend. Split approximately 10mm
(0.393in) long. Suspect caused by inter-granular
corrosion. Loss of hydraulic fluid.
P/No: 27810322750. TSN: 19,817 hours/27,868
cycles/27,868 landings/192 months.
(2 similar occurrences)
Bell 412 Aircraft vibrates and ground bounce
Ref 510008618
Aircraft suffering from vibration and ground bounce.
Extensive investigation has found numerous faults
with components repaired/replaced. The ground
bounce is still evident. Investigation continuing.
(1 similar occurrence)
PULL-OUT SECTION
Piper PA44180 Carburettor air box cracked.
Ref 510008626
Carburettor air boxes cracked around mount
attachment holes.
P/No: 86245041. TSN: 3,277 hours. TSO: 2,200 hours.
Schweizer 269C Main rotor flapping hinge bolt
head washer missing. Ref 510008633
(photo below)
Main rotor ‘yellow’ flapping hinge bolt head washer
missing. Investigation found marks consistent with
the washer being incorrectly installed with the
chamfered side towards the bearing. Inspection of
the other two flapping hinge bolts found the washers
installed the wrong way around as well.
P/No: 269A1356. TSN: 48 hours. (1 similar occurrence)
Lycoming LTIO540J2BD Engine hold-down stud
broken. Ref 510008837
No6 cylinder hold-down studs part no 50-15 (1off)
and part no 38-13 (2off) sheared.
P/No: 5015AND3813. TSO: 910 hours/28 months. (2
similar occurrences)
PULL-OUT
PULL-OUT SECTION
SECTION
Lycoming O235L2C Engine con-rod big end bolt
broken. Ref 510008511
Engine connecting rod big-end bolt failed. Crankcase
damaged.
P/No: 78027. TSN: 1,643 hours.
Lycoming O320D3G Carburettor float broken.
Ref 510008512 (photo below)
Carburettor float broken. Float is manufactured from
plastic material.
P/No: 30804. TSO: 1,642 hours.
Turbomeca MAKILA1A Engine compressor stiff
to rotate. Ref 510008819
RH engine axial compressor stiff to rotate. Evidence
of compressor blades rubbing.
TSO: 1,082 hours.
GE CF348E5 Engine compressor section shaft
broken. Ref 510008624
No 1 engine inboard variable geometry (VG) shaft
broken. VG actuator rod end bearing also broken. (1
similar occurrence)
GE CFM567B EECU failed. Ref 510008515
No 2 engine electronic control Unit (EECU) failed.
P/No: 2042M67P02. TSN: 9,495 hours. TSO: 9,495 hours.
BF GOODRICH Wheel suspect faulty.
Ref 510008794 (photo below)
Newly-received wheel suspect faulty. Inspection of
wheel on receipt found excessive blemishes in the
casting which were found to be all over the wheel
including in the bead area.
P/No: 10180265.
Lycoming O320D3G Engine cylinder valve
spring broken. Ref 510008657
No1 cylinder valve springs, part no LW-11795, and
part no LW-11800, broken.
P/No: LW11795LW11800. TSN: 109 hours.
Lycoming O360A1A Carburettor butterfly valve
loose. Ref 510008502
Carburettor butterfly loose on throttle shaft.
Investigation found both retention screws loose.
Screws had been staked. Carburettor manufactured
by Volare and came fitted to a factory rebuilt engine.
Lycoming O360J2A Magneto drive gear
stripped. Ref 510008528
LH magneto plastic drive gear teeth stripped.
P/No: IO600614. TSN: 1,184 hours.
Lycoming TIO540J2BD Exhaust turbocharger
seized. Ref 510008548
LH engine exhaust turbocharger seized.
P/No: 4091709001. TSO: 1,771 hours. (5 similar
occurrences)
TURBINE ENGINES
Allison 250C20B Engine reduction gear bearing
failed bearing. Ref 510008650
Engine gearbox No 2.5 bearing failing. Metal
contamination of engine oil system.
P/No: 23034787. TSN: 3,161 hours. TSO: 3,161 hours.
Garrett TPE33112UH Engine fuel manifold
unserviceable. Ref 510008592
LH engine fuel manifold hose broken away from
fuel nozzle ‘T’ fitting. Manifold is Teflon hose
construction.
P/No: 31024692.
Garrett TPE33112UH Engine reduction gear
pinion failed. Ref 510008489
LH engine failure. Oil pressure increased to 150psi
with a chip detector indication approximately 15
minutes later. After another 15 minutes, the engine
COMPONENT
GE CFM567B Engine compressor section seal
missing. Ref 510008571
Engine vibration. Suspect fan blade platform strip/
seal missing. Investigation continuing.
(1 similar occurrence)
GE CFM567B Engine cooling system valve
leaking. Ref 510008652
No 1 engine high pressure turbine active clearance
control (HPTACC) valve leaking. Investigation
continuing.
P/No: 32911866. (1 similar occurrence)
36
FSA SEP–OCT09
surged followed by a drop in torque. The engine was
shut down. Preliminary investigation found failure of
the high-speed pinion gear resulting in other damage
within the engine. Investigation is continuing.
P/No: 310703612. TSN: 15,783 hours/21,683
cycles/217 landings/252 months. (1 similar
occurrence)
GE CFM567B Engine turbine section support
cracked. Ref 510008527
No 1 engine No 5 bearing support cracked at lower
flange. Investigation continuing.
(1 similar occurrence)
GE CFM567B HMU unserviceable.
Ref 510008774
No 1 engine hydro-mechanical unit (HMU) fuel
shutoff valve unserviceable. Valve would not shut off
when selected.
P/No: 185M56P12. (5 similar occurrences)
PWA PT6A34AG Engine turbine blade cracked.
Ref 510008605
Compressor turbine blades (2off) cracked on trailing edge.
P/No: 310240101. TSN: 6,315 hours. TSO: 834 hours. (2
similar occurrences)
PWA PW123B Engine turbine blade failed. Ref
510008668
RH engine high pressure turbine blade partially
missing. Secondary damage found. Found during
borescope inspection.
P/No: 311560101. TSN: 2,032 hours/1,411cycles/21
months. (1 similar occurrence)
PWA PW150A Engine fuel heater to FMU o-ring
leaking. Ref 510008603
RH engine fuel heater to fuel management unit (FMU)
interconnect transfer tube o-ring seals damaged and
leaking. Investigation continuing.
P/No: M834611116. (1 similar occurrence)
Turbomeca ARRIEL2S Engine turbine binding.
Ref 510008785
Engine free power turbine binding on supporting
shroud. Suspect caused by water accumulation in the
exhaust area during aircraft washing.
TSN: 178 hours.
Turbomeca ARRIUS1A Engine reduction gear
seal incorrectly fi tted. Ref 510008729
No 1 engine output shaft bellow oil seal incorrectly
fitted. Carbon mating ring was installed backwards
causing oil leakage.
P/No: 9668306526. TSN: 85 hours.
Note: occurrence figures based on data received
over the past five years.
In July-August’s Flight Safety
Australia (issue 69), SDR Ref
510008174 on page 36 under
the Propellers heading,
incorrectly referred to MTV as
the manufacturer of the subject
propeller pitch control valve.
The defective item with regard to
this SDR was in fact a propeller
control valve manufactured
by Thielert (the engine
manufacturer) and not MTV. The
defective item is currently the
subject of a service bulletin under
development by Thielert. CASA
apologises for any confusion and
undue concern this error may
have caused.
ALL YOU WANTED TO KNOW ABOUT TNS 32 .... CONT.
Thinking further along these lines, it seemed
to us that we were defining the need for a set
of Moth-specific maintenance data, guidance
notes for good trade practices, rather than
the sort of directed inspection which is the
true preserve of an airworthiness directive
system. Might there be a chance of laying
AD 002-03-98 to rest? We knew of recent
precedents for absorbing ADs into continuing
airworthiness instructions.
What will become of the corresponding ADs
in Australia and in New Zealand is for CASA
and the CAA of NZ to decide locally. However,
even if the UK example is not followed, the
practical application of TNS No 32 Issue 3 will
be little different whether mandated or not.
TNS NO 32 ISSUE 3 –
‘INSPECTION OF WOODEN
STRUCTURE’
The first point to note about the new TNS is that
we have amended the title, while retaining the
same number. An unconventional practice,
but we felt it worthwhile as ‘TNS 32’ is so
widely associated with structural inspection.
In terms of document layout, the good news
is that the main body of the TNS has been
scaled down to just three pages! In truth the
content has been moved into no fewer than
SEVEN appendices, as follows:
C. Inspection of Wooden Structure – During
Periods of Normal Service - at Annual
Inspections
D. Inspection of Wooden Structure –
Subsequent to Incidents Likely to Cause
Structural Damage
E. Generic Guidance on Identification of
Damage and Deterioration in Wooden
Structures
F. Moth Type-Specific Information Affecting
Wooden Structure
G. Required Inspection and Drainage Provisions
in Moth Aircraft Fabric
At a closer look you will see that a TNS No
32 inspection is likely to involve only one
of the first four appendices, supplemented
by in-depth guidance from the latter three.
Appendix D is deliberately hard-hitting,
our investigations having found numerous
instances in which wing spar breakages were
overlooked. This indeed was where we came
in, with the tragedy of VH-TMK.
TNS No 32’s new mantra is to ‘Adopt the
recommendations and perform structural
inspections in relation to the known history,
current usage, and storage conditions of the
specific aircraft’. Please do exactly that, with
rose-tinted spectacles removed! Look after
your aeroplane and for the benefit of us all,
keep it safe and help to preserve this new
privilege which has been so hard earned.
To contact uss
de Havilland SSuppo
port
po
rtt Ltd
t
Building 213
Duxford Airfield
Cambridgeshirre
CB22 4QR
ENGLAND
+44
44 ((0)
0)) 122
223
22
3 83
300
090
0
T: +
F: +4
+44
4 (0
(0)) 12
1223
23 830
30085
E: inf
n o@
o@dh
dhsupp
dh
port.co
com
co
m
W: ww
w w.
w.dh
dhsupp
dh
por
o t.
t.co
com
co
m
Skype: dhslh
hsslh
hq
37
AIRWORTHINESS
By doing all this it has been possible to
eliminate the UK AD status of TNS No 32, as it
were to seek the desired outcome by kindness
and good advice rather than by application of
a big stick. Mind you, bear in mind that no
coroner is likely to heap praise on an engineer
who has wilfully ignored an applicable
maintenance recommendation!
B. Inspection of Wooden Structure – Aircraft
Returning to Service after Extended
Storage
‘Adopt the
recommendations
and perform
structural
inspections in
relation to the
known histor y,
current usage,
and storage
conditions of the
speci fic aircraft’.
PULL-OUT SECTION
Moreover, as the Moth aircraft predate the
existence of type certificate data sheets, the
UK CAA, has in recent years, devised a generic
airworthiness approval note (AAN) to ‘define’
each Moth variant. Indeed, conformity to the
relevant AAN must now be certified at each C of
A renewal. It was a fairly simple matter for us to
draft a new paragraph for each AAN, itemising
the required maintenance data as a combination
of the airframe and engine instruction manuals
and the respective suites of TNS.
A. Inspection of Wooden Structure –
Aircraft Undergoing Restoration (Prior
to Fabric Covering)
APPROVED AIRWORTHINESS DIRECTIVES
2 July 2009
Part 39-105 - Lighter Than Air
There are no amendments to Part 39-105 - Lighter
than Air this issue
Part 39-105 - Rotorcraft
PULL-OUT SECTION
Bell Helicopter Textron Canada (BHTC) 407
Series Helicopters
AD/BELL 407/36 - Anti-drive Link Assembly
FSA SEP–OCT09
38
Bell Helicopter Textron 427 Series
Helicopters
AD/BELL 427/10 - Anti-drive Link Assembly
Eurocopter BK 117 Series Helicopters
AD/GBK 117/24 - External Mounted Hoist System
Eurocopter EC 135 Series Helicopters
AD/EC 135/17 Amdt 1 - Main Gearbox Oil Sampling
& Analysis
Eurocopter SA 360 and SA 365 (Dauphin)
Series Helicopters
AD/DAUPHIN/99 - Fuel Crossfeed High Level
Switches
Robinson R44 Series Helicopters
AD/R44/19 - Main Rotor Clutch Drive Shafts CANCELLED
Sikorsky S-76 Series Helicopters
AD/S-76/2 - Engine Oil Filler Service Door Modification - CANCELLED
AD/S-76/13 - Tail Rotor Outboard Retaining Plate
Bolts - Inspection - CANCELLED
AD/S-76/14 - Fuselage Bulkhead - Engine Support
Fitting Area - Inspection and Modification CANCELLED
AD/S-76/18 - Pilot and Co-Pilot Seats, Support
Frames - Inspection - CANCELLED
AD/S-76/20 - Power Plant Mounting Supports Inspection and Modification - CANCELLED
AD/S-76/22 - Main Rotor Control Servo Actuators Inspection for Balance Tube Passage - CANCELLED
AD/S-76/28 - Utility Hoist - Inspection CANCELLED
AD/S-76/37 - Engine Fire Extinguisher Harness Modification - CANCELLED
AD/S-76/38 - Main Rotor Gear Box No. 1 and
No. 2 Input Bevel Pinion Housing Assemblies Inspection - CANCELLED
AD/S-76/39 Amdt 1 - Main Rotor Blade Tip
Block and Tip End Assemblies - Inspection and
Rectification - CANCELLED
AD/S-76/41 - Emergency Flotation System CANCELLED
AD/S-76/42 - Upper Fuselage, Station 300 CANCELLED
AD/S-76/43 - Tail Rotor Servo Actuator Linkage CANCELLED
AD/S-76/46 - Electrical DC Power System CANCELLED
AD/S-76/47 - Engine and Engine Compartment
Drain Lines - CANCELLED
AD/S-76/48 - Main Gearbox Lower Housing Jet
Port Liners - CANCELLED
AD/S-76/52 - Power Turbine Speed Trim Control
Actuators - CANCELLED
AD/S-76/53 - Doors - Window Frame - CANCELLED
AD/S-76/54 - Main Gearbox Tail Takeoff Flange
Locknut - CANCELLED
AD/S-76/55 Amdt 1 - Retention Bolt for Stationary
Swashplate Expandable Pin - CANCELLED
AD/S-76/58 - Tail Gearbox Output Shaft CANCELLED
AD/S-76/59 Amdt 1 - Tail Rotor Control Rod - Rod
Ends - CANCELLED
Part 39-105 - Below 5700 kgs
Aerospatiale (Socata) TB9 and TB10 (Tobago)
Series Aeroplanes
AD/TB10/5 Amdt 1 - Elevator/Elevator Tab Control
Attachment Inspection and Modification
AD/TB10/13 - Aircraft Wiring/Support Bracket
Clearance - CANCELLED
Aerospatiale (Socata) TB20 (Trinidad) Series
Aeroplanes
AD/TB20/1 - Engine Mount - Inspection/
Replacement - CANCELLED
Airparts (NZ) Ltd. FU 24 Series Aeroplanes
AD/FU24/64 Amdt 1 - Fin and Leading Edge
AD/FU24/67 - Vertical Stabiliser
Beagle B121 (Pup) Series Aeroplanes
AD/BEA 121/4 - Dual Throttle Control CANCELLED
AD/BEA 121/10 - Rudder Drain Hole - CANCELLED
AD/BEA 121/11 - Fuel Tanks - CANCELLED
AD/BEA 121/13 - Internal Door Lock Operating
Handle - CANCELLED
AD/BEA 121/21 - Nose Undercarriage and Rudder
Control System - CANCELLED
Beagle B206 Series Aeroplanes
AD/BEA 206/3 - Chafing of Hydraulic Master
Switch/Lamp - CANCELLED
AD/BEA 206/5 - Nose Landing Gear Spring Box CANCELLED
AD/BEA 206/7 - Cabin Door Operating Placards CANCELLED
Cessna 150, F150, 152 & F152 Series
Aeroplanes
AD/CESSNA 150/50 - Rudder Limit Stops
Consolidated Aeronautics, Colonial and LA-4
Series Aeroplanes
AD/LA-4/2 - Fuel Line - Replacement - CANCELLED
AD/LA-4/4 - Fuel Filter - Installation - CANCELLED
AD/LA-4/5 - Battery Relay - Installation CANCELLED
AD/LA-4/7 - Hull Frame Station 97 - Inspection
and Modification - CANCELLED
AD/LA-4/11 - Engine Mount Upper Side Straps Inspection - CANCELLED
AD/LA-4/17 - Fuel Cell - Inspection - CANCELLED
AD/LA-4/18 - Trim Actuating Cylinder Bracket Inspection - CANCELLED
AD/LA-4/20 - Main Landing Gear - Rocker Castings
P/N 2-4113-1 - Inspection and Replacement CANCELLED
AD/LA-4/21 - Auxiliary Fuel Tank Lines - Inspection
and Replacement, Modification - CANCELLED
AD/LA-4/22 - Engine Mount Tie Rod Ends CANCELLED
DH 82 (Tiger Moth) Series Aeroplanes
AD/DH 82/11 Amdt 1 - Flight Limitations and
Structural Inspection - CANCELLED
De Havilland DH 83 (Fox Moth) Series
Aeroplanes
AD/DH 83/1 - Flight Limitations and Structural
Inspection - CANCELLED
DH 85 (Leopard Moth) Series Aeroplanes
AD/DH 85/1 Amdt 1 - Flight Limitations and
Structural Inspection - CANCELLED
DH 87 (Hornet Moth) Series Aeroplanes
AD/DH 87/2 Amdt 1 - Flight Limitations and
Structural Inspection - CANCELLED
DH 94 (Moth Minor) Series Aeroplanes
AD/DH 94/1 Amdt 1 - Flight Limitations CANCELLED
Fuji FA-200 Series Aeroplanes
AD/FA-200/1 - Battery Leads - Identification and
Relocation - CANCELLED
AD/FA-200/2 - Nose Landing Gear Piston Stop
Plate and Screws - Modification - CANCELLED
AD/FA-200/3 - Propeller Blade Inspection and
Operating Restriction - CANCELLED
AD/FA-200/4 - Main Fuel Tank Vent - Modification
- CANCELLED
AD/FA-200/5 - Fuselage Skin - Modification CANCELLED
AD/FA-200/7 - Rudder Cables - Inspection and
Modification - CANCELLED
AD/FA-200/8 - Pitot Static Water Drain Access Modification - CANCELLED
AD/FA-200/10 - Oil Cooler Lines - Modification CANCELLED
AD/FA-200/11 - Parking Brake Control Cable Inspection - CANCELLED
AD/FA-200/12 - Auxiliary Fuel Pump - Modification
- CANCELLED
AD/FA-200/13 - Spin Recovery Placard Replacement - CANCELLED
AD/FA-200/14 - Main Landing Gear Assemblies Modification - CANCELLED
AD/FA-200/15 - Nose Landing Gear Piston Stop
Plate Screws - Modification - CANCELLED
AD/FA-200/18 - Fuel System - Placard Installation
- CANCELLED
AD/FA-200/24 - Elevator Torque Tube Corrosion CANCELLED
Columbia (formerly Lancair) LC40, LC41 and
LC42 Series Aeroplanes
AD/LC40/3 - Rudder Hinges and Hinge Brackets
Mitsubishi MU-2 Series Aeroplanes
AD/MU-2/2 - Windows - Cabin and Cockpit Modification - CANCELLED
AD/MU-2/9 - Trim Aileron Bellcrank Bracket Bolt
Holes - Inspection - CANCELLED
AD/MU-2/19 - Engine Nacelle Upper Door
Rod Assembly - Removal and Modification CANCELLED
AD/MU-2/26 - Control Cable Turnbuckles Inspection and Replacement - CANCELLED
AD/MU-2/27 - Engine Control System Cable
Pulleys - Replacement - CANCELLED
AD/MU-2/33 - Rudder and Elevator Trim Idler
Installation - Modification - CANCELLED
AD/MU-2/38 - Landing Gear Aural Warning
System - CANCELLED
AD/MU-2/72 - Electrical Wiring
De Havilland DH 60 (Moth) Series Aeroplanes
AD/DH 60/5 Amdt 1 - Flight Limitations and
Structural Inspection - CANCELLED
Morava L200 Series Aeroplanes
AD/L200/3 - Propeller De-Icing Control Modification - CANCELLED
AD/L200/4 - Nose Wheel Retract Strut - Inspection
- CANCELLED
AD/L200/5 - Front (Pilot) Seats Restraint
Installation - Modification - CANCELLED
AD/L200/7 - Main Undercarriage Breakstrut
Hinges - Inspection - CANCELLED
AD/L200/8 - Fin and Stabiliser Front Attachment
Hinges - Inspection - CANCELLED
AD/L200/9 - Control Wheel Rod - Inspection CANCELLED
Pilatus Britten-Norman BN-2 Series
Aeroplanes
AD/BN-2/85 - Elevator Tip Assemblies
Turbomeca Turbine Engines - Arriel Series
AD/ARRIEL/24 Amdt 2 - Constant Delta Pressure
Valve Diaphragm
AD/ARRIEL/32 Amdt 1 - Engine - Module M04
Power Turbine Blades
Bombardier (Boeing Canada/De Havilland)
DHC-8 Series Aeroplanes
AD/DHC-8/147 - Main Landing Gear Airworthiness
Limitation Items
AD/DHC-8/148 - Elevator Power Control Unit
Turbomeca Turbine Engines - Artouste Series
AD/ARTOUSTE/2 - Oil and Fuel Lines - Replacement
and Support - CANCELLED
AD/ARTOUSTE/4 - Micropump Valve Rod Modification - CANCELLED
Embraer ERJ-170 Series Aeroplanes
AD/ERJ-170/23 - Airframe Structural Components
Turbomeca Turbine Engines - Makila Series
AD/MAKILA/14 - Engine Control Unit - Comparator/
Selector Boards
Embraer ERJ-190 Series Aeroplanes
AD/ERJ-190/21 - Airframe Structural Components
Rockwell (N American) & Autair (Noorduyn)
AT-6, BC-1A, SNJ, T-6G, Harvard, & AT-16
Series Aeroplanes
AD/AT-6/2 Amdt 1 - Horizontal Stabliser Rear Spar
Connector Fittings
SAAB SF340 Series Aeroplanes
AD/SF340/108 Amdt 1 - Hydraulic System
Accumulators
Robin Aviation Series Aeroplanes
AD/ROBIN/1 - Pilot Safety Harness - Change of
Straps - CANCELLED
AD/ROBIN/2 - Flap Control Mechanism Dented
Plate - Inspection - CANCELLED
AD/ROBIN/3 - Engine Mount - Inspection and
Replacement - CANCELLED
AD/ROBIN/10 Amdt 1 - Control Column Assembly
Welds - CANCELLED
AD/ROBIN/26 - ATL Rudder Bar - CANCELLED
Rolls Royce (Blackburn) Engines - Cirrus
Series
AD/RRP-C/1 - Connecting Rod - Modification CANCELLED
AD/RRP-C/2 - Connecting Rod - Modification CANCELLED
AD/RRP-C/3 - Crankshaft - Inspection - CANCELLED
Rutan Varieze Series Aeroplanes
AD/RUTAN/1 - Rudder Travel - Modification CANCELLED
Part 39-106 - Turbine Engines
Ryan ST Series Aeroplanes
AD/RYAN/1B - Lower Flying Wire Lug Replacement - CANCELLED
Short SC7 (Skyvan) Series Aeroplanes
AD/SC7/2 - Flying Controls - Inspection and
Modification - CANCELLED
AD/SC7/6 - Guards at Rear of Pilots Seats Installation - CANCELLED
SIAI Marchetti S205 and S208 Series
Aeroplanes
AD/SM-205/16 - Fuel Quantity Transmitter Scupper
- Inspection and Modification - CANCELLED
AD/SM-205/19 - Carburettor Air Intake Box and
Engine Cowling - Modification - CANCELLED
AD/SM-205/21 - Landing Gear Cross Members Inspection - CANCELLED
AD/SM-205/26 - Engine Air Induction Valve Replacement - CANCELLED
Part 39-105 - Above 5700 kgs
Airbus Industrie A319, A320 and A321 Series
Aeroplanes
AD/A320/230 - High Pressure Compressor
Deterioration - CANCELLED
Boeing 737 Series Aeroplanes
AD/B737/355 - Forward Airstair Doorway Backup
Intercostals and Upper Sill Web
AD/B737/356 - MLG Retract Actuator Beam
Boeing 747 Series Aeroplanes
AD/B747/334 Amdt 1 - Escape Slides, Ramp Slides,
and Slides/Rafts of Upper Deck, Off-wing, and
Main Doors
AD/B747/392 - Fuselage Upper Lobe Doubler
AD/B747/393 - Section 41 Upper Deck Floor Beam
Upper Chords
Boeing 767 Series Aeroplanes
AD/B767/250 Amdt 1 - Lower Wing Skin
Part 39-106 - Piston Engines
Teledyne Continental Motors Piston Engines
AD/CON/45 Amdt 3 - Camshaft Oil Transfer Holes
- CANCELLED
Allison Turbine Engines - 250 Series
AD/AL 250/13 - Improved Indicating Magnetic
Drain Plugs - Introduction - CANCELLED
AD/AL 250/76 - Falcon Helicopters - CANCELLED
AD/AL 250/77 - Third Stage Turbine Wheel P/N
23001977 - CANCELLED
CFM International Turbine Engines - CFM56
Series
AD/CFM56/30 - Engine - High Pressure Compressor
AD/CFM56/31 - High Pressure Compressor
Pratt and Whitney Canada Turbine Engines PT6A Series
AD/PT6A/7 - Re-Routing Of Governor Air Pressure
Line - CANCELLED
AD/PT6A/8 - Compressor Rear Hub Hardness CANCELLED
AD/PT6A/12 - Improved Wire Rope Reversing
Cable - CANCELLED
AD/PT6A/13 - Fuel Pump Drive Coupling - Improved
Lubrication - CANCELLED
AD/PT6A/14 - Sungear Coupling Shaft Retaining
Rings - CANCELLED
AD/PT6A/15 - Reversing Linkage Front End Clevis Incorporation of Inspection Hole - CANCELLED
AD/PT6A/21 - Replacement of Compressor Delivery
Heated Air Tube - CANCELLED
AD/PT6A/23 - Replacement of Compressor
Delivery Heated Air Tube by a Non-Metallic Hose
- CANCELLED
AD/PT6A/26 - Power Turbine Containment Ring CANCELLED
Pratt and Whitney Canada Turbine Engines PT6T Series
AD/PT6T/2 - Check and Regulating Valve Housing
Reinforcing Bracket - CANCELLED
AD/PT6T/6 - Fuel Pump Coupling - Replacement CANCELLED
Rolls Royce Turbine Engines - RB211 Series
AD/RB211/40 - Low Pressure Turbine Casing
AD/RB211/41 - Engine - Thrust Reverser Unit
Part 39-107 - Equipment
Air conditioning Equipment
AD/AIRCON/14 Amdt 4 - Zonal Drying System
Regeneration Air Duct Overheat
Auxiliary Power Units
AD/APU/23 - Saphir 2 Exhaust Thermal Insulation
APPROVED AIRWORTHINESS
DIRECTIVES
30 July 2009
39
Part 39-105 - Lighter Than Air
There are no amendments to Part 39-105 - Lighter
than Air this issue
Part 39-105 - Rotorcraft
Aircraft - General
AD/GENERAL/4 Amdt 4 - Aircraft Exits
AD/GENERAL/82 Amdt 2 - Repair Assessment of
Pressurised Fuselages
Bell Helicopter Textron 47 (All Variants)
Series Helicopters
AD/BELL 47/102 - Main Rotor Blades Box Beam
Clips
Bell Helicopter Textron Canada (BHTC) 206
and Agusta Bell 206 Series Helicopters
AD/BELL 206/81 - Auxiliary Fin - Inspection CANCELLED
Bell Helicopter Textron Canada (BHTC) 222
Series Helicopters
AD/BELL 222/3 - Tail Boom - Inspection and
Modification - CANCELLED
AD/BELL 222/5 - Ng Operating Speed Restrictions
- CANCELLED
AD/BELL 222/7 - Fin Assembly Attachment CANCELLED
AD/BELL 222/8 Amdt 1 - Emergency Flotation
System and Squib Valve - CANCELLED
AD/BELL 222/11 - Swashplate Pins - CANCELLED
Eurocopter AS 332 (Super Puma) Series
Helicopters
AD/S-PUMA/6 Amdt 1 - Lucas Air Equipment
Hoists - Explosive Squib - CANCELLED
Eurocopter AS 350 (Ecureuil) Series
Helicopters
AD/ECUREUIL/5 - Tail Rotor Control Fixed Plate Inspection of Self Aligning Bearing - CANCELLED
AD/ECUREUIL/20 - Main Gear Box Oil Filter Inspection - CANCELLED
AIRWORTHINESS
Pilatus PC-12 Series Aeroplanes
AD/PC-12/32 Amdt 2 - Nose Landing Gear Drag Link
PULL-OUT SECTION
Bombardier (Canadair) CL-600 (Challenger)
Series Aeroplanes
AD/CL-600/108 - Air Driven Generator Power
Feeder Harness
AD/CL-600/109 - Nose Landing Gear Selector Valve
AD/CL-600/110 - Flap Actuator Pinion Gear
APPROVED AIRWORTHINESS DIRECTIVES ... CONT.
PULL-OUT SECTION
Part 39-105 - Rotorcraft (cont.)
FSA SEP–OCT09
40
AD/ECUREUIL/30 Amdt 3 - Main Rotor Sleeve Beams
AD/ECUREUIL/34 - Main Rotor Head, Main
Gearbox and Landing Gear - CANCELLED
AD/ECUREUIL/35 - Planet Gear Cage to Rotor
Shaft Attachment Bolts - CANCELLED
AD/ECUREUIL/36 Amdt 2 - Consolidation of Early
Airworthiness Directives - CANCELLED
AD/ECUREUIL/37 Amdt 1 - Tail Rotor Control
Spider - CANCELLED
AD/ECUREUIL/39 - Cargo Hook Emergency Manual
Control - CANCELLED
AD/ECUREUIL/41 - Battery Thermal Sensor
Connector - CANCELLED
AD/ECUREUIL/42 Amdt 1 - Servo Control Securing
Screw - CANCELLED
AD/ECUREUIL/49 - Lucas Air Equipment Hoist Explosive Squib - CANCELLED
AD/ECUREUIL/54 - Main Rotor Shaft Oil Jet CANCELLED
AD/ECUREUIL/84 - Hydraulic Fluid - CANCELLED
Eurocopter AS 355 (Twin Ecureuil) Series
Helicopters
AD/AS 355/1 Amdt 8 - Retirement Life - Fatigue
Critical Components - CANCELLED
AD/AS 355/14 Amdt 1 - Combiner Gearbox R.H.
and L.H. - CANCELLED
AD/AS 355/15 Amdt 1 - Sliding Door Ball Joint Inspection and Modification - CANCELLED
AD/AS 355/17 - Securaiglon (Ex Laiglon) Safety
Belts - Modification - CANCELLED
AD/AS 355/18 Amdt 1 - Main Rotor Sleeve Beams
AD/AS 355/22 - Main Rotor Head, Main Gearbox
and Landing Gear - CANCELLED
AD/AS 355/24 Amdt 2 - Consolidation of Early
Airworthiness Directives - CANCELLED
AD/AS 355/26 Amdt 1 - Tail Rotor Control Spider
- CANCELLED
AD/AS 355/30 - Cargo Hook Emergency Manual
Control - CANCELLED
AD/AS 355/31 - Tail Rotor Gearbox Casing CANCELLED
AD/AS 355/32 - Servo Control Securing Screws CANCELLED
AD/AS 355/35 - AC Generation System CANCELLED
AD/AS 355/42 - Lucas Air Equipment Hoist Explosive Squib - CANCELLED
AD/AS 355/46 - Main Rotor Shaft Oil Jet CANCELLED
Aerospatiale (Socata) TB9 and TB10 (Tobago)
Series Aeroplanes
AD/TB10/1 Amdt 4 - Airworthiness Limitations CANCELLED
Aerospatiale (Socata) TB20 (Trinidad) Series
Aeroplanes
AD/TB20/29 - Airworthiness Limitations CANCELLED
Airtractor AT-300, 400 and 500 Series
Aeroplanes
AD/AT/29 Amdt 1 - Engine Mount
Airtractor 600 Series Aeroplanes
AD/AT 600/4 Amdt 3 - Engine Mount
Auster/Beagle A.61 Series Aeroplanes
AD/AUS/1 - Lift Strut - CANCELLED
AD/AUS/2 - Tail Attachment Bolts - CANCELLED
AD/AUS/4 - Aileron Control Push Rod - CANCELLED
AD/AUS/7 - Engine Mount Attachment Bolt CANCELLED
AD/AUS/8 - Lift Strut - CANCELLED
AD/AUS/10 - Rudder Cables and Elevator Trim Tab
Cables - CANCELLED
Beagle A109 (Airedale) Series Aeroplanes
AD/BEA 109/2 - Propeller Inspection and
Operating Restriction - CANCELLED
Bushby Mustang II Series Aeroplanes
AD/BUSHBY M2/1 - Canopy Frame - Modification
- CANCELLED
AD/BUSHBY M2/2 Amdt 1 - Sta 114.75 Bulkhead
Member P/N 240.339 - CANCELLED
Cessna 150, F150, 152 & F152 Series
Aeroplanes
AD/CESSNA 150/10 Amdt 3 - Plastic Control
Wheel
Cessna 170, 172, F172, FR172 and 175 Series
Aeroplanes
AD/CESSNA 170/13 Amdt 3 - Plastic Control
Wheel
Cessna 180, 182 and Wren 460 Series
Aeroplanes
AD/CESSNA 180/14 Amdt 3 - Plastic Control
Wheel
Cessna 185 Series Aeroplanes
AD/CESSNA 185/1 Amdt 3 - Plastic Control Wheel
Cessna 205 (210-5) Series Aeroplanes
AD/CESSNA 205/3 Amdt 2 - Plastic Control Wheel
Eurocopter BK 117 Series Helicopters
AD/GBK 117/25 - Tail Rotor Gearbox Bevel Gear
AD/GBK 117/26 - Tail Rotor Drive Shaft Rivets
Cessna 210 Series Aeroplanes
AD/CESSNA 210/4 Amdt 3 - Plastic Control Wheel
- Inspection
Eurocopter BO 105 Series Helicopters
AD/BO 105/4 - Dual Flight Controls - CANCELLED
AD/BO 105/10 - Swashplate - CANCELLED
AD/BO 105/11 Amdt 1 - Tail Rotor Transmission CANCELLED
AD/BO 105/13 - Load Hook System - CANCELLED
DH 82 (Tiger Moth) Series Aeroplanes
AD/DH 82/16 - TNS Applicability to Thruxton
Jackaroo Aircraft
Eurocopter SA 360 and SA 365 (Dauphin)
Series Helicopters
AD/DAUPHIN/100 - Fuselage Frame N.9
Part 39-105 - Below 5700 kgs
Aircraft - General
AD/GENERAL/4 Amdt 4 - Aircraft Exits
AD/GENERAL/82 Amdt 2 - Repair Assessment of
Pressurised Fuselages
Dornier DO-27 Series Aeroplanes
AD/DO-27/2 - Tailplane Front Spar - Modification
- CANCELLED
AD/DO-27/3 - Elevator Hinge Bracket - Inspection
- CANCELLED
AD/DO-27/10 - Stall Warning System - Installation
- CANCELLED
Fairchild (Swearingen) SA226 and SA227
Series Aeroplanes
AD/SWSA226/37 - Fuselage, Lower L.H. Cargo
Area Belt Frames - Inspection and Modification CANCELLED
AD/SWSA226/45 - Battery Power Cable Inspection/Modification - CANCELLED
AD/SWSA226/84 Amdt 1 - Cargo Door Lower Belt
Frames
AD/SWSA226/97 - Chafing or Arcing Electrical
Wiring
Fuji FA-200 Series Aeroplanes
AD/FA-200/26 - Nose and Main Landing Gear
Cylinder Assemblies
Mitsubishi MU-2 Series Aeroplanes
AD/MU-2/73 - Baggage Compartment / Engine
Bleed Lines
Monnett Sonerai Series Aeroplanes
AD/SONERAI/1 Amdt 1 - Flight Restriction
and Limitations - Placard and Modification CANCELLED
Piper PA-28 Series Aeroplanes
AD/PA-28/40 Amdt 2 - Wing Rear Spar - Inspection
Piper PA-32 (Cherokee Six) Series
Aeroplanes
AD/PA-32/27 Amdt 3 - Wing Rear Spar Inspection
AD/PA-32/42 Amdt 2 - Wing Structural Fatigue
Life Limitation
Schweizer (Grumman) G-164 (Ag-Cat) Series
Aeroplanes
AD/G164/2 Amdt 1 - Hopper Load Jettison
Requirement - CANCELLED
AD/G164/6 - Carburettor Air Duct - Modification CANCELLED
AD/G164/7 Amdt 2 - Power Plant Fire Protection Modification - CANCELLED
AD/G164/10 - Elevator Pushrod Assembly Inspection - CANCELLED
AD/G164/11 - Spray Fan Brake Control Modification - CANCELLED
AD/G164/12 - Fuel Quantity Indicator Presentation
- Inspection - CANCELLED
AD/G164/13 - Outboard TE Boom Support Brackets
- Replace - CANCELLED
AD/G164/16 Amdt 1 - Rear Fuselage Extension Inspection and Modification - CANCELLED
SIAI Marchetti 260 Series Aeroplanes
AD/SM-260/1 - Engine Mount - Modification CANCELLED
AD/SM-260/2 - Stabiliser Front Spar - Modification
- CANCELLED
AD/SM-260/3 - Pilot Seat Stroke Limit Stops Installation - CANCELLED
AD/SM-260/5 - Carburettor Air Intake Box and
Engine Cowling Drain Holes - Modification CANCELLED
AD/SM-260/6 - Front Seat Restraint Installations Modification - CANCELLED
AD/SM-260/12 - Canopy Latch Assembly Modification - CANCELLED
AD/SM-260/15 - Wing Tip Fuel Tank Components Inspection and Replacement - CANCELLED
AD/SM-260/17 - Aileron Balance Weight Security
- CANCELLED
Part 39-105 - Above 5700 kgs
Aircraft - General
AD/GENERAL/4 Amdt 4 - Aircraft Exits
AD/GENERAL/82 Amdt 2 - Repair Assessment of
Pressurised Fuselages
30 July 2009... CONT.
Airbus Industrie A330 Series Aeroplanes
AD/A330/31 Amdt 4 - Airworthiness Limitations
Items - Time Limits/Maintenance Checks
AD/A330/61 - Pylon Lateral Panels at Rib 8 Level
- CANCELLED
Fokker F100 (F28 Mk 100) Series Aeroplanes
AD/F100/91 Amdt 1 - Fuel System - Crossfeed
Valve Actuator
Rolls Royce Turbine Engines - RB211 Series
AD/RB211/32 Amdt 2 - Stage 5 Compressor Disc Inspection - CANCELLED
Learjet 45 Series Aeroplanes
AD/LJ45/13 - Left Hand Engine Hydraulic Tubes
Turbomeca Turbine Engines - Arriel Series
AD/ARRIEL/34 - Module M05 - Lubrication Duct
Airtractor 800 Series Aeroplanes
AD/AT 800/9 Amdt 3 - Engine Mount
Part 39-106 - Piston Engines
Turbomeca Turbine Engines - Astazou Series
AD/ASTAZOU/5 - Return to Service for Civil Use CANCELLED
AMD Falcon 50 and 900 Series Aeroplanes
AD/AMD 50/47 - Crew and Passenger Oxygen
Lines
Boeing 737 Series Aeroplanes
AD/B737/332 Amdt 1 - Fwd Entry and Fwd Galley
Service Doorway Upper and Lower Hinge Cutout
AD/B737/357 - In-Flight Entertainment Systems
AD/B737/358 - Electronic Flight Instrument System
Cooling
Bombardier (Boeing Canada/De Havilland)
DHC-8 Series Aeroplanes
AD/DHC-8/149 - Spoiler Lift Dump Valve
Bombardier (Canadair) CL-600 (Challenger)
Series Aeroplanes
AD/CL-600/86 - Nose Landing Gear(NLG) and NLG
Door Selector Valves - CANCELLED
AD/CL-600/111 - Nose Landing Gear Selector Valve
AD/CL-600/112 - Main Landing Gear Torque Link
Apex Pin
AD/CL-600/113 - Passenger Door Corrosion
AD/CL-600/114 - Landing Gear Alternate Extension
System
AD/CL-600/115 - Air Driven Generator Strut
British Aerospace BAe 3100 (Jetstream)
Series Aeroplanes
AD/JETSTREAM/106 - Main Landing Gear Radius Rod
Part 39-106 - Turbine Engines
AlliedSignal (Garrett/AiResearch) Turbine
Engines - ATF3 Series
AD/ATF3/3 - H.P. Turbine Rotor Assembly P/No.
3001766-7 - CANCELLED
AlliedSignal (Lycoming) Turbine Engines T53 Series
AD/T53/2 - First Stage Power Turbine Rotor Blade
Retaining Pins Retirement Life - CANCELLED
AD/T53/4 - Engine Oil Pump Drive Gear Spline Inspection - CANCELLED
AD/T53/5 - Accessory Drive Gearbox - Rework CANCELLED
AD/T53/7 - Improved Gas Producer Turbine Rotor
Blades - Introduction - CANCELLED
AD/T53/8 - Second Stage Power Turbine Rotor
Disc - Rework - CANCELLED
AD/T53/10 - Inlet Guide Vane Feedback Tube
Assembly - Inspection - CANCELLED
AD/T53/12 - Fuel Regulator Main Pressure
Regulator Valve Diaphragm Replacement CANCELLED
AD/T53/16 - Power Turbine Clamping Plate Inspection - CANCELLED
General Electric Turbine Engines - CJ610
Series
AD/CJ610/6 - Stage 2 Turbine Wheels CANCELLED
General Electric Turbine Engines - CT7
Series
AD/CT7/3 - Compressor Modification, Power
Lever Control Adjustment and Engine Inspection
Procedure - CANCELLED
Part 39-107 - Equipment
Propellers - Variable Pitch - Hamilton
Standard
AD/PHS/25 - Propeller Blade Corrosion
Propellers - Variable Pitch - Hartzell
AD/PHZL/92 - Propeller Blade Counterweight Slug
Attach Bolts
Supplementary Equipment
AD/SUPP/18 Amdt 1 - SIREN Load Release Units
AD/SUPP/22 - Lifesaving Systems D-Lok Hook
41
AIRWORTHINESS
Boeing 747 Series Aeroplanes
AD/B747/131 Amdt 1 - Flap Control Unit Wiring
Change
AD/B747/168 Amdt 3 - Engine Pylon Aft Torque
Bulkhead
AD/B747/212 Amdt 1 - Modular Avionics Warning
Electronic Assembly
AD/B747/314 Amdt 2 - Aft Pressure Bulkhead Web
Franklin Piston Engines
AD/FK-P/1 - Air By-Pass Valve - Modification CANCELLED
AD/FK-P/2 - Connecting Rods - Replacement CANCELLED
AD/FK-P/4 - Starter Gear/Damper Assembly P/No
18708 - Inspection - CANCELLED
AD/FK-P/5 - Engine/Propeller Oil Transfer Plug Replacement - CANCELLED
PULL-OUT SECTION
AMD Falcon 10 Series Aeroplanes
AD/AMD 10/4 Amdt 1 - Wing Anti-Icing Flexible
Hoses - Replacement and Modification CANCELLED
AD/AMD 10/25 Amdt 1 - Wing Anti-Ice Hoses CANCELLED
The one-man
‘war on error’
The war on error, Tony Kern
Ben Cook (CASA human factors
manager- left) & Tony Kern
explained to attendees at his
recent Australia-wide error
42
management roadshow, will
be ‘won one heart and mind
FSA SEP–OCT09
at a time’.
Tony received very positive feedback from the
more than 1000 pilots, LAMEs, AMEs, safety
and human factors personnel who attended
the day-long sessions around the country.
Flight Safety sat in on one of the sessions, and
talked with Tony Kern about his increasing
focus of late: effective error control requires a
greater consideration of the role of individual
performance. Until now, he argues, the
focus has been on a systemic approach to
dealing with human error in aviation. Safety
management systems (SMS) deal with the
issue at a systems level, and crew resource
management (CRM) and its fifth-generation
incarnation, threat and error management
(TEM) at a team level, but no-one, according
to Kern, is dealing with the root cause.
‘Safety management begins with personal
accountability’, he explains.
With around 80 per cent of accidents in
aviation attributable to human error, Tony
Kern argues that the current approaches are
not working – ‘CRM and TEM are polished
antiques. We’re stuck in an antique mindset;
people are bored with recurrent training,’
which has no effect on reducing error.
Rather, Kern argues, the war on error must
begin with the individual. His journey to this
conclusion began with experience of the
past ten years. As a US Defence Force flight
instructor, he was deeply affected by the
death of colleagues in controlled flight into
terrain accidents. ‘They were all my equal or
better,’ he recounts. ‘They were all flying good
aircraft, so why them, and not me?’ After
leaving the US air force, he became head of
aviation services with the US firefighting force,
and also undertook some work with the US
Marines. High accident rates and numerous
fatalities (13 in just over 18 months) led him
to question the accepted systems approach
to human error. ‘Individual improvement will
trump organisational fi xes. Things have to be
at the personal level,’ he says, ‘but personal
accountability is not intuitive. It’s a learnt
skill, but not a taught skill.’
He is therefore now a passionate advocate of
the need for individuals to adopt a daily regime
of personal error control, beginning with a
war on complacency. ‘In emergencies you will
perform worse, not better than your average,
so your goal must be perfect performance; not
being comfortable with being average.’ He encourages development of
the capacity to visualise perfection. ‘What would a perfect drive to
work look like?’ for example, arguing that this life skill, this pursuit
of perfection, translates into the cockpit, or to the workshop. ‘Human
error is no more inevitable or part of “being human” than cancer is.’
Tony Kern is well known for his work on airmanship, and his recent
work builds on his bedrock principles of airmanship – discipline and the
first of his pillars of knowledge – self. ‘Without personal professional
discipline’, Kern told attendees, ‘SMS disintegrate from within’.
Building a personal code of compliance should be in 3D, where the
three Ds are: ‘attention to detail; diligence – every time, all the time;
and discipline – the ability to self-check, and to resist the temptation
to deviate.’ By practising these habits of professional discipline, the
individual then makes them permanent.’
so your goal must be
perfect performance;
not being comfortable
with being average
Attendees at the Melbourne workshop
Thank you for organising and providing a world class training event for us. The day was without fault, and
hearing Tony Kern speak in person adds significant value to the knowledge I have already gleaned from his
books, and this will flow through to the training sessions I conduct at work. (B737 training captain)
I would just like to reiterate how fantastic Tony Kern was today. His presentation showed his progressive and
practical approach to human factors training, and for the first time ever, I walked away from an HF training
seminar with tools to genuinely improve human performance. It was a thoroughly enjoyable and interesting
day. (Human factors training manager)
The leading edge
in aviation insurance.
Aviation Insurance Australia is the country’s largest indepen
independent aviation
insurance broker providing specialist insurance assistance to a wide range
ge
of aviation clients.
With over 90 years combined experience as pilots, we speak your
our llangu
language
and communicate your needs to insurers and finance brokers.
kers.
rs
For you, ultimate peace of mind is all about honesty, commitment and
integrity. For us, it’s the only way we do business.
admin@aviationinsurance.com.au | www.aviationinsurance.com.au
Archerfield Office
Ian Tait , Chris Stainer
Dylan
ylan Jones
(07) 3274 4732
S uthern Regional Officce
Southern
Geoff
eoff Bu
Butle
Butler
(03)
03) 5778 7680
76
0407 170
70 789
89
43
ERROR MANAGEMENT
Kern presented attendees at the workshop with his ‘blue threat’
workbook. In military terms, ‘red threats’ are external threats, while
‘blue threats’ are internal obstacles, such as human error, poor
communication, inadequate planning. In the workbook, Kern has
outlined a number of ‘blue threat’ proverbs – number three states
that ‘Life is a mission simulator’. For Kern, effective error control in
the industry requires aviation professionals to set uncompromising
standards in their daily life, refusing to allow the ‘crushing grip of
mediocrity’ to take hold: these life skills will then gravitate into the
cockpit and workshop. The feedback (below) from the workshops
showed that many attendees embraced this approach.
FSA SEP–OCT09
44
Freightful
flight
One lovely cloudless Saturday morning, I was taking it easy when the
telephone rang.
‘Hello Ron,’ said the oil company representative, ‘We have a medivac.
There is a guy on board with a fever and the medic thinks he should
be evacuated. Can you do it?’
‘No worries!’ It was a beautiful day to go flying. No cloud and a light
and variable wind.
One and a half hours later, I landed on the huge deck of the Zapata
Arctic. It was standard procedure not to shut down, but to keep
everything burning and turning, with the throttles at ground idle.
Soon enough there was activity on the helideck, and the helicopter
landing officer (HLO) escorted three men on board. One of them was
in obvious distress and the other two were there to look after him. It
was not uncommon when a medivac took place for all the patient’s
mates to volunteer to look after the guy. A free night in town was on
the cards. I watched them being loaded in and secured. I was vaguely
conscious of activity to the rear of the helicopter and assumed the
deck crew were loading luggage in the tail boom locker.
Eventually the passengers were securely strapped in and the sliding
door was slammed shut. I looked round at the passengers and gave
them the thumbs-up. One of them returned the gesture. There was
no voice communication available between the cockpit and passenger
cabin. The HLO stood outside the cockpit window and handed me the
manifest. It simply had the names of the three passengers on it, plus
the fateful words: ‘some freight’. In those days standard weights were
CLOSE CALL
Twenty
years
y
ago,
I was the base manager of a
helicopter operation supporting
an oil drilling rig in Bass Strait.
We flew a couple of Bell 212
helicopters, and were based
at Welshpool and the semisubmersible rig the Zapata
Arctic, which was about 100nm
to the south east. For some
strange reason not important
to this story, we flew with two
pilots aboard Monday to Friday,
but at the weekends we were
permitted to fly single pilot.
45
tre of
The cenw
so
s
a
y
t
i
v
a
r
g
far behinbdaibtly
was prohere near
somew aland.
New Ze
used for passengers, and everyone was a bit
lax about weighing freight if the helicopter
was light. In this instance I only had the three
passengers and about 1,000 lbs of fuel and
I assumed the freight was luggage. ‘Piece of
cake!’ I thought to myself.
FSA SEP–OCT09
46
When the deck was cleared I lifted into a hover
to check temperatures and pressures (Ts and
Ps) and power availability. Everything was in
the green and I was only using about 75 per
cent torque. I moved to the edge of the deck
for the takeoff, pointing west for home. A final
check and everything seemed normal, except
the aircraft seemed a bit tail heavy. Ah well,
it was probably that the direction of takeoff
I had selected was a bit down wind. At this
weight, no worries!
I pulled close to full power and up we went
like a homesick angel. But as soon as I left
the ground cushion, the tail really dropped. I
shoved the stick forward, and to my absolute
surprise and fright, I could only move the
stick about three cms forward before I hit the
stops. By now the helicopter was climbing
fast and clear of the deck, but the tail was still
dropping, and the nose was an alarming 30
degrees up and rising.
Terror took control. The nose continued to rise
and the airspeed was minimal. I guessed I was
clear of the oil rig and I did what seemed to be
the only action available. Instinctively I rolled
steeply to the left, away from all obstructions
and applied a hefty piece of left pedal. The
aircraft banked hard left. It seemed about 90
degrees of bank, but was probably only about
60, and the nose swung down through the
horizon. Immediately the airspeed started
to rise, but the sea was getting really close.
I rolled level again and pulled out of the dive, but this time, when
stabilised, the nose was only about 10 degrees up and the airspeed
was building. Soon I had 60 knots on the clock and the rear elevator
started to assist the attitude control. I still had the cyclic jammed
hard against the forward stop, but at least the nose was in a constant
attitude and we were gently climbing. I had a stabilised airspeed of
about 80 knots and I had reduced power to about 68 per cent torque.
We had survived! Now I had to try to sort out the problem.
There was obviously something seriously wrong with the configuration
of the helicopter. I triggered the radio, attempting a controlled voice,
but it was more likely close to a scream, and asked the oil rig if they
would mind educating me as to what the ‘freight’ was. Their reply
floored me. ‘Captain, we loaded 200 kilograms of core samples into
the tail locker.’ That explained a lot. The tail locker was only cleared for
a maximum of 400 lbs and then only when the front of the helicopter
was fully loaded. The centre of gravity was so far behind it was
probably somewhere near New Zealand. It was foolhardy to even think
of getting back on the deck of the rig. I reckoned that as soon as the
airspeed dropped below about 45 knots, the elevator would be useless,
and the nose would start its horrible ‘pointing-at-God’ routine.
I looked behind at the passengers. Three extremely white faces with
huge, round eyes stared back. But these were oil rig workers and not
easily scared. I pointed at the biggest bloke and indicated that I wanted
him to climb over the back of the front row of seats and get himself into
the vacant co-pilot’s seat. He nodded and gingerly unstrapped. Slowly
and carefully, he removed the headrests and hoisted himself over
the obstruction and into the co-pilot’s seat. There was an immediate
easing of the centre of gravity problem. It’s amazing what 300 pounds
of oil rig worker can do! The nose dropped a bit and I was able to
ease off full-forward cyclic. I then indicated that the other two guys
were to move into the most forward seats. This they did, and there
was a further easing of the problem. Now I could achieve about 90
knots with the nose more or less level with the horizon and have a
bit of forward cyclic to play with. We gingerly made our way back to
Welshpool with me quietly giving a special thanks to the designer who
thought to include a moveable elevator in the Bell 212.
On arrival at base, I decided not to let the speed drop below 60
until I was just off touchdown. Welshpool had a lot of grass areas
edging the runway and I decided to run it on over the grass. This was
accomplished without too much trouble, and soon we were sitting
on the ground surrounded by anxious and curious spectators, all
wanting to know what the trouble was. With my most casual voice I
asked the chief engineer to remove the offending freight from the tail
locker. When that was done, I was able to lift off and hover normally
back to dispersal.
Since those days, things have improved. Standard weights for
passengers are no longer used. All freight is properly weighed and
notified to the crew–even when the aircraft is largely empty. However,
one thing remains. All helicopter pilots should be properly trained in
aerobatic manoeuvres.
Sky
dive
by Travis
Frontin-R
ollet
It was a bright Saturday morning and it was turning
out to be a good day for flying. I was on my second
flight for the day, and my second flight in a Cessna
206 for five years taking skydivers to 10,000ft.
I couldn’t believe my eyes. I lowered the nose, shut down the engine and
made a MAYDAY call. The smoke in the cabin was increasing rapidly,
and the amount coming through the instrument panel alone was so
intense that I remember thinking that I may also have an electrical fire.
I turned the master off, but there was no change. I assumed that the
smoke therefore was coming from the engine and turned the master
back on. I saw the look of horror on the faces of my five passengers and,
being below 2000ft, they knew they couldn’t jump. I hoped that the look
on my face didn’t match theirs. I told them that I had a field down to
our left where I was going to land, to remain calm and ensure that their
single point restraint was fastened (as skydivers don’t sit on seats, they
use a single point restraint instead of a seat belt). Fortunately, we were
on a wide downwind for the other ALA with plenty of height and it was
only a matter of completing the circuit.
I stayed high deliberately until base, and then progressively used the
40 degrees of flap that this model was fitted with. We landed about a
third of the way down the strip and I let the plane coast to a stop at the
end. I think I would have just sat there for a while taking it all in, but my
passengers had the door open as soon as we stopped and were quickly
distancing themselves from this plane that they felt had cheated them.
When I got out, I found that my knees were knocking and a huge shot
of adrenalin was still coursing through my body. As I looked around
47
I saw the look
of horror on
the faces of my
five passengers
and, being below
2 0 0 0 ft , they knew
they couldn’t
jump.
CLOSE CALL
I was still getting used to the differences again from the Cessna 182
that the company also owned. I always plan to climb and descend
within gliding distance of the drop zone (DZ) aircraft/authorised landing
area (ALA) or the nearby ALA, just in case of the ‘unlikely event of an
engine failure’. This slowed the climb a little as more manoeuvring was
required, but I knew the DZ owner/operator supported this. Climbing
through 2000ft, I was requesting an airways clearance through
Amberley clearance delivery when the engine gave a large ‘bang’ and
instantly lost all power. Oil started spraying on the windscreen and the
cabin quickly started filling with smoke. The prop just windmilled lazily
in the slipstream, totally out of my control.
though, it seemed that some of my passengers where in a far greater
state of shock than me. The tandem customer that we had on board
looked deathly pale and said she wasn’t sure how she was going to
get home to Ireland now, as she sure wasn’t going to fly after that!
Some private pilots who flew from that ALA came up and described
how they had seen a large trail of smoke behind the aircraft from the
downwind leg onwards.
were so
at this
highly strung lmost
a
stage I was p ut
o
ready to jum tr y
My ner ves
FSA SEP–OCT09
48
the door andh the
my luck witchute
round para
on my
back,
I phoned Airservices to cancel the MAYDAY, only to be told that they
did not hear my call due to terrain shielding in the area. I ended up
filing an incident report over the phone and called the boss who came
to pick us up. On the trip back to the DZ, he asked me if I wanted to fly
the rest of the day in the Cessna 182, as there were plenty of tandems
who still needed to go up. I thought it would be a good way of ‘getting
back on the horse’, and so I agreed. As luck would have it, the engine
started coughing through 8000ft on the first flight. My nerves were so
highly strung at this stage I was almost ready to jump out the door and
try my luck with the round parachute on my back, (Most jump pilots fly
wearing a parachute in case of structural failure caused by a skydiver). I
applied carburettor heat quickly and the engine thankfully resumed its
normal melodic tones.
An analysis of the Cessna 206 revealed that a big-end bearing had
failed, breaking the crankshaft and pushing a part of the conrod out
through the top of the crankcase–hence the oil and smoke. The part
thankfully just missed a fuel line, or I may have also been dealing
with an engine fire.
As I look back at the incident, I’m glad I stayed within gliding distance
of an ALA-something I still do to this day when operating at the DZ. All
the practice of forced landings that I’ve done over the years was not a
waste of time, and I am grateful for it. It also proves once again that the
instructing technique of practising a precautionary search and landing
down to 500ft, and then practising a glide approach back
in the circuit area can be easily amalgamated for the real
thing when required.
I wonder sometimes, given my tense state, if
I should have flown the C182 afterwards. This
perhaps may have had a negative impact on my
decision-making ability.
By Emma Christensen
S
SWAMPED
The four of us left the hotel bright and early the
next morning, with a bit of scepticism about
the low cloud around. We found a ‘surrogate’
flying school and they kindly printed off our
weather for us. Before actually planning our
flight however, we all preflighted our aircraft
and refuelled.
Our flights were all planned along the coast,
and because of the low cloud and bumpy
conditions, our convoy decided it was best to
communicate on the uni-ops frequency.
We all made it to Coffs Harbour where we
re-fuelled, and made a quick call to base for
an update of the weather down the coast. It
sounded as if things were clearing up down
south and our flight was going according to
plan, so we all decided to makee a move. The
plan
other
er thing
t
in our favour thatt day was that
we h
had
d a 35kt tailwind,
a
nd, m
making
ng our trip
rip a lot
shorter
o
than
t n it w
tha
would normally
ma y be, and
nd hence
saving
av
on
n fu
fuel.
ue
49
CLOSE CALL
I am currently completing my aviation degree,
which also includes completing my flight
licences. During the CPL phase of flight, one
of the planned flights for flying students is to
fly from our base in Bankstown to Archerfield
return. This was one of the anticipated overnight trips where four of us would leave one
morning and return the following afternoon.
I flew up via Moree where we had all planned
to refuel, and have a quick refuelling break
ourselves. We all arrived safely in Archerfield
and caught a taxi to our hotel for the night to
get some much needed sleep.
ur
at
n
s
ng
of f
i
C
k
ma ck to e
ba ld hav out
than
nkfully I got reception
u
e
an e noforluck),
m
e
my
mo
obile
phone and called
wo
c
wn he o assiv
base at Bankstown. My chief
o
l
b
r t he m d... instructoor pointed out that it
e
v
o
would be
b a good idea to switch
to t win
e
u
l
my
ELT
on. It says only to be
i
d
ta
used in an emergency, but for
some reaason I didn’t think it was
an emerg
gency; I mean, I didn’t
seem to be injured!
i
FSA SEP–OCT09
50
I put my hand up to go first as I was keen to get going. I departed Coffs
Harbour and could see some showers off to my right a bit inland along
the coast. I figured as I got down the coast the weather was clearing,
so no need to worry. The further I went however, it seemed that the
weather was not clearing; in fact, it was closing in on me. I managed to
radio back to the others in my convoy that they should turn back while
they still could. However, I was left with making a turn back to Coffs
which would have blown me out over the ocean due to the massive
tailwind, or turn over the land and into the terrible weather. The only
good option seemed to be to make it to Port Macquarie at least, and
see how the weather was from there.
from 50ft it
still looked fine
to land on.
The cloud at this stage had forced me down to 1000ft along the coast,
and the turbulence was now causing my height to fluctuate down to
only 700ft at some points. I was getting a really bad feeling about
staying in the air. I saw on my VTC that the ALA (authorised landing
area) South West Rocks was in the area, but as I drew nearer, the area
was covered in showers and low cloud.
The wonderful people from Westpac
Life Saver Rescue Heelicopter found me and
took me back to Coffss Harbour, where I was
given a bit of TLC and checked for any major
injuries. I only had a bit of bruising from
where my harness waas. The most important
thing that can come out
o of any such incident
is a lesson learned. I leearnt a few lessons that
day. I’ll never expect a safe route up ahead
and instead will turn back to safety when I
still can. If in doubt I’ll
I take the safe route
rather than risking tthe unknown. I’d also
like to stress the importance of carrying an
ELT for a flight
flight. The re
rescue helicopter would
have had a pretty hard time tracking me
had it not been for the ELT, especially as it
was close to last light by the time they found
me. Although none of my other flights have
been as eventful, I still like to make a point of
learning something new each and every time
I fly, to get the most out of it!
It was then that I decided my best option was to land in a field. I flew a
little further down the coast and flew over a small town that seemed to
have a lot of wide fields available for making a nice landing. I did part
of a precautionary search and landing, but honestly didn’t feel I had the
time to make the two and a half circuits to analyse the ground. Instead
I looked for the major obstacles at both ends, and noted that the ground
looked a little bumpy, but still decided it would work to land on. I made
a PAN PAN call on the downwind leg, but I wasn’t sure if I was even
on the right frequency, as I was concentrating so hard on landing the
aircraft safely. Coming in on late finals I could better see the surface of
the ground, but even from 50ft it still looked fine to land on.
It turns out my ‘perfect landing field’ was a swamp. The plane crashed
into the thick tussock that was growing out of the swamp, and I sat in
my seat for a minute in complete shock at what had just happened!
After hopping out of the plane and having a go at the radios (with
Write to us about an aviation
incident or accident that you’ve
been involved in. If we publish
your story, you’ll receive
EVER HAD A
CLOSE CALL? $500
Write about a real-life incident that you’ve been involved in, and send it to us via email: fsa@casa.gov.au.
Clearly mark your submission in the subject field as ‘CLOSE CALL’
51
ADVERTISEMENT
Tired of being on auto-pilot? Is it your time to soar?
Fly over to The Australian on Fridays for up-to-date
industry news and employment opportunities.
Call (02) 9288 3333 or 1300 307 287
to discuss your advertising needs.
newspace.com.au
The Australian
Chief Commissioner’s Message
I would like to introduce myself
as the first Chief Commissioner of
the Australian Transport Safety
Bureau (ATSB). Coincident with
my appointment on 1 July 2009,
the ATSB became a separate
statutory Agency, governed
by a Commission, within the
Infrastructure, Transport,
Regional Development and Local
Government portfolio.
For the past ten years, the ATSB has operated
successfully as part of the Department of Infrastructure
and its predecessors. Now, as a newly separate Agency
in Australia’s transport safety framework, the ATSB’s
independent role in transport safety investigation
has been enhanced. The establishment of our new
Commission marks a major milestone in the ATSB’s
history but at the same time recognises what remains
to be done in transport safety investigation. It is also
a privilege that the ATSB and its commissioners value
and respect. We understand that the authority and
powers of an independent safety investigator are given
in the public interest: to ensure that when things go
wrong in transport safety, the contributing factors and
safety issues are understood and the necessary safety
improvements are made.
In responding to its future challenges, the ATSB will
maintain its focus on improving transport safety through
rigorous investigation, through cogent communication of
safety issues and the facilitation of safety actions, and
through the dissemination of safety advice and effective
education. Without compromising its independence,
the ATSB will seek to cooperate with governments,
regulators and industry participants to achieve our
common objective of improved transport safety. I
am proud to lead such a competent and professional
organisation and to support the continued work of its
staff.
Finally, I wish to take the opportunity to thank the
former Executive Director, Mr Kym Bills, who built the
ATSB into an internationally respected and world-class
organisation that I am proud to lead.
Martin Dolan
Chief Commissioner
Amateur-built and experimental
aircraft survey: The results
I
n the last three decades, both in Australia and overseas, there has been
significant growth in the number of amateur-built and experimental
(ABE) aircraft. While these aircraft continue to increase in popularity,
there has been little formal study of them in Australia and worldwide.
In the September-October 2007 edition of Flight Safety Australia, the
ATSB invited owners of non-factory ABE aircraft to participate in a
survey, which sought to provide some insight into the operational and
demographic aspects of this sector of the industry.
In June 2009, Part 1 of this two-part series was released. This report,
based on the responses from the survey, explored the issues affecting ABE
aircraft owners when selecting, building, purchasing, testing, designing,
operating, and maintaining these aircraft.
The report outlined some key features of these owners, including that:
t "#& PXOFST XFSF QSJNBSJMZ PG SFUJSFNFOU BHF BOE QSJWBUF QJMPUT
t PO BWFSBHF PG UIFJS UPUBM ĘZJOH IPVST XFSF ĘPXO JO "#& BJSDSBę
t PO BWFSBHF "#& BJSDSBę BDDVNVMBUFE BJSGSBNF IPVST JO UIF QSFWJPVT
year
t CVJME DIBMMFOHF QFSTPOBM TBUJTGBDUJPO BJSDSBę QFSGPSNBODF QSJDF
operational costs, and ability to perform maintenance, were important
reasons for purchasing an ABE aircraft
t PG CVJMEFST NBEF NBKPS NPEJĕDBUJPOT EVSJOH UIF CVJME QSPDFTT
t PG "#& PXOFST VOEFSUPPL USBOTJUJPO USBJOJOH BOE UIJT XBT NPSF
likely among private pilots, and those with fewer total hours
t GPS PG SFTQPOEFOUT POF QFSTPO QFSGPSNFE BMM NBJOUFOBODF PO UIF
aircraft
t BVUPNPUJWF FOHJOFT BOE BWJPOJDT XFSF BTTPDJBUFE XJUI UIF HSFBUFTU CVJME
challenge.
While many of these facts have been known anecdotally, this report
placed greater specificity on different aspects of ABE aircraft building
and operation. This will allow aviation regulators and ABE associations
to understand better the needs and activities of ABE aircraft designers,
builders, operators and maintainers. This, in turn, will help to foster a safe,
highly-skilled, and better represented amateur-built aircraft community.
The second part of this series will examine the safety of VH- registered
ABE aircraft through the analysis of accident data held by the ATSB. The
survey results presented in Part 1 will also be used to inform the analysis
of ABE aircraft safety trends and issues in Part 2.
The ATSB would like to thank those who participated in the survey, which
provided an interesting picture of ABE aviation in Australia. !
ATSB Research and Analysis Report AR-2007-043(1)
Aviation Safety Investigator
Engine Failure
O
O 'FCSVBSZ BU BCPVU CST, following takeoff from Jabiru
Airport, NT, a Beech Aircraft
Corporation 1900D, registered VH-VAZ,
sustained a failure of the left engine and
the subsequent auto-feathering of the left
propeller. The aircraft was on a charter
ĘJHIU UP %BSXJO XJUI UXP QJMPUT BOE B
passenger on board.
'PMMPXJOH UIF FOHJOF GBJMVSF UIF ĘJHIU
crew correctly identified the problem
engine and took timely and appropriate
action to return to Jabiru and complete a
single-engine landing.
the release of a power turbine secondstage blade. Metallurgical examination
determined that the failure of the secondstage turbine blade had occurred as a
consequence of the initiation and growth
of a high-cycle fatigue crack from the
downstream trailing corner of the blade
fir-tree root post. Damage to the crack
origin prevented the identification of any
features that may have contributed to the
initiation of fatigue damage. At the time
of blade fracture, approximately
QFS DFOU PG UIF SPPU DSPTTTFDUJPO IBE
been compromised by fatigue cracking.
The engine manufacturer advised that
the engine was manufactured with post
4FSWJDF #VMMFUJO 4#
3 QPXFS
turbine second-stage blades installed
QBSU OVNCFS 1/
CMBEFT
During the subsequent overhaul of the
engine by an overseas overhaul facility,
PVUEBUFE 1/ CMBEFT XFSF
installed, and compliance with
4# 3 XBT JODPSSFDUMZ BOOPUBUFE
in the engine’s documentation. Advice
from the engine manufacturer indicated
that the older blades should
not have been installed in the
FOHJOF BT UIFZ XFSF UIF TVCKFDU
PG BO FBSMJFS ĘFFUXJEF FOHJOF
upgrade campaign.
The involvement of the
overseas overhaul facility
contributed to the inability of
the investigation to establish
XIZ UIF QSF4# 3 CMBEFT
were installed during the May
FOHJOF PWFSIBVM BOE
the reason for the incorrect
annotation in the engine’s
documentation. However, the
PMEFS 1/ 15 CMBEFT
JG JOTUBMMFE XFSF TVCKFDU UP B
SFDVSSFOU QFSJPEJD IS JOTQFDUJPO
A review of the engine’s maintenance
documentation did not show any evidence
that those recurrent inspections had
been carried out. Technicians scheduling
engine maintenance subsequent to the
.BZ PWFSIBVM NBZ IBWF CFFO
misled by the incorrect annotation of the
FOHJOFT DPNQMJBODF XJUI 4# 3
The effect would have been that the
technicians would have interpreted that
the routine inspection of the blades was
not yet required. !
ATSB Investigation Report AO-2008-008
53
ATSB
The passenger reported
to the crew that debris,
which was described
as ‘white chunks of
metal’, was coming out
of the exhaust of the left
engine. Observers on
the ground saw a puff
of smoke, followed by
ĘBNFT DPNJOH GSPN UIF
left engine. At the time
of the engine failure,
the aircraft’s landing
gear was retracted and
the engine was in the
TAKEOFF POWER
configuration. The
engine failure occurred
shortly after selecting the engine bleed
air OPEN, and it was preceded by a loud
‘banging’ noise, followed by a left yaw of
UIF BJSDSBę ćF BJSDSBęT ĘJHIU SFDPSEFS
data later showed that the engine failure
occurred about 20 seconds after takeoff,
at about 600 ft above ground level and at
an indicated airspeed of 169 kts. The data
indicated normal operation of the engine
prior to the occurrence.
Ground personnel reported that there
was visual evidence in the engine exhaust
of catastrophic damage to the power,
or hot section of the engine. The left
engine was removed by the operator and
shipped to an approved engine overhaul
facility for disassembly and examination
under the supervision of the ATSB.
Examination of the left engine revealed
that the initiator of the damage was
Investigation briefs
Midair collision
ATSB Investigation AO-2009-005
On 7 February 2009, five aircraft were
engaged in circuit training and one
BJSDSBę XBT EFQBSUJOH SVOXBZ MFę
-
BU 1BSBĕFME "JSQPSU 4" "MM PG UIF
aircraft in the circuit at the time were
PQFSBUFE CZ B MPDBM ĘJHIU TDIPPM ćF
control tower was not open and Common
Traffic Advisory Frequency - carriage
and use of radio required, CTAF (R),
procedures were in place.
FSA SEP–OCT09
54
"U BCPVU $FOUSBM %BZMJHIU
saving Time, a S.O.C.A.T.A.-Groupe
Aerospatiale TB-10 (Tobago), registered
VH-YTG, with an instructor and student
on board, was on final approach. In
the circuit behind the Tobago was a
(SPC #VSLIBBSU 'MVH[FVHCBV (
(Grob), registered VH-TGM, with an
instructor and student on board, also on
final approach. The Grob collided with
the Tobago from behind, however both
aircraft remained controllable and were
MBOEFE PO SVOXBZ - BOE SJHIU
The investigation found that the pilots
of the Grob experienced sun glare and
background visual clutter on the base leg
GPS SVOXBZ - BOE XFSF VOBCMF UP TJHIU
the preceding Tobago. The pilots of the
Grob did not discern some broadcasts
from the Tobago pilots, significantly
diminishing their situational awareness.
The pilots of the Grob continued the
approach without positively identifying
the preceding aircraft in the circuit.
Soon after the accident, the aircraft
PQFSBUPST ĘJHIU TBGFUZ PďDFS QSPEVDFE
a comprehensive accident investigation
report that captured the key aspects of the
accident. Included in the report were a
number of recommendations, which were
implemented by the operator.
The investigation identified a safety issue
regarding definition of the circuit traffic
limit in CTAF(R) and a safety issue
related to the positive identification of
traffic before turning final.
CASA has considered these issues in the
context of the GAAP Training and Utility
Reviews. !
Wake turbulence event
Approach to land on closed
section of runway
ATSB Investigation AO-2007-041
0O "VHVTU BU $45 B 4""#
"JSDSBGU $PNQBOZ # 4""#
aircraft departed from Adelaide Airport’s
SVOXBZ PO B TDIFEVMFE QBTTFOHFS
service to Mount Gambier with two flight
crew, one cabin crew and 29 passengers
PO CPBSE "QQSPYJNBUFMZ TFDPOET
FBSMJFS BO "JSCVT " "JSCVT
IBE
BMTP EFQBSUFE GSPN SVOXBZ ATSB Investigation AO-2008-033
0O .BZ B #PFJOH $PNQBOZ
$9 BJSDSBGU SFHJTUFSFE 1,(&' XBT
being operated on a scheduled passenger
service between Denpasar, Republic of
Indonesia and Perth, WA. On board were
two flight crew, six cabin crew and
76 passengers.
8IFO UIF 4""# SFBDIFE B IFJHIU PG UP GU BCPWF HSPVOE MFWFM "(-
BOE
BU BO JOEJDBUFE BJSTQFFE PG BCPVU LUT
the flight crew reported an abrupt, severe
buffeting and an uncommanded roll
to the left. The angle of bank increased
UP PWFS EFHSFFT BOE XBT DPVOUFSFE
by full right aileron by the copilot, who
was the flying pilot. That action initially
produced no corrective aerodynamic
response. After a short pause, however,
the left roll stopped and was followed by
an abrupt roll to the right. The copilot
applied left aileron and levelled the
aircraft. As the aircraft climbed through
UP GU "(- GVSUIFS NPEFSBUF
buffeting was experienced. The flight
continued to Mount Gambier as planned.
"U UIF BQQSPBDI DPOUSPMMFS BU 1FSUI
cleared the flight crew to conduct the
runway 21 localiser approach. At 1600,
the aerodrome controller issued the flight
crew with the landing clearance,
‘... runway 21 displaced threshold, cleared
to land’. When the aircraft was about
TFDPOET GSPN UPVDIEPXO UIF GMJHIU
crew questioned the presence of cars on
the runway and conducted a go-around.
As a result of this occurrence, the aircraft
operator advised that they reviewed
their operating procedures relating
UP EFQBSUVSFT CFIJOE KFU BJSDSBGU BOE
will use the ATSB report as part of a
safety promotion strategy directed at
all company pilots. Company pilots are
delaying their departures when behind
‘larger’ medium-category aircraft
where the effect of wake turbulence is
considered to be a hazard. In addition,
CASA is reviewing the safety implications
of this incident in particular, noting the
action taken by the United Kingdom Civil
Aviation Authority to expand the number
and specification of wake turbulence
categories. CASA is also considering
the development of a safety education
program for flight crew and air
traffic controllers in regard to wake
turbulence. !
The flight crew reported that, once
established in the cruise, they reviewed
their briefing material and noted that
the threshold for runway 21 at Perth was
displaced due to runway works.
On the second approach, the flight crew
were again issued the landing clearance ‘...
runway 21, displaced threshold, cleared to
land’. The aerodrome controller recalled
observing the aircraft on what appeared
to be an approach to land on the closed
section of the runway and instructed the
flight crew to go around. The go-around
instruction also included information
to assist the flight crew in identifying
where the aircraft was to be landed. That
additional information, together with
the high workload being experienced by
the flight crew at that time, may have
momentarily confused them, with the
result that they did not assimilate and act
on the instruction to go around.
As a result of this incident, the airport
operator undertook a number of safety
actions. Those actions included the
review of its dispatch of Method Of
Working Plan (MOWP) to relevant
stakeholders; the implementation
of a more robust MOWP receipt
and acknowledge system; and the
FTUBCMJTINFOU PG B QSPKFDU TBGFUZ HSPVQ JO
support of all critical airside works. !
Controlled flight into terrain
ATSB Investigation AO-2007-066
On 7 December 2007, the pilot of an Air
5SBDUPS *OD "5 BJSDSBę SFHJTUFSFE
7)-*4 XBT DPOEVDUJOH B UFTU ĘJHIU BU
-BLF -JEEFMM /48 ćF QVSQPTF PG UIF
ĘJHIU XBT UP UFTU BO FYQFSJNFOUBM JO
ĘJHIU XBUFS DPMMFDUJPO TZTUFN VTJOH TLJT
attached to the aircraft’s main landing
gear. At about 0910 AEST, the pilot was
conducting the second test run of the day.
After the skis had been in contact with
UIF TVSGBDF PG UIF MBLF GPS TFDPOET
witnesses observed the aircraft pitching
nose down, about its right main landing
gear while rotating to the right. The
aircraft then overturned and sank. The
aircraft was substantially damaged and
UIF QJMPU XBT GBUBMMZ JOKVSFE
In addition, the ATSB issued a safety
recommendation to CASA in respect of
the need to consider the safety of third
parties, including on the ground or water,
before issuing a Special Certificate of
Airworthiness. !
ATSB Investigation AO-2007-017
0O +VOF BU 845 BO
Empresa Brasileira de Aeronáutica S.A.
&.#&3 BJSDSBę SFHJTUFSFE 7)96&
departed Perth, WA on a contracted
QBTTFOHFS DIBSUFS ĘJHIU UP +VOEFF
"JSTUSJQ ćFSF XFSF UXP QJMPUT POF ĘJHIU
BUUFOEBOU BOE QBTTFOHFST PO UIF
aircraft. While passing through
ę BCPWF HSPVOE MFWFM PO ĕOBM
BQQSPBDI XJUI ĘBQT TFU UIF BJSDSBę
drifted left of the runway centreline.
When a go-around was initiated, the
aircraft aggressively rolled and yawed left,
causing the crew control difficulties. The
crew did not immediately complete the
go-around procedures. Normal aircraft
control was regained when the landing
HFBS XBT SFUSBDUFE BCPVU NJOVUFT MBUFS
The left engine had sustained a total power
loss following fuel starvation, because the
left fuel tank was empty. The investigation
identified safety factors associated with;
the fuel quantity indicating system, the
ability of the crew to recognise the left
engine power loss, and their performance
during the go-around. There were clear
indications that the operator’s fuel
quantity measurement procedures and
practices were not sufficiently robust to
ensure that a quantity indication error was
detected. The failure of that risk control
provided the opportunity for other safety
barriers involving both the recognition
of, and the crew’s response to, the power
loss, to be tested. Organisational safety
factors involving regulatory guidance,
UIF PQFSBUPST QSPDFEVSFT BOE ĘJHIU DSFX
practices were identified in those two
areas. The operator introduced revised
procedures for measuring fuel quantity
BOE $"4" JOJUJBUFE B QSPKFDU UP BNFOE
the guidance to provide better clarity and
emphasis. The crew’s endorsement and
other training did not include simulator
training and did not adequately prepare
them for the event. There was no EMB ĘJHIU TJNVMBUPS GBDJMJUZ JO "VTUSBMJB
and no Australian regulatory requirement
for simulator training. In March 2009,
BO &.# ĘJHIU TJNVMBUPS DBNF JOUP
operation in Melbourne. !
Midair collision
ATSB Investigation AO-2008-010
0O 'FCSVBSZ B 1JQFS "JSDSBę
$PSQPSBUJPO 1" 4VQFS $VC BJSDSBę
BOE B 3PCJOTPO )FMJDPQUFS $PNQBOZ 3
Raven helicopter, were engaged in feral
goat culling operations in the Kennedy
Range National Park, WA.
The two aircraft collided in mid-air as the
pilot of the helicopter executed a climbing
left turn that brought the two aircraft into
close proximity. The pilot and shooter
PDDVQBOUT PG UIF 3 XFSF BXBSF UIBU UIF
Super Cub was approaching them at the
same height, and the helicopter pilot was
aware of the position of the aeroplane
during the helicopter’s climbing turn, but
it appeared probable that the pilot and
spotter occupants of the Super Cub did
not see the helicopter.
The helicopter’s main rotor blades struck
the Super Cub’s right wing, severing
the lift struts. The right wing detached
JO ĘJHIU BOE UIF 4VQFS $VC GFMM UP UIF
ground. The pilot and spotter were fatally
JOKVSFE ćF IFMJDPQUFS XBT BCMF UP MBOE
safely.
The investigation determined that the
occupants of the Super Cub were probably
VOBXBSF PG UIF QSPYJNJUZ PG UIF 3
BOE UIBU UIF 3 QJMPU EJE OPU SFDPHOJTF
the collision hazard until there was
insufficient time to prevent contact with
the Super Cub.
The investigation also identified that there
were no formalised operating procedures
detailing the conduct of culling
operations involving multiple aircraft that
may have assisted in the maintenance of
aircraft separation.
In response to this accident, a number
of safety actions were undertaken by the
3 BOE 4VQFS $VC PQFSBUPST *O BEEJUJPO
extensive safety action was carried out
by the WA Government departments
that were involved in the operation. That
included in the areas of risk management,
the review and amendment of guidelines
and procedures affecting multiple
aircraft operations, the adoption of Safety
Management Systems, and the
provision of training for departmental
personnel. !
55
ATSB
The investigation concluded that the right
experimental ski breached the surface
of the water which caused a substantial
amount of drag to act on the right side
of the aircraft, rendering the aircraft
uncontrollable. The circumstances of
this accident highlight the need for due
diligence and detailed risk assessments
to be performed as part of experimental
test programs. As a result of this incident,
CASA has proposed amendments to
Advisory Circular 21-10 - Experimental
Certificates to provide updated guidance
information to persons applying for the
issue of experimental certificates, and
advice on risk management for test pilots
EVSJOH FYQFSJNFOUBM ĘJHIU UFTUJOH
Fuel starvation
REPCON briefs
Australia’s voluntary confidential aviation reporting scheme
Navigation (Confidential Reporting)
Regulations 2007 and allows any person
who has an aviation safety concern to
report it to the ATSB confidentially.
Unless permission is provided by the
person that personal information is about,
the personal information will not be
disclosed. Only de-identified information
will be used for safety action. To avoid
doubt, the following matters are not
reportable safety concerns and are not
guaranteed confidentiality:
56
(a) matters showing a serious and
imminent threat to a person’s health
or life;
FSA SEP–OCT09
(b) acts of unlawful interference with an
aircraft;
(c) industrial relations matters;
(d) conduct that may constitute a
serious crime.
Note 1: REPCON is not an alternative
to complying with reporting obligations
under the Transport Safety Investigation
3FHVMBUJPOT TFF XXXBUTCHPWBV
Note 2: Submission of a report known
by the reporter to be false or misleading
JT BO PČFODF VOEFS TFDUJPO PG UIF
Criminal Code.
If you wish to obtain advice or further
information, please call REPCON on
Cabin crew rostering
R200800099
Report narrative:
The reporter expressed safety concerns,
particularly fatigue levels and lack of rest
facilities for cabin crew, due to the long
duty times being rostered by the operator,
which could contribute to errors being
made in an emergency situation.
0O POF QBSUJDVMBS ĘJHIU JU XBT SFQPSUFE
that due to delays, the anticipated cabin
crew duty time was at least 17 1/2 hours.
Due to the anticipated delay, the cabin
crew requested a hotel room to facilitate
resting, but the request was denied and
UIF DSFX XBJUFE PWFS IPVST JO UIF
terminal, with some crew having to sit on
UIF ĘPPS
The reporter also expressed concerns
that reports have been submitted via
the operator’s safety reporting system
detailing fatigue of cabin crew who have
fallen asleep during critical phases of
UIF ĘJHIU CVU UIF SFQPSUFS CFMJFWFT UIBU
nothing has changed.
Cabin crews can be rostered to operate up
to 20 hours of duty and are often provided
inadequate resting facilities, such as two
economy seats that are used to provide
rest for the nine cabin crew. Each crew
member often does not get more than
2 hours rest in a 20 hour period.
REPCON comment:
REPCON supplied the operator with the
de-identified report. The operator advised
that there were a number of assertions
in the report that they believed to be
factually incorrect, including that crew
rest facilities vary and depend on the
aircraft type, sector length and time of
day. This REPCON relates to an aircraft
type that is configured with a curtained
off area of four seats available at the rear
of the cabin for crew rest.
The operator advised that a number
of cabin crew have submitted reports
relating to fatigue. The process for
management of fatigue related reports
continues to operate. Each reporter’s
hours worked are reviewed using a fatigue
model. Results of the analysis and a copy
of the original report are forwarded to the
applicable manager for their review and
follow up action.
Management reports are tabled at relevant
safety meetings. The actions that have
resulted from this management review
activity resulted in a change to the routes
ĘPXO UP BEESFTT UIF GBUJHVF SFMBUFE
reports. This action was communicated to
all staff via the company intranet.
A Fatigue Risk Management System
program is being implemented across
the entire company. As a part of this
program, all cabin crew have been
provided with fatigue awareness training,
reinforcing the need to manage their
lifestyle choices prior to duty. It also
includes the need for cabin crew to
declare themselves unfit for duty, should
they be too fatigued to perform their
operational duties.
There are adequate processes in place to
identify and implement improvements
to our rostering practices as a result of
reported fatigue.
REPCON supplied CASA with the deidentified report and a version of the
operator’s response. CASA advised that
it has reviewed the REPCON report in
DPOKVODUJPO XJUI UIF PQFSBUPS BOE JT
satisfied with the operator’s management
of the issue.
Decommissioning of a NDB
(Non-Directional radio Beacon)
R200800104
Report narrative:
The reporter expressed safety concerns
about the imminent decommissioning
of the Adelaide Airport NDB (NonDirectional radio Beacon) and that new
NDB approaches at Parafield Airport
have been NOTAMED as unavailable for
training operations. The reporter was also
concerned that there was an increased
risk of mid-air collision due to so many
training aircraft having to use the already
overcrowded airspace associated with the
Tailem Bend NDB.
REPCON comment:
REPCON supplied CASA with the deidentified report and CASA provided the
following response:
CASA was aware of the decommissioning
of the Adelaide NDB and that the Parafield
NDB was relocated and commissioned for
instrument approaches into that aerodrome.
These events had been discussed at the
Adelaide Regional Airspace Users Advisory
Committee meetings some time before the
aids were decommissioned and relocated.
CASA has been informed that Adelaide
"JSQPSUT -JNJUFE SFRVFTUFE "JSTFSWJDFT
Australia (Airservices) to decommission the
Adelaide Airport NDB. While the Adelaide
NDB did not form part of the backup
network of navigation aids, at the time it
was in operation and [sic] it did provide
an instrument approach into Parafield.
Accordingly, there was a need to provide
a replacement instrument approach into
Parafield and once the Adelaide NDB was
decommissioned, the re-located Parafield
NDB, together with its associated instrument approach procedure, was commissioned. The safety assessments involved are
matters for Airservices.
The reporter was concerned about the safety
implications of this situation for the large
number of training aircraft operating in
the affected area. CASA understands that
Airservices had provided an undertaking
that the Adelaide NDB would not be decommissioned until Parafield NDB approaches
were available. Although the Parafield
NDB approaches became available, due to
environmental considerations identified
by Airservices, the Parafield NDB is now
TVCKFDU UP B QFSNBOFOU /05". $
with effect from 11 March 2009 that states:
i703 "/% /%# 130$ /05 "7#"
'03
TRAINING OPS. OTHER OPS IN IMC
PERMITTED”.
However the management of these airspace
issues remains the responsibility of Airservices.
Runway standards for the
operation of the A380
R2008000116
Report narrative:
The reporter notes the growing awareness
of runway excursions as a significant
safety risk factor, and has expressed
safety concerns about runway standards
required by the regulator, such as runway
width and lights for the operation of
UIF "JSCVT " BJSDSBę JO "VTUSBMJB
that do not meet the International Civil
Aviation Organization (ICAO) minimum
standards. Runway pavement width as
requirements determined by ICAO for
Reporter comment: Is this a realistic
FYQFDUBUJPO UIBU UIF " XJMM EJWFSU
or not take off when the crosswind
DPNQPOFOU JT HSFBUFS UIBO LOPUT
The reporter is also concerned that the
runway shoulder constructions should
be signed off by CASA to eliminate the
chance of lesser standards being applied
and CASA should be more detailed in
specifying the standards expected e.g.
bituminous concrete surfacing rather
than bitumen sealing.
Reporter comment: According to the
ĕOBM SVMF NBLJOH UIF " XJMM SFRVJSF
B NFUSF TIPVMEFS PO FBDI TJEF GPS
occasional aircraft run off, and an
BEEJUJPOBM NFUSF PG CMBTU QSPUFDUJPO
on each side. How is this to be interpreted
JO FOHJOFFSJOH UFSNT 'PS FYBNQMF
what is the percentage of capacity design
thickness under Equivalent Single Wheel
-PBE &48-
The reporter believes that the concession
for the runway edge lights seems to allow
them to remain in their existing positions
GPS B NFUSF XJEF SVOXBZ
BOE
therefore not meet the ICAO standards
that require the lighting to be no more
UIBO NFUSFT GSPN UIF FEHF PG B NFUSF
wide runway. The reporter believes that
the runway edge lights are significant
PCTUBDMFT GPS UIF " FTQFDJBMMZ BT UIF
runways are not being upgraded to the
ICAO minimum standards and the
existing positions of the runway edge
lights are almost in line with the outboard
FOHJOFT PG UIF "
3FQPSUFS DPNNFOU ćF ĘVTI ĕUUJOH
options that are being suggested to
eliminate the potential risks of the
elevated lights have their own set of safety
issues and should not be introduced as an
option.
The reporter is also concerned that
KVEHJOH CZ B MBDL PG QSPHSFTT UP EBUF
the ‘upgrades’ to the airports where the
" PQFSBUFT NBZ OFWFS PDDVS BOE
consequently Code F aircraft will be
operating at airports that were never
designed for that size aircraft.
Reporter comment: CASA should set a
firm timetable for all airports where the
" PQFSBUFT UP DPNQMFUF UIF AVQHSBEFT
REPCON comment:
REPCON supplied CASA with the deidentified report. In response, CASA
advised that it had already undertaken a
detailed review of airport compatibility
GPS UIF " QVCMJTIFE JO +BOVBSZ
XIFO BNFOENFOUT XFSF NBEF
UP UIF A.BOVBM PG 4UBOEBSET 1BSU "FSPESPNFT XIJDI QFSNJUUFE " B
Code F aeroplane) operations at existing
Code E runways. This document is
available on the CASA website. CASA
advised that the review considered all the
concerns raised in the REPCON report.
REPCON reports received
Total 2007
117
Total 2008
121
First Quarter 2009
41
Second Quarter 2009
28
57
What happens to my report?
For Your Information issued
Total 2007
58
Total 2008
99
First Quarter 2009
42
Second Quarter 2009
20
Alert Bulletins issued
Total 2007
1
Total 2008
12
First Quarter 2009
0
Second Quarter 2009
Who is reporting to REPCON?
0
#
Aircraft maintenance personnel
27%
Air Traffic controller
4%
Cabin crew
3%
Facilities maintenance personnel
/ground crew
1%
Flight crew
34%
Passengers
6%
Others*
25%
+BO UP +VMZ * examples include residents, property owners, general
public
How can I report to REPCON?
On line: ATSB website at <www.atsb.gov.au>
Telephone: 1800 020 505
by email: repcon@atsb.gov.au
by facsimile: 02 6274 6461
by mail: Freepost 600,
PO Box 600, Civic Square ACT 2608
ATSB
In December 2007 there were changes to
CASA requirements for NDB training
following the amendment of the Civil
Aviation Orders dealing with instruNFOU SBUJOHT $"0 UP SFNPWF
the mandatory requirement that a [sic]
NDB approach must be undertaken on
a Command Instrument Rating issue or
renewal. NDB training is now optional for
the command instrument and night VFR
ratings...
B DPEF ' BJSDSBę "
JT SFRVJSFE UP
be a minimum of 60 metres. CASA has
BMMPXFE UIJT UP CF SFEVDFE UP NFUSFT BT
documented in the CASA Notice of Final
Rule Making. To mitigate the risks of a
crosswind landing, CASA has reduced the
DSPTTXJOE DPNQPOFOU UP LOPUT IBMG
the certified crosswind component for the
"
BOEING 737
STALLS
DURING ILS
APPROACH
FSA SEP–OCT09
58
Photo: co
of Jenny urtes y
Coffe y
Macarthur Job provides a summary of a report
cidents
published earlier this year by the UK Aircraft Accidents
Investigation Branch.
After a night flight to Bournemouth
from Portugal, in September 2007, a
Boeing 737-300 began an ILS approach.
Soon afterwards, unnoticed by the crew,
the auto-throttle disengaged with the
thrust levers in the idle thrust position.
When the airspeed decayed alarmingly
because the aircraft was configured for
landing, the captain began a go-around.
The aircraft pitched up excessively, with
the airspeed reducing to 82kt. The
stick-shaker activated, but the crew
recovered control and completed a
second approach and landing.
The Boeing,
G-THOF, was
operating
i g from Faro
in Portugal to Bournemouth with the first
officer flying. Before departing, the crew
decided on a full flap (flaps 40) landing, and
the F/O programmed the fl ight management
computer for the final approach. Both pilots
confirmed the flaps 40 reference speed
as 129kt and the fi nal approach speed
as 135kt.
Eleven nm from Bournemouth, when level
at 2500ft at 180kt with flaps 5 set, the
autothrottle was engaged in the speed mode,
with N1 averaging 60 per cent. Autopilot B was
engaged in CMD mode with VOR-LOC and
altitude hold modes engaged.
At seven nm DME the autopilot captured the
glideslope. The F/O asked for the undercarriage
to be lowered, flaps 15 to be selected and the
landing check list. The F/O then selected a
lower speed on the mode control panel and,
as expected, the autothrottle retarded the
thrust levers to idle.
About 20 seconds later, with the thrust levers
still at idle, the autothrottle disconnect warning
was triggered and the autothrottle disengaged.
The crew did not recognise this, and with the
autopilot still engaged, the aircraft continued
to track both the localiser and the glideslope.
The airspeed was decaying at about one knot per second, in line with
the F/O’s expectations and
d as it decr
decreased below 150kt, flaps 25 was
selected. As the aircraft continued d
down the glideslope, the autopilot
gradually raised the nose to prevent any glideslope deviation, adjusting
the stabiliser to keep the aircraft in
n trim.
At this stage the F/O increased the illumination
of his map
ap lamp to check the placard speed
for flaps 4
40, turned it down again, and called
for flaps 40. He then selected 135kt on the
mode conttrol panel. When the captain saw the
flaps were iin the flaps 40 position, he completed
the landing checklist by calling ‘flaps’. The F/O
rresponded ‘flaps 40, green lights’. But
aafter stowing his checklist on top of
th
he instrument panel, the captain looked
down to see
e the airspeed had fallen to 125kt. He
called out ‘speed’, and th
he F/O pushed the thrust levers forward a
little, but almost immediately
y the stick-shaker stall warning activated.
The captain pushed his control
c
column forward to counteract the
pitch-up, reducing
ducing it to 5 d
degrees nose-up. The stick-shaker operation
stopped and with the airspeed increasing and both engines spooling
up through 81 per cent N1 the takeoff-go-around (TOGA) mode became
active. Then the autopilot disengaged, the pitch attitude increased again
and the stick-shaker reactivated. Although the pilots were holding their
control columns fully forward, the nose-up pitch reached 22 degrees.
At an airspeed of 118kt, the pitch attitude appeared to stabilise at
22 degrees nose-up then started to decrease. Both engines were
producing 96-98 per cent N1, in excess of the rated go-around thrust
of 94 per cent. The first officer selected flaps 15 and the stickshaker ceased but, as the flaps retracted past flaps 25, the nose
began to pitch up again at an increasing rate. The airspeed
began to decay again, and the stick-shaker reactivated. The
first officer called ‘high pitch’ and the captain responded ‘I
have full forward stick’.
59
th
stil rust l
dis autloat idlevers
waconn throe, the
thes triggect wt tle
dis auto ered arnin
eng thro and g
ag t tle
ed.
With the First Officer also holding full forward stick, both
pilots felt they had no pitch control authority. As the pitch
increased above 36 degrees the TOGA mode disengaged,
the airspeed fell below 107kt. and the aircraft stalled 44
degrees nose-up. With no change in elevator position the
pitch rate then reversed, yet the airspeed decreased for a
further five seconds to 82kt when the pitch was 33 degrees
nose-up.
Over the next 10 seconds, the pitch angle reduced to 20 degrees
and, as the airspeed began to rise again, the crew reduced the thrust
to 86 per cent. The pitch reduced a further 15 degrees and the aircraft
Autothrottle switch
BOEING 737 STALLS
Taking over, the captain cal
alled, ‘I have control’, pushed the thrust
levers fully forward, and ca
alled ‘Go-around, flaps 15, check thrust’.
This occurred when the airrspeed had fallen to 110kt, at a height of
1500ft, and the pitch attitud
de, steadily increasing under the influence
of pitch trim, had reached 12
1 degrees nose-up.
t
en r ted
d
i
inc epo til
un
is
tr
Th s no AIB er it
wa the A s af t
to day
ed
r
r
12 ccu
o
stabilised 5 degrees nose-up. As the
speed increased the captain regained
control and the TOGA mode was reengaged as the airspeed reached 147kt.
Climbing to 4000ft, the captain
manoeuvred the Boeing for a second
approach, the F/O remarking to him that
‘the autothrottle did not capture it’. The
captain flew the second approach with the
autopilot and the autothrottle engaged, and both
systems performed normally.
After the crew shut down, the captain told the company’s base
engineer that, although he thought the aircraft was serviceable, there
had been an incident, and the company would want the flight data.
No defects were entered in the technical log. The engineer assured the
captain that the operational flight data monitoring information would
have been sent from the aircraft by an automatic mobile telephone
based data link.
60
The next morning the captain telephoned the airline’s safety
department to advise them of the incident. But his report was not
passed on to the Civil Aviation Authority for 11 days.
FSA SEP–OCT09
THE CREW
The captain, aged 56, had 11,000 hours experience, of which 420
were on the Boeing 737. He had been one of the company’s Boeing
757/767 fi rst officers for 17 years, and a year before the incident had
completed a combined type conversion and command upgrade.
The fi rst officer, 30, had 3000 hours, of which 845 were on type.
Before joining the airline he had flown DHC Dash 8s and had
converted to Boeing 737s about a year previously. Both based at
Bournemouth, the pilots commented that they did not often conduct
flaps 40 landings, as only one of their usual destinations required
its use.
THE AIRCRAFT
The Boeing 737-300, G-THOF, was manufactured in 1995 and at the time
of the incident had flown 37,000 hours. Its autothrottle computer was
fitted over five years ago. The autothrottle system, part of the automatic
flight control system, positions the thrust levers to maintain a computed
engine thrust level. The autothrottle is selected by operating a twoposition, solenoid-held paddle switch on the left side on the glareshield.
Once armed, the switch is held in position unless disengaged. The
autothrottle can be disengaged manually, either by moving the paddle
switch to the OFF position, or by pressing either of the push buttons on
the outboard end of each thrust lever. A green annunciator light beside
the switch illuminates when the autothrottle is engaged. Disengagement
extinguishes the green light and illuminates a flashing red autoflightstatus annunciator on the instrument panel. This can be cancelled by
a second press on the buttons on either side of the thrust levers, or by
pressing the switch light itself.
The autoflight-status annunciator illuminates
with a flashing amber light if the autothrottle
is not holding the target speed. The light
flashes when the airspeed is 10 knots above
the target speed and not decreasing; when
the airspeed is five knots below the target
speed and not increasing; or when the
airspeed has dropped to alpha floor (1.3
times the stall speed) during a dual-channel
autopilot approach. On approach, with the
aircraft decelerating, it routinely flashes for
extended periods. Flight mode annunciators
on the primary flight display also show the
autothrottle’s status and mode.
Disengagement of the autothrottle will result
from any of the following:
Moving the autothrottle ARM switch to
OFF
Activation of one of the autothrottle
disengage switches on the thrust levers
Detection of an autothrottle fault
within the computer by its built-in test
equipment
Touching down
The thrust levers becoming separated
by more than 10 degrees during a dual
channel autopilot approach after FLARE
ARMED is annunciated
Autopilot roll control requiring significant
spoiler deployment and the thrust levers
becoming separated, when flaps are at
less than 15º and the autothrottle is not
in take-off or go-around mode.
Autothrottle disengagement results in the
ARM switch releasing to OFF and the red
autothrottle disengage lights flashing,
unless it has disengaged automatically
after touchdown. Moving the thrust levers
by hand does not cause the autothrottle
to disengage.
WEATHER
The crew received the Bournemouth
terminal forecast before departing from
Faro. A surface wind from 200° at 14kt was
expected, 6000m visibility, with broken
cloud at 800ft. Between 1900 hrs and 0100
hrs, the visibility was expected to reduce to
2000m in light rain and mist, with broken
cloud at 300ft.
As the aircraft approached Bournemouth, the
ATIS was reporting runway 26 in use, with the
wind from 220° at 14 knots, 4000m visibility
in light rain, and overcast cloud at 400ft. The
temperature was 17ºC and the QNH 1011.
THE AIRPORT
Bournemouth (Hurn) Airport on the south
coast of England is 3.5 nm NNE of the city of
Bournemouth. Its single runway is 2270 metres
long and orientated 26-08. Runway 26 in use
at the time was equipped with a category 1 ILS
with high-intensity approach lighting.
Flight recorders
INVESTIGATION
Both pilots said they had not seen the
autothrottle disconnect warning. The AAIB
learnt there had been a number of other
autothrottle disconnects followed by a long
period of warning without crew recognition.
The efficacy of the autothrottle warning system
therefore became a matter of interest.
An on-board test of the autothrottle computer
fitted to G-THOF found no faults. The computer
was then removed from the aircraft to undergo
a full test procedure using the manufacturer’s
automatic test equipment. The computer failed
two of these tests which were related to small
tolerance errors in inputs and outputs. After
adjustments, the computer successfully passed
further tests.
Using recorded data from the flight, Boeing
conducted an engineering simulation of the
approach and go-around. This determined that
the nose-up pitching moment, generated as the
engine thrust increased and by the stabiliser’s
trimmed position, overwhelmed the elevator
until recovery after the stall.
And a month after the incident, G-THOF
experienced a similar autothrottle disconnect.
In this case the autothrottle warning was
active for 31 seconds, but a manual disconnect
was not recorded until ten seconds after the
warning ceased. The airspeed decreased to
128kt and the crew applied 75 per cent N1. The
aircraft recovered without the pitch attitude
exceeding 8° nose-up.
Turbofan aircraft with under-slung engines
tend to pitch up as the thrust is increased,
because the thrust line is below the centre of
gravity. Conversely, as power is reduced the
aircraft tends to pitch down. On the Boeing
737-300, applying go-around thrust will
cause a nose-up pitching moment which is
counteracted with nose-down elevator. When
the autopilot is engaged, it automatically
trims the aircraft using the stabiliser and as
the aircraft decelerates, the autopilot applies
more nose-up trim. But this increasing trim
effectively reduces the amount of pitch
authority available from the elevator.
The Boeing 737-300’s engines are not thrust
limited; if the thrust levers are pushed
fully forward, the engines will produce the
maximum thrust available for the altitude and
temperature. On colder-than-standard days,
this could exceed the engines’ maximum
rated thrust. If the elevator authority is
reduced because of the amount of nose-up
ose-up
trim applied, and the go-around thr ust is
greater than rated, there may be insufficient
c t
elevator authority remaining to counteraact
the nose-up pitching moment.
ANALYSIS
The crew did not respond to the
autothrottle’s disconnection either
because the autothrottle warning did
d
not work, or the crew did not notice it.
i
61
BOEING 737 STALLS
This incident was not reported to the AAIB
until 12 days after it occurred, and by
then the trip’s recordings on the flight data
recorder and the cockpit voice recorder had
been deleted. But the aircraft’s operational
flight data monitoring system, using onboard
equipment, was programmed to transmit the
aircraft’s quick access recorder data to the
airline’s headquarters, and this data was made
available to the AAIB.
Three months before, an autothrottle
disconnect occurred in another Boeing
737-300 during an approach to Belfast’s
Aldergrove Airport, and the aircraft
decelerated below its commanded speed of
170 knots. At 112kt with a 16 degree nose-up
attitude the crew advanced the engines to 96
per cent N1 and a rapid change of pitch to 22
degrees ensued. The aircraft lost some 300ft
before recovering.
flightator
o
t
u
i
The aannunce
s
t s
statulumina hing
il a flas if the
wither light e is
ambutothrotntlg the
a
ldi
d.
o
not rhget spee
ta
The recorded flight data showed the warning was active, and testing
could find no fault in the warning system. The incident involving
another Boeing 737 three months before, and the subsequent event
a month later in G-THOF, showed that the problem of the warning
system’s failure to alert crews could be a wider issue. Data gathering
carried out by the AAIB during the investigation appeared to justify
the need for a larger study of the autothrottle warning system on the
Boeing 737. The AAIB recommended that Boeing, in conjunction with
the US Federal Aviation Administration, conduct a study of Boeing
737-300, 400 and 500 autothrottle warning systems, and if necessary,
take steps to improve their means of alerting crews.
The autothrottle warning on G-THOF was typical of its era. Later
generation aircraft incorporate an autothrottle warning, including an
audio alert, into their engine indication and crew alerting systems.
Pilots who are familiar with these older aircraft with less reliable
electronic systems are nearing the end of their careers, and so there is
now a generation of pilots whose only experience is that of operating
aircraft with highly-reliable automated systems. There is thus a
concern that crews could encounter a situation in which a normally
reliable system failed.
62
FSA SEP–OCT09
Because the autothrottle warning on the Boeing 737-300 routinely
flashes amber for extended periods during an approach, it is likely
that crews subconsciously filter out what they perceive as a nuisance
message. This, combined with the high level of reliability in modern
automation, could lead to a lack of awareness of autoflight modes.
Top image: Autothrottle red warning of disengagement
Bottom image: Autothrottle amber off speed caution
Crew reaction
The use of flaps 40 was not usual for crews operating out of
Bournemouth. The first officer needed to increase the brightness of
his map lamp to ensure the airspeed was below the flap-limiting speed
before asking for flaps 40 to be selected. This action appeared to have
distracted the pilots at a critical phase of the flight, and their lack
of effective monitoring resulted in the aircraft losing airspeed after
the autothrottle disconnected. As a result of the incident the operator
conducted an internal review, and additional training in general
han
andling, stalling and upset recovery was added to their simulator
trai
raining syllabus. All their pilots were to undergo this training by
the end of June 2008. The stall recovery training would include
the use of nose-down pitch trim.
Comment
The recommendations to prevent this sort of error
or mishandling certainly apply to simulator training
in Australia and back up the view of a highlyexperienced B737 captain and simulator instructor
that low-altitude stall recoveries and go-arounds, as
well as unusual attitude training, should be included
in our 737 syllabus.
The full text of the AAIB’s report is available at:
http://www.aaib.gov.uk/sites/aaib/publications/formal_
reports/3_2009_g_thof/g_thof_report_sections.cfm
GAAPCHANGES
Please note that the Visual Pilot Guides (Sydney Basin, Jandakot,
On 21 July 2009, CASA issued legal
Melbourne etc) and the Visual Flight Guide are no longer current and have
directions to Airservices Australia
been withdrawn pending revision.
(Airservices) and pilots in relation
In mid-August, CASA mailed an information booklet to all active pilots,
detailing these changes, and debunking some myths about operations
to General Aviation Aerodrome
at GAAP aerodromes.
Procedures (GAAP) at Archerfield,
FACT 1
Bankstown, Camden, Jandakot,
Moorabbin and Parafield aerodromes. Pilots are primarily responsible for separation in a GAAP control
zone in visual meteorological conditions (VMC)
The directions form part of CASA’s ongoing
efforts to improve safety at GAAP aerodromes
and complement CASA’s education and
awareness campaign regarding safety
and procedures at GAAP aerodromes as
recommended by the recent GAAP reviews.
An immediate limitation on the number of
aeroplanes in the circuitt for one runway,
controlled by one air traffic controller,
to six. If two runways and two controllers
are available then the total number of
aeroplanes in the circuit is limited to 12.
An additional departure may be permitted
at the discretion of the controller having
given due consideration to all relevant
safety factors.
An immediate requirement for all aircraft
to obtain an air traffic control clearance
to enter, cross or taxi along any runway,
irrespective of whether it is active. These
changes have been implemented in order
to reduce identified risk levels to as low
as reasonably practicable. The cap on
the number of aeroplanes in the circuit
is considered to be a temporary measure
whilst further assessments are conducted.
Transition to Class D airspace
On or before 21 April 2010, Airservices
must provide at each GAAP aerodrome air
traffic services (ATS) applicable to Class D
airspace. This will harmonise Australia with
international standards. More information
on the transition to Class D will be made
available in the coming months.
Pilots must keep an effective lookout and use information from ATC to
maintain appropriate spacing.
AIP reference: ENR 1.1 paragraph 24.1
In VMC, the pilot in command is primarily responsible for separation
from other aircraft. ATC controls runway operations with landing and
take-off clearances, and facilitates a high movement rate by providing
traffic information and/or sequence instructions.
GOOD AVIATION PRACTICE
Keeping an effective lookout and maintaining situational awareness
is critical in a GAAP control zone. With up to five other aircraft in the
circuit, and parallel runway operations, you must understand that you
are responsible for separating your aircraft from others. Manage your
aircraft’s performance to ensure appropriate spacing is maintained.
63
GAAP CHANGES
These directions came into effect on 21 July
2009, and require:
It is incorrect to assume that air traffic control (ATC) separates all flights
within a GAAP control zone. In VMC, the pilot in command of the
aircraft, operating under visual flight rules (VFR) or instrument flight
rules (IFR) is primarily responsible for establishing and maintaining
safe separation from all other aircraft. To assist in safe separation, ATC
will provide pilots with traffic information and instructions to establish
an orderly flow of traffic, in a sequence, to a nominated runway. ATC
may intervene to prevent an unsafe situation from developing by
providing an alerting service.
GAAP control zones are primarily flying training
environments. These procedures permit
maximum flexibility so training objectives
can be met while maintaining safety.
FSA SEP–OCT09
64
FACT 3
You must obtain a clearance to enter the GAAP control zone
FACT 2
You require clearance to enter the GAAP control zone. This clearance
is implied by the issue of ATC circuit entry instructions, following the
inbound radio call. A take-off clearance implies departure clearance.
Clearance is required to land on a runway
AIP reference: ENR 1.1 section 31 - Entry to the CTR
Pilots mustt obtain a landing clearance.
Irrespective of whether the runway appears to
be clear, if a landing clearance is not received
the pilot must conduct a go-around.
31.1 Entry to the CTR must be in accordance with the procedures specified
in ERSA for the particular GAAP aerodrome.
In a GAAP control zone, ATC only provide
runway separation. Pilots must obtain take
off and landing clearances so that ATC can
apply necessary runway and wake turbulence
separation standards.
31.3 Where practicable, terminal information must be obtained from the
ATIS prior to calling the tower.
GOOD AVIATION PRACTICE
Clearances via circuit entry instructions permit ATC to establish an
orderly flow of traffic and landing sequence. The instructions enable
you to sight traffic and establish necessary spacing. Inbound radio
calls should be made at the correct GAAP approach point shown on
the visual terminal chart and specified in ERSA. If the inbound radio
call cannot be made at the appropriate position, or if clearance is
unavailable, you should have an alternative plan.
ATC apply runway separation standards
between aircraft using the same and
crossing runways. If a landing clearance
is not received, and a landing is carried
out, a safety defence layer is removed.
This exposes all concerned to elevated
risk as the likelihood of something going
wrong increases. If you are established on
short final and haven’t received a landing
clearance, you must go-around.
31.2 Aircraft must not enter a GAAP CTR until in receipt of a circuit entry
or zone transit instruction.
GOOD AVIATION PRACTICE
Do not enter the GAAP control zone without a clearance
Do not orbit at an inbound reporting point
AIP reference: ENR 1.1 Paragraph 27.1.1
Potentially, this is dangerous. If you need to hold, or reposition the
aircraft to the GAAP approach point, do so in a manner that provides
lateral and vertical separation from other aircraft likely to be in the
same area. Ensure other airspace constraints are considered to avoid
penetrating controlled or restricted airspace.
Individual clearances are required for:
Keep a vigilant lookout
a. take-off and landing
FACT 4
b. taxiing across or along all runways
Do not overtake a slower aircraft in the circuit area
Note: An instruction to HOLD SHORT OF
You must not overtake a slower aircraft in a GAAP circuit area. ATC
RUNWAY (number) [LEFT (or RIGHT)]
issue instructions to aircraft to establish an orderly flow of traffic to a
requires a pilot to hold at a marked holding
nominated runway. Unless otherwise instructed by ATC, this is generally
point or hold short of the runway strip.
the order in which aircraft turn base and should be maintained to the
c. turns in a direction contrary to the circuit landing threshold.
for a particular runway
Note: An ATC circuit entry instruction GOOD AVIATION PRACTICE
constitutes a clearance for a contrary turn, If you are having difficulty maintaining spacing and need to overtake,
if required to comply with the instruction.
you should advise ATC immediately. You should manage your aircraft’s
d. circuits at a height different to the circuit performance in the circuit keeping in mind the relative performance of
altitude published in ERSA for the particular other aircraft. ATC manage traffic flow and priorities on the established
traffic sequence.
GAAP aerodrome; and
e. operations on routes or at altitudes Take-off clearances are issued on the basis of the time available
different from those published in ERSA for between the pending take-off and the nearest aircraft on final approach.
a particular GAAP aerodrome.
Instructions to sight and keep spacing from other aircraft are based on
the established order of the aircraft. This allows you to look and recognise
aircraft in the landing sequence. If the order changes because an aircraft
has been overtaken in the circuit, there is potential for you to sight and
follow the wrong aircraft. This might bring aircraft into close proximity
and present a collision risk. A sequence change will require ATC to amend
instructions such as traffic information and the cancellation of landing or
take off clearances. This may increase frequency congestion.
Civil Aviation Regulation reference: CAR
167 (1) (D)
FACT 5
GOOD AVIATION PRACTICE
Transiting within proximity of a GAAP aerodrome requires contact
with ATC
ATC decisions about the traffic flow, traffic
information to other pilots and related spacing
are made on the assumption that aircraft turn
at the required altitude after take off. Not only
is there a regulatory requirement, but early
turns may also create a noise nuisance by
taking aircraft over noise-sensitive areas.
Pilots of aircraft tracking within 5nm of a GAAP control zone boundary
(or at a distance as specified in the ERSA) but not entering the control
zone must obtain the automatic terminal information service (ATIS),
then broadcast their position, altitude and intentions. Pilots must
comply with any instructions issued by the tower and maintain a
listening watch on the tower frequency while in the area.
(iii) after take-off, maintain the same track
from the take-off until the aircraft is 500ft
above the terrain unless a change to the track
is necessary for terrain avoidance.
THE FACTS
AIP reference: ENR 1.1 paragraph 35.2, ‘Flight in Proximity’
Summary
35.2.1 When a radio-equipped aircraft will track within 5nm (or as
specified in ERSA) of a GAAP CTR boundary, without entering the
GAAP CTR, the pilot must:
1. Pilots are primarily responsible for
separation in a GAAP control zone in visual
meteorological conditions (VMC).
a. prior to entering this airspace, obtain the ATIS then broadcast
aircraft type, call-sign, position, altitude and intention on the
appropriate tower frequency; and
2. Clearance is required to land on a runway.
b. while operating in this airspace, maintain a continuous listening
watch on the appropriate tower frequency.
35.2.2 While operating in this airspace, all aircraft must maintain a
continuous visual surveillance for other aircraft
GOOD AVIATION PRACTICE
Most operations at GAAP aerodromes are training flights involving
relatively inexperienced pilots. This may result in circuits that are
wider than might be acceptable. There may also be high numbers of
arriving and departing aircraft. If you make the required broadcasts,
ATC and other pilots will be alerted to the fact that you are in proximity,
creating potential conflict with their aircraft.
You need to obtain the ATIS so that you know the duty runway and
associated circuit directions. This will permit you to avoid congested
areas while transiting. This procedure will also allow ATC to call you if
they need to issue instructions.
FACT 6
Do not turn early after take off
Pilots are not permitted to turn early after take off, without ATC
clearance, for a number of reasons. The Civil Aviation Regulations
require aircraft to reach 500ft above ground level (AGL) after taking
off before a turn is made. If this is changed by a local procedure, the
local procedure should be complied with or as amended by ATC.
3. You must obtain a clearance to enter the
GAAP control zone.
4. Do not overtake a slower aircraft in the
circuit area.
5. Transiting within proximity of a GAAP
aerodrome requires contact with ATC.
6. Do not turn early after take off.
This information is for aviation safety education
purposes. It does not replace information
contained in the Aeronautical Information
Publication (AIP), En-route Supplement Australia
(ERSA) and/or NOTAMs. Pilots should always refer
to these documents for up-to-date in
information.
Practical guidance,
e, in the form of ‘Good Aviation
Practice’, is offered
ed as a suggested means of
achieving safe operations. This is ‘advis
‘advisory’
material onlyy and is not the only methodol
methodology
that could be adopted. It is not legally binding.
For more information and to do the online
GAAP quiz, go to www.casa.gov.au and
click on the GAAP changes icon* on the
home page.
65
GAAP CHANGES
Pilots must maintain a vigilant look out
AVQUIZ
FLYING OPS
S
1.
When holding at a holding point, at right-angles to the runway,
in a tail-wheel aircraft, it is advisable to hold on the
(a) downwind side of the taxiway, so as to have sufficient
taxiway width to oppose ‘weathercocking’ when
subsequently movi
o ng forward.
(b) upwind side off t he taxiway, so as to have sufficient
taxiway width to oppose ‘weat
e hercocking’ when
subsequently moving forward.
(c) downwind side of the taxiway to allow for the increased
turn radius when turning on to the runway.
6.
(d) upwind side of the taxiway to avoid the tail wheel leaving
the taxiway when turning on to the runway.
2.
66
(a) will take 13 minutes.
(b) will take 10 minutes.
When an aircraft is parked facing west in a strong northerly
wind, the most effective use of two chocks to counteract
weathercocking would be
(a) one behind the right main wheel and in front of the left
main wheel.
(c) will take 8 minutes.
(d) cannot be determined without knowing the ground speed.
7.
FSA
FSA SEP–OCT09
SEP–OCT09
(c) 3 hours.
(d) one fore and aft of the nose or tail wheel.
(d) not applicable, since a METAR is a report, not a forecast.
On typical fuel-injected piston engines, turning on the electric
auxiliary fuel pump
8.
In a heavily polluted atmosphere or in haze, distant objects
(a) may appear closer than they actually are.
(a) will increase the reliability of the fuel delivery, but will not
affect the fuel fl ow.
(b) may appear further away than they actually are.
(b) will have no effect on the reliability of the fuel delivery or
fuel fl ow.
(d) may appear lower than they actually are.
(d) will always increase the fuel fl ow.
The otolith organs are found in
(a) middle ear and detect linear acceleration.
((b) middle ear and detect angular acceleration.
(c) the inner ear and detect linear acceleration.
(d) the inner ear and detect angular acceleration.
5.
(b) 60 minutes.
(c) one either side of the nose or tail wheel.
(c) depending on the type of system, may have a large effect
on the fuel fl ow.
4.
The validity period of METAR is
(a) 30 minutes.
(b) one behind the left main wheel and in front of the right
main wheel.
3.
A 500 fpm descent from A065 to circuit height at a destination
with elevation of 1500ft
The somatogravic illusion can result in fl ying into the ground
on a night takeoff
o because
(a) deceleration is interpreted as the nose pitch
hing up.
(c) may appear higher than they actually are.
9.
The wind direction is given in degrees
(a) magnetic in both area and aerodrome forecasts.
(b) magnetic in an area forecast, and true in an aerodrome
forecast.
(c) true in both area and aerodrome forecasts.
(d) true in an area forecast, and magnetic in an aerodrome
forecast.
10. A VFR aircraft may be authorised to make a vis
is
isual
is
approach
when within a distance of
(a) 30nm from the aerodrome but, by day, must maintain the
assigned ttrack/heading or route until within 5nm from the
aerodrome.
((c) rotation on takeoff is interpretedd as a high nose attitude.
(b) 10nm from the aerodrome but, by day, must maintain the
assigned track/heading or route until 5nm from the
aerodrome.
(d) the chang
an e of attitude with flap retraction is
misinterrpreted.
(c) 30nm from the aerodrome but, by day, must maintain the
assigned track/heading or route until 3nm from the aerod
o rome.
(b) acceleration is interpreted as the nose pitching up.
(d) 10nm from the aerodrome but, by day, must maintain the
assigned track/heading or route until 3nm from the aerodrome.
MAINTENANCE
1.
One method of oil temperature regulation on an engine
consists of a stack of bimetalllic discs exposed to the oil flow.
When the oil is cold these discs
7.
(a) pressure regardless of input RPM.
(b) pressure and thus does not require a pressure regulator.
(a) close a valve that bypasses the oil cooler.
(c) volume per cycle and thus requires an unloading valve to
limit
m pressure when system demand is low.
(b) open a valve that bypasses the oil cooler.
(c) close a valve that blocks the oil to the cooler.
(d) volume per cycle and thus requires a pressure regulator to
limit pressure when
e system demand is low.
(d) open a shutter which allows full air fl ow through the cooler.
2.
On an aircraft equipped with a stabilator, moving the control
column backwards causes the trailing edge of the stabilator to
8.
4.
(a) the motor speed to increase.
(b) the motor speed to decrease.
(b) rise, and the trim ta
ab to lower relative to it.
(c) the speed to decrease, but the torque to remain the same.
e
(c) lower, and the trim tab to rise relative to it.
(d) the synchronous speed to decrease and raise the
power factor.
Ideally, a stall should occur at thee wing roots first in order to
minimise the tendency to
The maximum number of wire terminals which should be
installed on a single stud on a terminal strip is
(a) 3.
(b) pitch about the lateral axis.
(b) 4.
(c) roll about the lateral axis.
(c) 5.
(d) roll about the longitudinal axis.
(d) 6.
When two wheels are installed on one undercarriage leg, a
flat tyre on one wheel
(a) the frequencies, output voltages and currents will be
the same.
(c) can be readily detected by additional bludging of the
outboard wall.
(d) the frequencies will be the same, but the output currents
may differ.
(a) chemical stability.
(b) lower oxidation.
(c) corrosion resistance.
(c
(d)) fire resistance.
The most commonly used material used in seals for a hydraulic
system using mineral based oil is
((a) butyl.
(b) natural rubber.
(c) neoprene.
((d) PTFE.
(c) the frequencies and output currents will be the same.
QUIZ
(b) the output voltages and loads will be the same.
Synthetic hydraulic fluids used in high performance systems
were developed primarily for
67
10. When two or more AC generators are connected in parallel
(b) can be readily detected by additional bulging of the
inboard wall.
(d) can be readily detected by comparing the top camber.
6.
9.
(a) cause aileron buffet.
(a) cannot be visually detected reliably.
5.
Reducing th
he field current on a DC electric motor wil
w l cause
(a) rise, and the trim tabb t o rise relative to it.
(d) lower, and the trim tab to lower relative to it.
3.
A constant-displacement hydraulic pump delivers a constant
IFR OPERATIONS
DME/GPS ARRIVAL
5.
Refer to the DME/GPS Arrivals for Launceston (YMLT) Tasmania
(a) The 310 radial and with 310 selected, a “TO” flag.
and TAC YMLT (dated 4.6.09). Part of the LT ATIS reads ‘... wind
(b) The 130 radial and with 130 selected, “TO”
O flag.
calm, visibility 4000m in drizzle, cloud broken 1600’.
(c) The 310 radial and with 130 selected, “TO” flag.
You are inbound to LT along W105 at 7000, in a category B aircraft.
LT Tower clear you for a DME/GPS arrival and to expect landing
rwy 14R.
1.
(d) The 130 radial and with 130 selected, “FROM” flag.
You report established inbound and LT TWR clear you for the
remainder of the D ME arrival.
Which is the correct DME/GPS arrival procedure to use?
(a) Sector A.
6.
(c) Sector C.
(b) Having passed Morris, descend to 4200, past 12 DME
3700, past 10 DME 2600, past 8 DME 2200, past 5 DME to MDA.
(d) Sector D.
LT Tower give you an instruction to ‘descend to 5000 not below
(c) Having passed Morris, descend to 4200, past 12 DME
3700, past 10 DME 2600, past 8 DME 2200, past 5 DME
1700, past 4 DME to MDA.
DME Steps and track via the Morris Intercept’.
2.
How will this descent be conducted?
FSA
FSA SEP–OCT09
SEP–OCT09
(a) After passing 25 DME descend to 5700, after 20 DME
5400, after 18 DME 5000 and await further descent clearance.
7.
(b) After passing 25 DME descend to 5800, after 18 DME 5000
and await further descent clearance.
3.
(b) False.
8.
What is the MDA for your approach?
(a) 1440’ with a visibility of 2.4 km.
The DME/GPS arrival cannot be continued once instructed to
track via the Morris Intercept. True or false?
(b) 1700’ with a visibility of 2.4 km.
(a) True, since the Morris Intercept places the aircraft out of
the DME/GPS arrival sector.
(d) 1340’ and a visibility of 2.4 km.
(b) False, since the Morris Intercept is still contained within
the appropriate DME/GPS arrival sector.
Approaching 14 DME LT on the Morris Intercept on a HDG of 090
with the ADF selected to LT and the LT VOR selected 130 “TO”.
4
4.
The clearance for the DME/GPS arrival also includes a
clearance to manoeuvre within the circling area for a
landing. True or false?
(a) True.
(c) After passing 25 DME descend to 5800, after 18 DME 5100,
after 15 DME 5000 and await further descent clearance.
(d) After passing 25 DME descend to 5800, after 18 DME 5100,
after 14 DME 5000 and await further descent clearance.
How will you complete the descentt now to MDA ?
(a) Having passed Morris, descend to 3700, pas
pa t 10 DME
2600, past 8 DME 2200, past 5 DME to MDA.
(b) Sector B.
68
What radial is this and, for a command indication, what would
you see on the nav. indicator?
Assuming a 5º lead in to the LT VOR track, what indications
w ld you expect to see on the ADF (fi xed card) and the VOR
wou
with the following scale?
(c) 1390’ including a PEC of 50 ‘ and visibility of 2.4 km.
LT TWR advise of a lowering cloud base and deteriorating
visibility, so to expect the missed approach and positioning for
the 32 L ILS.
9.
Where is the DME arrival missed approach point (MAPt), and
what is the fi rst track on this missed approach?
(a) MAPt is overhead the tracking aid of LT N
NDB
D or VOR, then
track 133° to NILE NDB.
(b) MAPt is overhead the LT NDB or VOR, then conduct a right
hand 80/260° procedure turn to track 313° to LT NDB
B or VOR.
(a
( ) ADF 035 R, half scale left and closing.
(c) MAPt is from the M.D.A. tracking 133° to NILE NDB.
(b) ADF 040 R, half scale left and closing.
(d) MAPt is from the M.D.A. tracking 133° to the LT NDB or
VOR then a right hand 80/260° procedure turn to track
313° back overhead LT.
(c
( ) ADF 045 R, half scale right and closing.
(d) ADF 035 R, half scale right and closing.
LT TWR asks you tto report establisheed inbound on the _ _ _ radial
when the turn at Morris is completed.
You do not establish visual reference at the MAPt so you conduct
the published missed approach.
10. What speed restrictions are placed on a category B aircraftt
during the conduct of this miss sed approach?
(a) Maximum I.A.S. to NILE NDB 190kts, then maximum
210kts for the procedure turn.
(b) Maximum I.A.S. 150kts throughout.
(c) Maximum I.A.S. to NILE NDB 190kts, then maximum
150kts for the procedure turn.
(d) Maximum T.A.S. 150kts throughout.
At NILE NDB at 3000ft you conduct the right hand procedure
turn. LT tower advise to repor
p t ‘established’ inbound and you
acknowledge.
11.
Passing a HDG of 330 and with the ADF
A on NILE
showing 344 R, you look at the LOC needle. Where
e
would the C.D.I. be and is this estaablished?
The scaling representation is:
69
(a) Full scale right and thus not
established.
(b) 1/2 “dot” right and thus
established.
(c) 2 “dots” right and thus
established.
(e) 2 “dots” right but not established
until glideslope intercept.
CHANGE
QUIZ ME
(d) 2 “dots” left and thus established.
CALENDAR 2009
SEP
OCT
FSA SEP–OCT09
70
NOV
Date
Event
Venue
Organiser & More info
22 Se
Sep
Aviation
ati Saf
Safety Sem
Seminar
ar
Parkes
arke
Parkes
arke Aeroo Clubb
www.casa.gov.au
22 Sep
Aviation safety
ty semin
seminar
M
Moree
M
Moree
Aero Clu
Club
www.casa.gov.au
2222 Sep
Aviation
A
iation Safety Seminar
Bunbury
Bunbury Aero club
www.casa.gov.au
23 Sep
Se
Aviation Safety Seminar
Dubbo
ubbo
Dubbo
ubbo Aero Club
www.casa.gov.au
223 Sep
Aviation
A
ation Safety Seminar
Port Aug
Augusta
Port Aug
Augusta
sta Aero Club
www.casa.gov.au
29 Sep1 Oct
Third int
international
ional he
helicopter
er safety
symposium
Montreal
M
t
In
International
tional he
helicopter
ter safet
safety team
schowdhury@bellhelicopter.textron.com
30 Sep
Se 2 Oct
RAAA
AA Convention
nv
n ((30th
h aanniversary
ers
of RAAA
A Hyatt
att Regency
enc Coolum,
oo
& 10th
0th annivers
anniversary
ary of the con
convention)
vention)
Sunshine Coast, QLD
Regional
gio Aviation
via n A
Association
iat
of Australia
ral
www.raaa.com.au
1-22 Oct
Safety
et man
management
e system
yst overview
er ew
worksho
workshop
Orlando
rlan
ATC
TC V
Vantage
ge
registrations@atcvantage.com
6 Oct
Pilot information
info
ion night Sydney
ne
Ai
Airtraffi
fic Services
Servic Centre
entre Ai
Airservices
ices Australia
Aus
a
Sydney
dne Airport
rpo
pilotinfonight@airservicesaustralia.com
6 Oct
Pilot
P
ot informatio
information
n night Brisba
Brisbane
ne
Brisbane ATC Centre
Brisbane
risb
Airport
Air rt
6-7 Oct
O
Greener Skies 2009
Hong
ong Kong
Island
land Shangri-la
hangri-la , Pacific Place, Hong Kong
greenerskies@orientaviation.com
66-8 Octt
Safeskies
S
es Conference
Confe
e
Hyatt Ho
Hotel Canberra
anberra
Biennial conference:
rence: M
Managing
ging avia
aviation safety
afet
in a changing
chan ing environment.
environment
E: safeskies@bigpond.com
www.safeskiesaustralia.org/
14 Oct
Aviation safety
ty semina
seminar
Go
Goulburn
rn
Go
Goulburn
rn Soldie
Soldiers Club
ub
www.casa.gov.au
155 Oct
Aviation
A
iation safety seminar
Mittagong
Berrima Aero Club
www.casa.gov.au
20 Oct
Oc
Aviation safety seminar
Warrn mbool
Warrnamboo
Warrn mbool Aero Club
Warrnambool
www.casa.gov.au
226 Oct
Aviation
A
n Safety Seminar
inar
Point Coo
Cook
Point Coo
Cook Flying
ng Club
www.casa.gov.au
2-55 N
Nov
62ndd annual
a
al International
rna
al Air Safety
afe
Seminar (IASS)
Kerry
ry Centre
tre Hotel,
el
Beijing, China
Flight
ht Safety
ty FFoundation
nd
http://www.fl ightsafety.org/seminars.html
10 Nov
Aviation
atio safety seminar
emi
N
Newcastle
R
Royal
Newcastle
cast Aero Club
ub
www.casa.gov.au
111 Nov
Aviation
A
ation safety seminar
Gloucest
Gloucester
Gloucest r Aero Club
Gloucester
www.casa.gov.au
11 Nov
No
Aviation safety seminar
Goolw
oolwa
Goolw
oolwa Aero Club
www.casa.gov.au
1122 Nov
Aviation
A
iation safety seminar
Scone
Scone Aero
Aero Clu
Club
www.casa.gov.au
14 Nov
Aviation safety
ty semin
seminar
K
Katanning
in
Ka
Katanning
ng Flyin
Flying Club
b
www.casa.gov.au
Key
P ase note:
Please
e: AvSafety
Saf
Seminar
em ar calendar
c
ar subject
bje to change,
cha ge, pplease
e cconfi
firm date an
and ven
venue
with your regiona
regional AvSafety
afety Adv
Advisor
CASA events
Other organisations’ events
Have you got the latest copy
of the AOPA magazine?
Out now!
Look out for the September/October issue of
Australian Pilot
For pilots and aircraft owners.
In tthi
hiss mo
mont
nths
hs iiss
ssue
ue::
>> A Mustang heads west
Dude
de,, wh
wher
ere’
e s my a
air
irpo
port
rt?
?
>> Du
>> The future of ight - Sun Power
71
Support AOPA - working for YOU
On sale early September
QUIZ ANSWE
ANSWERS
WERS
RS
Like to attend one of CASA’s AvSafety seminars?
Then go to CASA’s homepage:
Click on education/seminars on the home page drop-down menu.
www.casa.gov.au
QUIZ ANSWERS
FLYING OPS
1. (a) When taxiing,
the aircraft tends to
‘weathercock’ into
wind; if you stop on
the upwind edge, you
can be off the taxiway
before gaining
sufficient speed to
maintain direction
2. (a) particularly with
tail wheel aircraft.
3. (c) on some systems,
with constant
displacement engine
driven pumps, this will
increase the fuel flow
sufficiently to cause
power loss.
4. (c)
5. (b)
6. (c) A065 minus 1500
minus 1000ft
7. (d).
8. (b)
9. (c) GEN 3.5.12.6.1
10. (a) The clearance may
be given at up to 30nm
but the assigned track
must be maintained
until 5nm (ENR 1.1
para. 11.6)
MAINTENANCE
1. (b) the open valve
bypasses oil around
the cooler thus
reducing cooling.
2. (a) the trim tab or
anti-servo, opposes
the movement of the
stabilator.
3. (d)
4. (a)
5. (d)
6. (c)
7. (c) such a pump is not
sensitive to demand.
8. (a)
9. (b)
10. (d)
IFR OPERATIONS
VDME/GPS ARRIVAL
1. (b) D.A.P. approach
plate
2. (d) D.A.P. approach
plate AIP ENR 1.5-44
PARA 13.3.3
3. (b) D.A.P. approach
plate T.A.C. 3, AIP
ENR 1.5-43 PARA
13.1.1
4. (a)
5. (c)
6. (c) DAP approach
plate
7. (a) AIP ENR 1.5-45
PARA 13.3.5 note 1.
8. (d) DAP approach
plate AIP ENR 1.5-30
PARA 5.3.2
9. (a) DAP approach plate
10. (b) AIP ENR 1.5-11
PARA 1.15.1
11. (c) HDG 330-16 (344R)
= 314 to NILE. LOC is
313 . .1° = 2 dots
(command sense) right.
Remember LOC freq is
1/2° per dot
QUIZ ANSWERS
Ph: 02 9791 9099 Email: mail@aopa.com
m.au Web: www.aopa.com.au
Cozart® provides peace of mind
with saliva drug testing.
Cozart® has a highly advanced reader which removes user error or
bias through accurate analysis and recording of results. Processing
ve drug classes in only ve minutes, Cozart® signicantly reduces
workforce downtime. All tests are fully supervised, decreasing
any chances of tampering and adulteration. Australian police trust
the accuracy and robustness of Cozart® and currently use this
technnology across ve states. Cozart® is also being utilised by CASA
as part of their random testing program.
For more information, email salivadrugtesting.au@siemens.com or
telephone 1300 368 378.
72
Cozart® saliva drug testing
FSA SEP–OCT09
Innovation for generations.
=NEDM>66A:GIIDDA6I:8DB:HIDDFJ>8@AN
9dZh ndjg igV^c^c\ Xdbean l^i] 86D '%#&& VcY 86G '*(4
HV[ZVcYZ[ÒX^ZcicdgbdWVg^X]nedm^VigV^c^c\^hcdl
VkV^aVWaZ Vi 6jhigVa^Vc XZcigZh# >cY^k^YjVa dg \gdje
hZhh^dch[dgVaaÓ^\]ieZghdccZa#
I]Z <D'6ai^ijYZœ cdgbdWVg^X ]nedm^V VlVgZcZhh
hnhiZb ^cXdgedgViZh XdbeaZiZ
e
ZYjXVi^dcVa eVX`V\Z/
i]ZdgZi^XVaVcYegVXi^XVa]nedm^V`cdlaZY\Z!Xd\c^i^kZ
eZg[dgbVcXZ iZhi^c\ l]^aZ bdc^idg^c\ e]nhh^dad\^XVa
eVgVbZiZgh# ;jaan VjidbViZY VcY ^chiVci k^Y
YZd VcY
eg^ciZYgZedgi[dgVaahijYZcih#
`cdlaZY\Zd[i]ZZ[[ZXihd[Vai^ijYZ
BZaWdjgcZ™EZgi]™6YZaV^YZ™BVgddX]nYdgZ™lll#]nedm^V"ZYjXVi^dc#Xdb
flightsafety
safety
… essential aviation reading
INSIDE NEXT ISSUE
Our feature looks at runway excursions
SafeSkies wrap-up … all the hot topics
Getting a handle on ground safety
And … more of the ever-popular quiz and ‘close calls’
w w w. s a f e s k i e s a u s t r a l i a . o r g
SAFESKIES A
AV I AT I O N S A F E T Y C O N F E R E N C E
> C A N B E R R A > 6 – 8 O C TO B E R 2 0 0 9
WO N D E R I N G H OW
TO KE E P YO U R
SA F E T Y P R O G R A M S
O N T R AC K ?
W tth
Wi
h the dif
iffi
ficu
fi
cu
ultt bus
u in
i es
e s
envi
en
nvi
v ro
ronm
nm
men
entt plac
pllac
acin
in
ng in
ncr
crea
easi
sn
si
ng
g
pe
pr
esssu
s re
r on operat
erat
er
atio
ions
io
ns,, th
ns
the
e bi
bien
e nial
en
al
Safe
Sa
fesk
fe
s ie
sk
es co
onf
n er
eren
ence
en
ce
e in
in Ca
Canb
nberrra
nb
a
from
fr
om 6–8
8 Oct
c ob
berr is yo
your
urr pri
rime
oppo
op
port
po
rtun
rt
unit
ityy to
to h
hea
earr av
ea
avia
ia
attiion
n lea
lea
aders
de
ers
rs
and expe
an
exxpert
rtss di
rt
discus
usss th
us
he ch
chal
a leng
al
le
eng
nge
es
es
o Ma
of
M nagi
nagi
g ng
gA
Avi
v atio
vi
ioon Saafe
fety
tyy in a
Chan
Ch
anging
g Env
Env
nvir
iron
ir
onme
on
men
me
nt.
CONFERENCE
ORGANISER
Conferencce Logistics
PO Box 615
15
50 Ki
King
ng
gston ACT 260
04
PHONE
FA X
EMAIL
WEB
+6
+6
61
126
62
28
81
1 662
6624
+61
+6
61 2 62
628
85
5 133
13
33
36
conf
co
conf
nfer
e en
ncce
e@ccon
onllo
og.co
om.
m au
au
ssa
afe
fessk
skiesa
skie
ie
esa
aus
u ttrrallia
a.o
org
S P E A KE R S I N C LU D E :
>
A U S T R A L I A N G OV E R N M E N T ,
>
>
>
>
>
>
A U S T R A L I A N AV I AT I O N P O L I CY G R O U P
the Ho
the
Hon
n An
A th
hon
ny Al
Alba
bane
ba
ne
ese
se MP
MP,, Mi
Mini
nist
ster for
ster
st
for
o
In
nfr
fras
a trrucctu
as
ture
re
e, Tr
Tran
ansp
an
sp
por
ort,
t, Reg
egio
iona
io
nall De
D ve
elo
lopm
pmen
pm
e t an
en
a d Lo
Loca
call Go
ca
Gove
ern
nme
ment
n
nt
Q A N TA S Al
A an
n Joy
Joy
oyce
c CE
ce
EO
O,, S
Sir
irr Reg
egin
in
nalld An
Ansett
tt Mem
tt
e oria
ia
al Lec
Lect
cturrer
ctur
A I R F R A N C E Ca
Capt
p ain
aiin Be
Bert
rtra
rand
ra
nd de Co
C ur
u vi
vill
l e Ma
ll
Mana
nage
ge
er, Cor
o po
porate
te
eS
Saf
affet
etyy
T I G E R A I R WAY S Shel
e le
l y Ro
Robe
b rt
be
rts
s Ma
ana
nagi
giing
g
n Dir
irec
ecto
ec
to
or
R E X Jim
Jim Da
Ji
Davi
vis
vi
s Ma
M na
nagi
ging
gi
ng
gD
Dir
irec
eccto
t r
I CAO Na
Nanc
nccy Gr
G ah
aham
am
m Di
Dire
r ct
re
ctor
or, Air
or
Air Na
Ai
N vviiga
igati
ga
ati
tion
on Bu
urrea
eau
u
-
Air Ma
Air
Ai
ars
rsha
h l Ma
ha
Mark
rk Bin
Bin
i sk
s in
nA
AM
M, Ch
Chie
i fo
ie
off A
Air
ir For
o ce
ce
Jo
ohn
n F McC
cCor
ormi
ormi
mick
icck
k Di
D re
ect
c orr, Av
A ia
iation
on Saffe
etty
A I R S E R V I C E S Gr
G eg
g Rus
usse
sell C
se
sell
CE
EO
CA A U K Si
SrR
Ro
oy Mc
McNu
N lt
ltyy CB
BE,
E, Pas
astt Ch
Chai
aiirm
ma
an
n
n,, Past
Past C
Pa
Chairrma
an UK NAT
A S
GA PA N Ai
A r Co
Comm
m o
mm
od
dorre Ri
Rick
cck
k Pea
eaco
cco
ock
k-E
-Edw
Edwar
dwar
dw
a ds
ds RA
R F (R
Rtd
td),
), Immed
),
ediia
iate
te
Past
stt Mas
Maste
te
er
M c G I L L U N I V E R S I T Y , Ca
Cana
nada
a Prof
Proff Dr Pa
Pr
P ull Ste
tep
eph
phen
en D
Dem
emps
em
psey
ey Di
Dirre
ect
c or, In
nst
s itu
itute
of Air and Space Law
R A A F Ai
A r Vi
V ce-Mar
a sh
shal
all Ma
Mark
rk Ski
k dm
dmor
o e Air
ir Co
C mma
mman
mm
ande
er Au
Aust
Aust
s ra
ali
lia
a
R A N Co
Comm
m od
mm
odor
o e An
Anth
t on
th
o y Da
alt
lto
on Co
on
Comm
mm
m
man
ande
er Au
Austtrali
ra
ali
l an
a Nav
Navva
all Av
Avviia
attio
ion Gr
Grou
oup
ou
p
ARMY B
Brrig
gad
adie
ierr Sh
Shay
ayne
ay
ne E
Eld
ld
der
e Co
C mm
m an
ande
der Au
de
A st
stra
rali
liian
a Arm
my Av
Avia
ia
ati
t on
on C
Co
orps
orps
ps
-
>
>
>
>
>
>
D E P T O F I N F R A S T R U CT
C T U R E , T R A N S P O R T , R E G I O N A L D E V E LO
OPMENT
M ke Mrd
dak Se
Secr
cret
ret
etar
arry
a
A N D LO
L CA L G OV
O V E R N M E N T Mi
RAAF
C SA
CA
C A N YO U A F F O R D N OT TO J O I N T H E M ?
Fu
ull
ll p
pro
rogr
ro
grram
ma
and
nd reg
nd
gistr
isstr
trat
atio
at
i n:: www
w.s
.saf
a es
esk
kiesau
ki
esau
es
a sttrra
ali
lia.
a or
org
g
There has never been a better time
to be with good people.
Safe. Secure. Strong.
They are the foundations of a business partnership you can rely on.
What holds your head together in the cockpit?
My first memories of flying were that the guys who
flew the bigger aircraft were known as Captain and
Captains had headsets. When I started to learn to fly,
no one at the flying school had a headset - reason,
we only had small aircraft.
• Another great advantage of a headset is that
I had about 400 hours when a pilot friend and I were
doing a local flight together and he asked me why I
didn’t wear a headset. I rattled off the reasons that
seemed perfectly valid to me. I rejoined the circuit,
landed and taxied to park. My friend then grabbed a
spare headset from his flight bag, told me to plug it
in and put it on.
• A headset isn’t an accessory. It is a necessity.
What followed was a short course in intercom,
squelch and volume control. When I called for a
clearance for another local flight my perception of
the cockpit environment changed, forever. The
tower’s response was clear, no need to stop
everything so I could concentrate on what they were
saying. During that flight not once did I ask my mate
“What did they say?” or ask the tower to “Repeat”. I
was an instant convert to headsets and immediately
purchased two, together with a portable intercom.
requiring a great deal of paper management,
manipulation of primary controls, throttle, mixture
and pitch adjustments plus undercarriage and
flap activations. No need to compound these
activities by listening for clearances in a noisy
environment and needing to pick up a microphone
to transmit at a time when all feet and hands
are busy flying.
This single package of equipment has put more
enjoyment and safety into my flying experience
than any other accessory or piece of gadgetry could
come near to.
Why wear a headset?
• Improved hearing in the cockpit. The reason
my mate jammed a headset on my ears was that
during the earlier flight he had apparently told me
about another aircraft in our area and I had
obviously not heard a word he said.
Contact details for you and your broker:
Melbourne Ph: (03) 8602 9900
Brisbane Ph: (07) 3031 8588
Sydney Ph: (02) 9299 2877
Adelaide Ph: (08) 8202 2200
it comes with a boom mike activated by a ptt
(press to talk) switch. The hand held mike is a
back-up but it is no replacement for the boom
mike and ptt.
All flying schools should supply them to their
students and insist on their instructors using them
on all flights. All students should be required to
supply their own headsets once they have
completed their ab-initio instruction.
• The cockpit is a noisy environment and one
• There is the other benefit which you will not
appreciate until a little later in life. Protecting
your hearing. If you damage your hearing because
of a noisy environment it is permanent damage.
Since there is little that can be done to treat
noise induced hearing loss, prevention by
avoidance is the best course.
It is not just aviation that has a noisy work environment. But the aviation industry has a very effective
way of addressing the problem.
Tony Ward
Manager, Underwriting - Aviation
Good people to be with.
QBE Insurance (Australia) Limited
ABN: 78 003 191 035
AFS Licence No 239545