Harmonising navigation
Performance based navigation
Jan-Feb 2010
Issue 72
Free fall, not
free-for-all
Drop zone safety
Staying alert
A hypoxia near miss
And... more
close calls!
Weighing up safety
The dangers of exceeding MTOW
Issue 72
Features
ISSUE NO. 72, JAN-FEB 2010
CHIEF EXECUTIVE OFFICER, CASA
John McCormick
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
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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
2
8
‘GAAP changes’
18 January 2010
‘Harmonising navigation’
Performance based navigation–global harmonisation.
20 ‘Weighing up safety’
Flight Safety looks at two R44 helicopter accidents.
24 ‘Staying alert’
Flight Safety writer, Darren McDonnell, looks at a hypoxia near miss.
28 ‘Free fall, not free-for-all’
Glenn Blakiston’s heartfelt plea to fellow pilots.
31 ‘Improved safety – through defect reports’
Why the quality of SDRs is important to safety.
58 ‘A cheap accident for Qantas’
Macarthur Job on the lessons from a 1960 accident.
62 ‘UAS training’
Opening of the new Australian UAS Academy.
64 ‘Flight path to the future’
Aviation policy white paper released.
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 2010, 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: Flying into Juneau, Alaska.
Photograph © Alaska Airlines
4
Regulars
Flight Bytes–aviation safety news
16 ATC Notes– news from Airservices
Australia
18 Accident reports– International
19 Accident reports– Australian
31 Airworthiness pull-out section
33. SDRs
38. Directives
44 Close Calls
44 ‘Engine croaks’
46 ‘Plagued with confidence’
48 ’When in doubt …’
50 ‘Knowledge GAAP’
52 ATSB supplement
67 Av Quiz
71 Quiz answers
GAAP 18 JANUARY 2010
INCREASE TO EIGHT AEROPLANES IN THE CIRCUIT
From 18 January 2010 the maximum number of aeroplanes
operating in the circuit and undertaking circuit operations under
the control of one Air Traffic Controller within a GAAP Control
Zone (CTR) will be increased from six to eight. Arriving and
departing traffic to/from the GAAP CTR will be managed by Air
Traffic Control, with no directed limitation imposed by CASA.
These changes follow a review initiated by the Director of
Aviation Safety into the aeroplane circuit cap. CASA and
Aerosafe Risk Management conducted a series of Workshops
at GAAP locations. CASA has determined that an increase
in the circuit cap is warranted on the basis that pilots and
operators have a heightened awareness of the operational
risks associated with operating at GAAP aerodromes.
All pilots are reminded of the need for:
› Situational Awareness – proper planning, lookout, radio
use and flight management are all important aspects
of maintaining effective situational awareness, which is
particularly essential in high traffic density areas in and
around GAAP CTRs:
› Lookout – maintain an effective lookout by adopting the
proper scan technique
› Separation – you are responsible for separation from other
aircraft within the GAAP CTR and circuit area. Maintain the
correct traffic spacing and sequence and advise ATC as
soon as possible if this cannot be achieved
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Issue 72
2
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› Radio use – make the correct radio calls using standard
phraseology and listen for other transmissions to build
situational awareness
› Plan B – always have a pre-considered alternative if
your request to ATC cannot be met, such as a denial of
clearance into the GAAP CTR, or a denial of circuits
TRANSITION TO CLASS D
CASA has amended the implementation date for the transition
from GAAP to Class D from 21 April 2010 to 3 June 2010.
This aligns with the AIRAC amendment cycle and will ensure
all publications and charts are amended to reflect the new
procedures. Australia is adopting new Class D procedures
based upon the US Federal Aviation Administration Class
D procedures. These procedures will be implemented at
GAAP aerodromes on 3 June 2010. Further information and
educational material will be provided over the coming months.
Further GAAP information, including the
Aerosafe Risk Management report, can
be viewed at:
web www.casa.gov.au/gaap/
phone 131 757
email gaap@casa.gov.au
3
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GAAP SAFETY
SAFETY MESSAGE
AOC safety survey
In late January 2010, CASA will be
conducting its annual survey of all
holders of air operator’s certificates –
the AOC holder safety questionnaire.
This survey has been in use since
2008, gathering and updating aviation
safety data.
FSA JAN–FEB10
Issue 72
4
So that we can continue to make
informed judgements and decisions
about aviation safety across Australia,
CASA requires detailed and accurate
operational information from the
aviation industry. The survey therefore
will collect data from all AOC holders
about their activities, including the
types of aircraft operated, hours
flown, categories of operations and
other factors which might have an
impact on safety.
CASA will continue to use the data to
prioritise safety oversight activities,
assess risks within the industry and
target safety support for industry.
Further information will be provided
to all AOC holders prior to the
commencement of the survey. If you
have any questions or concerns, please
email AOCsurvey@casa.gov.au. Or
you can phone 131 757, and ask for
Julie Codyre, on extension 1841.
Australian
Helicopter
Advisory Group
Late last year, the Flight Safety
Foundation announced the formation
of a new Australian Helicopter Advisory
Group (AHAG), whose mission is the
continuous improvement of helicopter
safety. Terry Summers of Rotor-Lift
Aviation will serve as the chair of
this group.
‘This is the first time in 40 years
of active flying in the Australian
helicopter industry that I have felt so
positive about a flight safety initiative.
With the key guiding principles of
being impartial, independent and non-
Airthsouth
parochial, the AHAG will, I believe, go
a long way towards galvanising the
industry and improving helicopter
safety,’ Summers said.
The formation of the Group comes at
a time when the Australian helicopter
industry does not have a functioning
representative body looking after
its safety interests. The Group will
identify current and emerging safety
issues, working with the industry to
address them, as well as providing an
independent safety-focused voice for
the industry.
‘Although the AHAG will be working
exclusively with the challenges facing
the Australian helicopter industry,
we’re optimistic that their findings
will have relevance in many other
countries,’ said William R. Voss, Flight
Safety Foundation president and CEO.
The creation of this working group
has been greeted with enthusiasm
by Australian industry authorities.
‘The ATSB (Australian Transport
Safety
Bureau) is pleased
to support
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any process that seeks to enhance
the safety of rotary operations in
Australia,’ said Chief Commissioner
Martin Dolan.
The Australian Advisory Board (AAB)
is one of several advisory bodies for
the Flight Safety Foundation. It is
made up of more than 20 individuals
representing every facet of the
Australian aviation industry. The
AAB met in early October in order to
identify the priorities it will study. For
a complete list of the members of the
AAB, please go to the FSF webpage.
The Foundation’s Melbourne office
provides the technical support for
the AAB with the assistance of the
Foundation’s home office.
Etihad’s first
female cadet pilots
the time during the type conversion
‘Salma and Aisha are a key part
of Etihad’s expanding female pilot
community and we wish them, as
well as their male colleagues, the best
of luck as they enter the next phase of
their careers with Etihad,’ said Etihad
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checks and will qualify as A320
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simulator as well as training in the
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5
FLIGHT BYTES
Salma Al-Baloushi and Aisha AlMansouri–successfully
graduated
from flight training in late 2009,
alongside nine male colleagues, and
gained their airline transport pilot
licence (ATPL). The cadet pilots were
Etihad’s second group to graduate,
and were conferred with their flying
wings in a ceremony at the airline’s
training academy.
SkySail safety
concerns
A paper presented at the October 2009
ICAO operations panel meeting in
Montreal outlined concerns regarding
the introduction into service of the
SkySail towing kite propulsion system
for shipping.
FSA JAN–FEB10
Issue 72
6
Instead of a traditional sail fitted to a
mast, the SkySail uses a large towing
kite to assist the ship’s propulsion.
SkySails operate at between 100m
and 600m above sea level depending
on size, and are designed to reduce
fuel consumption by a minimum
of 15 per cent. By the end of 2010,
it is anticipated that approximately
25 ships utilising these will be in
service worldwide. There have been
a number of meetings between the
German company manufacturing the
SkySail, Luftfahrt-Bundesamt (LBA)
and the German ministry of transport
over the past few years, where it has
been stated that the technology is not
a threat to aviation because:
Visibility is better than gliders (due
to the size)
It is not an aircraft
It is operating in the vicinity of a
visible ship
VFR rules apply. The SkySails
operate in Class G air-space
below 2500 feet (800 m). This
is recognised as uncontrolled
airspace where visual flight rules
(VFR) apply.
The SkySail must be visible at
night – it has lighting when flown
at night.
Moreover, it has also been stated by
the manufacturer that:
Use of transponders is not
recommended to avoid spamming;
and
Operations will be no closer than
three miles from a coastline.
(However, they also state that operations will be outside
territorial waters – 12 miles.) [From SkySails literature:
SkySails-Systems operate outside the 12-mile limit,
i.e. beyond the limits of national jurisdiction under
the United Nations Convention on the Law of the Sea
(UNCLOS)]
Flying Boats on
�e Clarence
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It is known that at least one offshore helicopter has been
‘surprised’ by the appearance of a Skysail operating just
below the cloud base in the vicinity of an oil platform.
More information regarding the technology and
operations of the SkySail are available on the web site:
www.skysails.com
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RUNNING TIME:
74 minutes (approx)
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In spite of the manufacturer’s comments, there are
concerns about the safety of such operations in close
proximity with aircraft. In particular, helicopters servicing
offshore platforms are seen to be at potential risk,����
particularly in marginal weather conditions. Moreover,
the ICAO definition of an aircraft in Annex 2, namely: Any
machine that can derive support in the atmosphere from the
reactions of the air other than the reactions of the air against
the earth’s surface, would suggest that the SkySail may be
considered to be an aircraft and therefore subject to the
relevant international aviation standards and practices.
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The system operates within the ship’s safety zone,
which low-flying aircraft – including military aircraft
– must avoid pursuant to regulations. As a preventive
measure, information is provided to the aviation
authorities of the states being passed to ensure that
all pilots are informed using NOTAMs. SkySails will
continue to recommend to its customers that they
adhere to this internationally recognised and proven
practice.
FSA JAN–FEB10
Issue 72
8
Performance
Based
Technology
Increasingly, airlines around the world are capitalising on the safety,
operational and environmental benefits offered by performance
based navigation (PBN). Flight Safety editor, Margo Marchbank,
talks to PBN specialists in Australia and internationally about these
navigation procedures and moves towards global harmonisation.
Performance based navigation employs
satellite technology for optimal use of
increasingly congested airspace. It also allows
safer operations into challenging terrain,
and increasingly, is being recognised for the
operational and environmental efficiencies it
brings. PBN encompasses a shift from groundbased navigational aids emitting signals
to aircraft receivers, to a system that relies
more on the performance and capabilities of
equipment onboard the aircraft. Conventional
route procedures require an aircraft to follow
the ground-based navigational infrastructure
in a point-to-point fashion – an uneconomical
use of airspace. PBN, on the other hand, fully
utilises the onboard navigation capability of
modern aircraft, is not tied to the ground
based infrastructure and permits the aircraft
to fly much more economical routes (for
example, polar route, jet streams etc).
Last year, 2009, was a landmark year for
performance based navigation, according to
the International Civil Aviation Organization
(ICAO). Late in 2009, Flight Safety spoke to
Nancy Graham, head of ICAO’s Air Navigation
Bureau, and ICAO PBN project manager,
Erwin Lassooji, in Montreal. ‘As the 36th ICAO
Assembly recognised in 2007, when it urged
member states to have PBN implementation
plans finalised by 2009, we will only be able to
realise the full benefits of PBN through global
implementation’, Graham explained. ‘PBN is
the single-most important project ICAO has
undertaken relating to safety, efficiency and
being good stewards of the environment.’ PBN
delivers safety, environmental and operational
benefits according to Graham because ‘It’s the
best technology we have, and it’s the best use
of that technology’.
Australia’s PBN implementation plan has
been submitted, and addresses navigation
authorisations for Australian operators
under CASR Part 91U. All the authorisations
will align under PBN. ICAO’s timetable for
approaches with vertical guidance requires
member states to have APV implementation
30 per cent complete by 2010, 70 per cent
by 2014, and fully complete by 2016. ‘APV’,
Noordewier explains, ‘are an ICAO safety
initiative with the goal of preventing controlled
flight into terrain. APV will be the standard
instrument approach – it’s our intention that
2D approaches will become a thing of the
past. PBN,’ he adds, ‘is more than just RNP
AR.’ A focus on RNP AR underestimates the
safety and efficiency benefits of Baro-VNAV
capability for light aircraft, and APV generally,
he contends.
Australia plans to introduce a limited APV
capability using Baro-VNAV as the base case,
principally because of the cost involved with
APV-SBAS. Australia’s IFR fleet comprises
some 3,600 aircraft. Of these, 15 per cent are
APV-capable using Baro-VNAV, and 85 per cent
are APV-capable using augmented GNSS, or
satellite based augmentation systems – SBAS.
‘PBN is the
single-most
important
project
ICAO has
undertaken
relating
to safety,
efficiency
and being
good
stewards
of the
environment.’
9
PBN
The Global PBN Task Force is driving
the concerted worldwide push for rapid
implementation
of
performance-based
navigation. The Task Force comprises the
ICAO, ICAO member states, such as the USA’s
Federal Aviation Administration and CASA in
Australia, industry representation such as the
International Air Transport Association (IATA),
national air navigation service providers (for
example Airservices Australia), manufacturers,
and companies designing procedures, such as
the American-based Naverus. With the Global
PBN Task Force established during 2009, the
next task, Graham explained, was to focus
on regional groups. ‘Implementation has to
done on a regional basis. We’re looking at “goteams”,’ she continued, ‘to bring together the
right kind of skills to support implementation.’
The various regional groups have formulated
specific timelines for their respective regions,
and in early 2010, ICAO is setting up a Flight
Procedures Office in Beijing to assist states
in the Asia-Pacific region. She acknowledges
that implementing PBN is a challenging task,
because it is demanding, both technically, and
in its performance aspects – flight trials and
training. PBN is a ‘first step for the regulator,
it’s a first step for the airlines, and it’s a first
step for the designers – all these things (the
suite of regulations, the training of personnel
and having suitably equipped aircraft, the
design of appropriate procedures) have to
come together,’ but Graham stresses the
committed involvement of the global aviation
community.
Implementing PBN is a challenging task,
Dirk Noordewier agrees. He is an air
transport inspector, and CASA’s PBN project
manager. ‘Worldwide, there are all these
different navigation approvals, with different
terminology,’ he explains. ‘The whole point of
PBN is to rationalise these and get consistency.
Satellite navigation and satellite comms have
enabled aircraft to be self-sufficient, so the bit
of land you’re over is no longer the issue it
used to be.’ ICAO has set deadlines for PBN
– the primary ones for Australia were the
submission of a PBN implementation plan by
the end of 2009; and a 2010-2016 timetable for
implementation of approaches with vertical
guidance (APV).
By implementing APV using Baro-VNAV, it
is anticipated that Australia will be able to
provide APV protection to:
15 per cent of the IFR fleet, BUT
97 per cent of fare-paying passengers.
However, if APV is implemented using BaroNVAV and SBAS, Australia could provide APV
protection to:
99 per cent of the IFR fleet (one per cent is
deemed to be too old to retrofit) and
100 per cent of fare-paying passengers.
FSA JAN–FEB10
Issue 72
10
The adoption of Baro-VNAV has significant
workload implications. In Australia, the project
team has identified two hundred aerodromes
as being suitable for APV Baro-VNAV
implementation. This assessment is based on
the amount of traffic, and the type of traffic
using these aerodromes (generally high-end
airline jet and turbo-prop aircraft which are
capable of performing these approaches). This
workload arises from three factors:
Baro-VNAV approaches require accurate QNH
at the destination aerodrome, and therefore
an operable automatic weather information
station (AWIS). Currently, only 60 of the
identified 200 aerodromes have AWIS, (80
have automatic weather stations [AWS], but
these do not transmit to the aircraft; and the
remaining 60 have nothing).
At least two APV Baro-VNAV approaches
will be required for each aerodrome – in
other words, 400 new approach procedure
designs. However, ‘if we subsequently
invested in an SBAS,’ Dirk says, ‘all of
these 400 approaches could be used by
any aircraft with GPS, so GA light aircraft
would not be left behind.’
The training and education program
required for all IFR pilots – the Baro-VNAV
will be a new approach classification for
licensing purposes, and therefore will have
currency implications. Every licensed pilot
will need to be trained and tested between
now and 2016.
What is PBN?
PBN is an ICAO initiative to harmonise global
navigation specifications. This includes all
phases of flight–from oceanic and enroute,
to terminal and approach procedures. PBN
Performance
based
navigation
Required
navigation
performance
(RNP)
Area navigation
(RNAV)
RNAV 10 (RNP 10)
Oceanic & remote
continental
RNAV 5, RNAV
2, RNAV 1
Continental en
route & terminal
area
RNP 4 (Oceanic
& remote
continental)
RNP 2, RNP1
(basic &
advanced)
RNP0.3
RNP APCH
LNAV, LP, LNAV/
VNAV, LPV
RNP AR APCH
specifications already implemented include RNAV 10 and RNP 4 for
oceanic operations, and RNP APCH and RNP AR APCH for approach
operations. PBN encompasses two types of navigation specifications:
RNAV (aRea NAVigation) and RNP (required navigation performance).
Distinctions between the two are difficult to pinpoint accurately
– ‘It’s often hard to tell the difference,’ Noordewier says. Some
identify differing requirements for onboard performance monitoring
and alerting as distinguishing RNAV and RNP. Area navigation
specifications, for example RNAV5, RNAV1, do not require this.
Required navigation performance utilises the aircraft’s navigation
system to integrate numerous sources of positioning data (e.g. inertial,
satellite and barometric data) to provide highly accurate navigation
solutions with real-time integrity monitoring and alerting. All RNP
specifications require onboard performance and monitoring. In a flight
management system (FMS)-equipped aircraft this can be achieved
through AAIM (aircraft autonomous integrity monitoring) where the
RNP is compared to the actual navigation performance (ANP). In a
aircraft utilising an IFR GNSS Navigator this can be achieved through
RAIM (receiver autonomous integrity monitoring).
RNP APCH–LNAV can be considered the
simplest RNP approach procedure providing
2D instrument approaches to runways without
the need for ground-based navigation facilities.
RNP APCH 2D procedures have been flown in
Australia for many years, initially identified
as GPS/NPA procedures and more recently as
RNAV (GNSS) procedures. These procedures
are now known as RNP APCH – LNAV.
An RNP APCH may be flown as either a twodimensional or three-dimensional procedure.
Where RNP APCH procedures involve only 2D
guidance they are classified as non-precision
approaches (NPA); where they have 3D
Comparison of approach paths with radar vectors,
RNAV & RNPAR
11
PBN
Broadly, RNAV is an equipment-based navigation concept and RNP is a
performance-based navigation concept. With RNP, the aircraft has an
onboard ‘quality management system’. Information from the global
satellite system calculates its position from the satellites in view. A
timely warning is provided when the quality of that positional solution
deteriorates below an acceptable limit, alerting the pilot of the need
to discontinue the approach. For example, in the case of an RNP-AR
approach to an RNP value of 0.1, we are setting the ‘alarm limit’ so
that should the quality of the navigation solution deteriorate below the
threshold of 0.1nm, then the alarm will sound a warning long before
the accuracy of navigation is compromised.
RNP APCH & RNP AR APCH
Under PBN harmonisation, all approaches are now classified as RNP
navigation specifications. There are two broad categories: RNP APCH
and RNP AR APCH. RNP APCH can be either two-dimensional (2D) or
three-dimensional (3D) and operate only to an RNP value of 0.3nm.
RNP AR APCH is by definition a 3D approach and operates to an RNP
value of 0.3nm and below.
There are four types of RNP APCH procedures:
RNP APCH – LNAV: where lateral guidance is provided by GNSS
signal in space (SIS) (currently known as RNAV GNSS procedures);
RNP APCH – LNAV/VNAV: where lateral guidance is provided by
GNSS SIS and vertical guidance is provided by barometric vertical
navigation (Baro-VNAV);
RNP APCH – LP (localiser performance): where lateral guidance
equivalent to a localiser approach is provided by augmented GNSS
SIS; and
RNP APCH – LPV (localiser performance with vertical guidance), where
lateral and vertical guidance is provided by augmented GNSS SIS.
RNP approach to Lin Zhi, Tibet, a 95–mile serpentine
approach between 17-20,000 ft mountains
guidance they are classified as approaches
with vertical guidance (APV). Therefore RNP
APCH NPA and APV can be summarised as:
NPA:
RNP APCH – LNAV
RNP APCH – LP
APV:
RNP APCH–LNAV/VNAV, and
RNP APCH – LPV.
FSA JAN–FEB10
Issue 72
12
Required
navigation
performance
‘authorisation required’, or RNP AR APCH,
utilises IRS and GNSS in combination to provide
far higher accuracy and performance over an
RNP APCH–to quote Naverus, by ‘allowing for
predetermined, precise, curved flight paths
which navigate within an airspace to reduce
track miles, conserve fuel, preserve the
environment and increase airspace capacity.’
RNP AR APCH procedures
operate to RNP values as low as 0.1nm,
utilise radius to fix (RF) turns, and
have non-normal events such as engine
failure incorporated into the procedure
profile.
Australia is in a unique position in
implementing PBN technology according to
Dirk Noordewier. Australia’s high-capacity
regular public transport fleet is relatively
young, with an average age of around 15 years,
and therefore equipped with the appropriate
onboard technology. Over 60 per cent of
Australia’s domestic jet fleet is certified to
RNP0.3 or better. Importantly, too, Australia
does not have a high-density ground-based
nav-aid network. This is on stark contrast
to somewhere like the United States, which
has an older fleet of legacy aircraft, a highdensity network of ground-based navigation
aids, and therefore a low dependency on
global navigation satellite systems (GNSS).
‘Many countries don’t “get” countries like
us,’ Noordewier explains. ‘We are almost
completely bypassing RNAV, and going
straight to RNP. The end result is that we’re
seen as world leaders.’ Nancy Graham agrees.
‘You’re early adapters. Australia’s always one
of the first to do anything, especially when it
comes to safety and efficiency.’
RNP AR & safety
It was this concern for aviation safety that led
to the development of RNP AR – to make flying
into airports located in challenging terrain, or
with a challenging climate, safer. Juneau, Alaska
is a case in point. There, a high mountainous
range flanking the Gastineau Channel created
challenges for aviation safety. Frequently,
operations into the Juneau International Airport
runway 08 had been interrupted or delayed
because of low visibility and ceilings, and if wind
affected runway 08, the opposite runway, 26,
was not usable because there was no approach
landing aid and associated procedures. These
conditions had led to hull accidents and loss
of life, as well as cancellations and diversions
because of bad weather. In May 1996, Steve
Fulton, the founder of US procedures design
company Naverus, and Hal Anderson, both
pilots and engineers, worked with Boeing
navigation system specialists to pioneer RNP
at Alaska Airlines. They designed a new RNP
approach for the airlines’ 737-400 aeroplanes
flying into Juneau.
Qantas Airways was also early to recognise
the safety benefits of RNP AR for its
flights into similarly challenging terrain in
Queenstown, New Zealand. High mountains
circle the airport; there is no radar; it is a
popular tourist destination, and therefore
can be a high traffic environment; and the
weather can often be a significant factor.
The original approach to Queenstown was a
circling approach, with an associated risk of
controlled flight into terrain. The 737-800s
Qantas flies into Queenstown offer advanced
capability, so the carrier commissioned
Naverus to design an RNP approach for the
port. The RNP approach gives the pilot positive
three-dimensional guidance all the way to the
Queenstown runway. According to Captain
Alex Passerini, Qantas technical pilot, ‘With
RNP, if there’s a non-normal event like engine
or GPS failure, the crew will have more tools
in the toolkit to manage the work, solve the
problem, and extract the aeroplane if they’re
at a low altitude.’
Naverus has also worked with civil aviation
authorities, air navigation service providers
and airline carriers to implement ‘safety-case’
RNP at Lhasa in Tibet, and Cusco in Peru. IATA; carrier LAN Peru; and the Peruvian civil aviation
authority, DGAC Peru, collaborated on a new RNP approach to Cusco. Guenther Matsschnigg,
senior VP, IATA safety operations and infrastructure, argues that the, ‘ RNP safety advantage
is significant, enabling airports located in the most remote areas of the world to have runwayaligned approaches with horizontal and vertical guidance, without having to install, calibrate
and monitor expensive ground-based navigation aids’. On 22 May 2009, a LAN Airbus 319
completed its first scheduled RNP procedures flight into Cusco with passengers, the first flight
of its kind in South America.
Cusco Airport, the gateway to the popular tourist destination of Macchu Pichu, has an elevation
of approximately 10,860ft, and is located at the end of a long valley surrounded by mountains
reaching 15,500ft. Ten to fifteen flights a day deliver visitors to Cusco, and in the last three
years, unfavourable weather has meant the cancellation or diversion of approximately 200
operations. The new RNP procedures lower the minimum descent altitude from 14,500ft
to11,800ft, almost eliminating such weather-induced delays and cancellations.
RNP AR savings
However, it soon became apparent that not only did RNP procedures mean improved safety,
but they could also deliver significant environmental and operational benefits. The ability to
curve the approach path allows the aircraft to be manoeuvred around obstacles and restricted
or built-up areas, often resulting in a shorter approach when compared to the zig-zag pattern
of conventional ground-based navigation procedures.
The Queenstown approach
PBN
Australia’s Brisbane Green project highlighted these environmental and operational benefits. In
2007, Airservices Australia introduced RNP AR approach procedures at Brisbane International
Airport. Brisbane International Airport is Australia’s third busiest, with 21 international and
five domestic carriers operating aircraft ranging from turbo-prop and helicopter, to heavy jets.
In 2007, there were approximately 173,000 aircraft movements, involving in excess of 17.5
million passengers. Working closely with Naverus, Qantas Airways and CASA, Airservices
implemented six RNP approaches and 12 RNP departures.
13
The Brisbane Green project has three stages:
Stage 1 – involved 33 Qantas 737-800s
Stage 2 – involved Jetstar A320/A321 & Air Vanuatu 737NGs
Stage 3 – Virgin Blue & other international carriers, with additional aircraft types.
The Stage 1 results (2007-2008) were very encouraging. Over
15,500 RNP procedures were conducted, including more than 8,000
approaches. Of these 8,000 procedures, 1612 were flown in instrument
conditions, resulting in:
estimated flight time savings of 4,200 minutes
estimated 17,300nm reduction in distance flown
estimated jet fuel saving of more than 200,000kg
estimated carbon dioxide emission reduction of 650,000kg
reduced impact of aircraft noise
reduced delays for non-RNP aircraft, because of shorter arrival
times for RNP aircraft.
FSA JAN–FEB10
Issue 72
14
Qantas-commissioned, proprietary RNP procedures are used at 17
aerodromes in Australia. Former Qantas chief pilot, Chris Manning,
is a passionate advocate for RNP, and in a presentation he gave to
the 2009 annual Airports & Aerodromes Association conference,
argued that ‘the use of RNP is imperative if we are to get the greatest
efficiencies from the system. We can’t impose RNP on current tracks;
the tracks can be drawn according to community concerns, but the
program needs to continue apace until it is completed.’ The community
concerns Manning alludes to relate especially to noise levels near
airports. The Brisbane trial demonstrated that noise emissions over
built-up areas could be minimised by conducting the RNP approach
over the river, highway and industrial areas, Chris Henry, general
manager of Naverus Australasia, reasons. And in response to the
claim from some that RNP concentrates the noise, he replies that ‘RNP
allows a flexible matrix of paths, so that procedurally, you can “share
the noise” by having multiple paths to the same airport.’
The next step for RNP in Australia, Henry
explains, is for the development of public
domain procedures. Airservices and Naverus
have signed a new contract for the deployment
of public domain RNP in 28 airports
across Australia, beginning with Brisbane,
Melbourne, Sydney and Adelaide. Under
this strategy flexible paths will be designed
to accommodate a broad range of transport
aircraft, and new multi-variant design criteria
will mean other operators can benefit from the
technology’. Under these multi-variant design
criteria (to RNP 0.3 only), aircraft are divided
into four categories: ‘four-engine heavy’;
‘two engine heavy’; ‘two engine, single-aisle’;
and ‘regional’, with decision heights and
thrust ratings in a matrix to determine the
appropriate RNP value.
While much of the PBN focus has been on
approach procedures, in no small part because
of their safety implications, it’s important
not to lose sight of the benefits harmonising
global navigation specifications for enroute
operations can bring. ‘The potential here
for significant safety, environmental and
economic benefits should not be overlooked,’
Dirk Noordewier emphasises. ‘There’s no
point in an aircraft flying RNP4 trans-oceanic,
at 30 miles’ separation, only to reach an FIR
boundary requiring 80 miles’ separation,’ he
explains. ‘In the absence of a global standard,
air traffic control will group mixed traffic
according to the lowest common denominator,
so you cannot derive any efficiency benefit
from the capability of the aircraft.’

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







°


Given that these procedures are still relatively
new, he says, ‘There is still a reasonably high
level of regulatory oversight,’ but as these
procedures become the default, that will
obviously diminish. And in conclusion, he was
keen to emphasise that ‘PBN is for everyone.
It’s not just airline stuff. If I’ve got a GPS IFR
navigator in my aircraft, I’ve achieved RNP 0.3
LNAV standards. That’s what it means. I have
to have RAIM (receiver autonomous integrity
monitoring) if I’ve got a GPS IFR navigator,
and RAIM is performance monitoring.’
For more information
CASA Advisory Circulars covering all
navigation specs in the PBN Manual
Advisory circulars due early in 2010, and will be available for
download from the CASA website: www.casa.gov.au
Brisbane Green RNP Project
Stage one report, March 2008.
www.airservicesaustralia.com
Chinese square off with Europe in space
Dan Levin. New York Times: 23 March 2009
Approaching precision
P50-51 Flight Safety Australia January-February 2005
Advancing efficiency – the promise of PBN
The ICAO Journal, Vol 64, No. 4, 2009
ICAO Performance based navigation
program
www2.icao.int/en/pbn/
Waypoints – the official newsletter of the
global PBN task force
Issues 1 & 2, Quarters 2 & 3, 2009
Challenges in implementing performance
based navigation in the US air
transportation system
US Dept of Transportation submission to the House of
Representatives sub-committee on aviation, 29 July 2009
RNP comes of age
Aviation Week & Space Technology, 15 December 2008
15
PBN
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ATCNotes
FSA JAN–FEB10
Issue 72
16
Deviations into active
restricted areas
R
ecent changes to the AIP Book and the Manual of Air Traffic
Services (MATS) emphasise the potential dangers associated
with deviations off track without a clearance, particularly
where this results in entry into an active Restricted Area.
Regular incident reports show that these deviations are not always
being managed effectively and may not ensure the safety of the
aircraft concerned.
In the past there has been a misunderstanding that if a release
or clearance through an active Restricted Area is not available
for aircraft deviating around weather, then it is acceptable for
the aircraft to enter the Restricted Area if the pilot squawks 7700
(emergency) and broadcasts on 121.5 MHz. This is not the case.
Hazardous activities that may be completely unknown to air traffic
control occur in Restricted Areas. These can include operational
flying, target towing and firing by all kinds of platforms using all
kinds of weapons. In addition, users most often do not have the
capability to monitor frequencies or detect SSR codes, or have airto-air radar.
The need for aircraft to deviate from track is reasonably predictable
based on forecasts and weather observations. Management of
deviations in controlled airspace due to weather is a joint pilot/
operator-ATC responsibility.
Whilst ATC will normally attempt to obtain a release of active
Restricted Areas when weather deviations are expected, this
is not always possible due to user operational requirements or
contactability.
The changes to AIP clarify the need for pilots to obtain a clearance
prior to any deviation off track in controlled airspace. If a clearance
is unobtainable and there is no alternative, then pilots are to
squawk 7700 and declare a PAN. They must also broadcast on
appropriate ATC frequencies and 121.5 MHz.
Pilots are also left in no doubt that the declaration of an emergency
in such circumstances does not guarantee safe passage.
These requirements apply in all situations, not just in relation to
Restricted Areas.
The corresponding changes in MATS require ATC to:
• Issue a safety alert as soon as controllers become aware that an
aircraft will enter an active Restricted Area without a clearance
• If possible, provide an alternative clearance – this may include
deviation around, under or over the active Restricted Area;
a return to the aerodrome of departure; or cancellation of an
existing clearance and holding on the ground at the departure
aerodrome.
• When deviation into an active Restricted Area without a
clearance is unavoidable, ATC will:
- Advise the pilot that they are proceeding at their own risk
- Terminate control services (Note that an onwards clearance
is required to re-enter civil controlled airspace)
- Continue to provide a Flight Information Service and SAR
Alerting Service
- Declare an Alert Phase
Ref: AIP ENR 1.1-37 19.7-19.9 and GEN 3.4 (phraseologies)
17
ATC NOTES
Safety Net
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Safe operations around
controlled airspace
Airservices has produced a Safety Net factsheet
specifically aimed at helping pilots operate safety
around controlled airspace.
The factsheet is available at:
www.airservicesaustralia.com/pilotcentre/training/
flyingaround/docs/safe_operations_fs.pdf
For more information about what Airservices is doing to
reduce the incidence of violations of controlled airspace,
email: safety.promotions@airservicesaustralia.com
International accidents/incidents 14 October 2009 - 28 November 2009
Date
14 Oct
Aircraft
Antonov 2TP
15 Oct
Antonov 28
17 Oct
Douglas
DC-3C
21 Oct
Boeing
707-330C
21 Oct
Boeing 737
22 Oct
BrittenNorman BN2A-8 Islander
26 Oct
Bae 125-800B
29 Oct
29 Oct
FSA JAN–FEB10
Issue 72
18
Location
NE of ManaguaAugusto C Sandino
Airport, Nicaragua
Kwamalasamutu
Airfield, Suriname
SW of ManilaNinoy Aquino
International
Airport, Phillippines
Sharjah Airport,
United Arab
Emirates
Cairo International
Airport, Egypt
Klein Bonaire,
Netherlands
Antilles
Minsk-2
International
Airport, Belarus
Cessna 208B
Aldeias Aurélio,
Grand Caravan Brazil
Lockheed HC- 24 km E off San
130H Hercules Clemente Island,
California
Fatalities Damage
0
Written off
Description
The Antonov 2TP, while on approach to the airport at a height of about 200m,
had engine problems. The pilot made a forced landing in the field of a farm 800m
short of the runway.
0
Substantial
The Antonov 28 was damaged in a runway excursion.
4
Destroyed
6
Destroyed
A Douglas DC-3 crashed in a warehouse shortly after takeoff, bursting into
flames. The crew had requested an emergency landing after the aircraft
reportedly experienced engine problems. Air traffic control cleared the flight
to turn around and land, but the pilot was unable to maintain altitude and the
aircraft crashed 3.5 km short of the runway.
The Boeing 707 was destroyed when it crashed in a desert area immediately
after takeoff, breaking up and burning. Eyewitnesses reported seeing the
airplane in an excessive right bank after takeoff.
0
None
1
Written off
5
Destroyed
2
Substantial
The flight was reported missing. The Cessna 208B was located the next day.
There were nine survivors, one person was reported missing and one dead.
7 (Missing,
presumed)
Missing
A Lockheed C-130 Hercules was missing after a reported mid-air collision
between the C-130 and a US Marine Corps Bell AH-1 Super Cobra. The C-130
was part of a search for a 12-foot vessel that had been missing for two days. No
trace of the C-130 or the Cobra has been found.
The Ilyushin 76 was destroyed when it crashed immediately after takeoff. News
reports indicate that the airplane climbed to a height of 20-30m, banked right
and crashed about 1.5 km from the runway.
Two passengers wielded guns and demanded to be flown to Las Qorey.
Passengers overpowered both hijackers, who were arrested when the flight
returned to Bossaso.
The turboprop plane went missing during a domestic flight. The wreckage was
found on November 4 on a mountainside.
A Sudanese passenger pulled out a knife, threatening a female attendant minutes
after takeoff. He said he wanted the flight diverted to Jerusalem ‘to liberate it’.
Two air marshalls overpowered the hijacker, later found to be intoxicated.
One engine failed on the Britten Norman, while it was approaching Bonaire;
the pilot could not maintain altitude, being forced to ditch the plane off the
coast. The captain was unable to leave the sinking plane; all nine passengers
evacuated and were rescued by a small submarine from the local Plaza Hotel.
The Bae 125-800B crashed into a forest and broke up while on approach to
runway 31.
1 Nov
Ilyushin 76
Mirnyy Airport,
Russia
11
Destroyed
1 Nov
Antonov 24RV
Bossaso Airport,
Somalia
0
None
2 Nov
PZL M28-05Pl
Skytruck
Grumman
G-111
Albatross
Boeing 727
Mulia, Indonesia
4
Destroyed
Saint Lucie County
Airport, United
States of America
Gao, Mali
0
Written off
The number 1 engine on the Grumman Albatross seaplane failed on takeoff. The
plane was damaged substantially in the ensuing crash.
0
Written off
The United Nations Office on Drugs and Crime (UNODC) reported that a Boeing
crashed on takeoff from an illegal airstrip near Gao. The airplane had arrived
from Venezuela carrying a cargo of drugs.
9 Nov
Beechcraft
1900D
Nairobi-Wilson
Airport, Kenya
1
Written off
The cargo plane crashed on approach to Nairobi-Wilson Airport. It left Wilson
Airport, transporting cargo to Somalia, when the crew decided to return after a
problem developed in flight. The aircraft struck the perimeter fence on landing,
crashed and broke up.
10 Nov
ATR-72-212A
Substantial
An ATR-72 passenger plane was damaged when it skidded off the runway on
landing at Mumbai Airport. Maintenance on main runway 27 at Mumbai, detailed
in several NOTAMs, affected operations at the airport between certain times.
12 Nov
Canadair CL600-2B19
Mumbai-Chhatrapati 0
Shivaji International
Airport, India
Kigali Airport,
1
Rwanda
Substantial
15 Nov
Cessna 208B
Windhoek-Eros
Grand Caravan Ariport, Namibia
3
Destroyed
18 Nov
Fokker 100
0
Substantial
A Canadair RegionalJet passenger plane was substantially damaged when it
struck an airport building at Kigali Airport, killing one passenger. Two minutes
after takeoff from Kigali the pilot requested to return because of unspecified
technical problems. It landed safely and taxied back to the apron. However,
when the plane reached its parking spot, the engines failed to stop and it moved
forward, knocking over blast fences and smashing through the concrete wall of
the airport building. The nose gear collapsed and the nose was buried inside the
building up to and including the forward passenger doors.
A Cessna 208B was destroyed when it struck terrain shortly after takeoff.
It failed to gain sufficient height after takeoff, turned right and descended,
ploughing into some bushes. The pilot and two passengers were killed in the
accident, one passenger survived.
Shortly after takeoff the undercarriage of the Fokker 100 passenger plane failed to
retract. The crew decided to return to Isfahan. After touchdown, the shock absorber
of the left main landing gear broke and the left hand wing struck the runway.
19 Nov
MD-82
0
Written off
A McDonnell Douglas passenger plane overran the runway on landing at Goma
Airport. Some twenty passengers were injured; initial press reports indicate the
runway was wet.
19 Nov
de Havilland
Canada-8-200
0
Substantial
A US military DHC-8-200 made an emergency landing in Mali. The right wing
separated and the undercarriage collapsed.
5 Nov
5 Nov
Isfahan-Shahid
Beheshti Airport,
Iran
Goma Airport,
Congo Democratic
Republic
Tarakigne, Mali
International accidents/incidents 14 October 2009 - 28 November 2009
23 Nov
Lockeed KC130J Hercules
Le Rene, Italy
5
Written off
28 Nov
MD-11F
Hai-Pudong
International
Airport, China
3
Destroyed
A Lockeed transport plane was destroyed when it crashed and burned
immediately after takeoff from Pisa-Gal Galilei Airport, killing all five crew
members. It came down on a railway line, broke up and caught fire.
A McDonnell Douglas cargo plane was destroyed when it crashed and burned on
takeoff, fatally injuring three of the seven crew members. Initial reports indicate
that the tail struck the runway before the airplane crashed past the runway end.
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 2 October 2009 - 29 November 2009
Aircraft
CESSNA R182
Skylane RG
Location
Apollo Bay (ALA),
VIC
Injuries
Minor
Damage
Serious
3 Oct
DE
HAVILLAND
DH-82A Tiger
Moth
AIR TRACTOR
AT-502
PIPER PA-31
Navajo
Taree Aerodrome,
NSW
Minor
Serious
Narrogin (ALA),
065° M 47Km, WA
Glen Innes
Aerodrome, NSW
Fatal
Serious
Nil
Serious
9 Oct
CESSNA 152
Nil
Serious
18 Oct
KAVANAGH
BALLOONS
E-260
Maryborough (Qld)
Aerodrome, 002°
M 13Km, QLD
Bendigo
Aerodrome, NNE
M 35Km, VIC
Serious
Serious
5 Nov
CESSNA 172R
Skyhawk
CESSNA
A188B
AgWagon
GLASFLUGEL
HORNET
BELL 412
Gold Coast
Aerodrome, QLD
Bedford Harbour
Station (ALA), WA
Minor
Serious
Nil
Serious
3 Oct
7 Oct
6 Nov
8 Nov
9 Nov
11 Nov
12 Nov
14 Nov
17 Nov
17 Nov
18 Nov
25 Nov
29 Nov
Wahring Field
Fatal
(ALA), VIC
Serious
Horn Island
Aerodrome, W M
139Km, QLD
HUGHES 269A Dalby (ALA), WNW Nil
M 21Km, QLD
Unknown
SCHEMPPHIRTH
FLUGZEUGBAU
NIMBUS 3DM
ROBINSON
R22 BETA
KAVANAGH
BALLOONS
E-240
CESSNA
A188B
AgWagon
ISRAEL
AIRCRAFT
INDUSTRIES
1124A
Westwind
AMATEUR
LANCAIR 320
PIPER
PA-28-140
Cruiser
Serious
Serious
Description
The aircraft ran off the side of the runway when landing in a 10kt crosswind.
The aircraft flipped when the landing gear sank in soft groundi injuring the two
passengers & seriously damaging the aircraft.
During take-off run on runway 30, the aircraft encountered a wind gust and the
right lower wing struck the ground. The aircraft nosed over and came to rest on
the propeller hub. The pilot and passenger sustained minor injuries.
During agricultural operations, the aircraft hit the ground.The pilot was fatally
injured. The investigation is continuing.
When the landing gear was selected down, the pilot received an unsafe landing
gear indication and the right main landing gear did not extend. The pilot diverted
to Tamworth and conducted a wheels-up landing on the grass runway 24.
The aircraft’s engine failed during cruise and the pilot made a forced landing in a
paddock. During the landing roll, the nosewheel detached from the aircraft.
The balloon contacted the ground on landing and the basket rolled over on its
side. After being dragged for a distance, the basket rolled, inverted and the burner
ignited. Three passengers received burns, before the pilot was able to turn the gas
off at the cylinders. The basket rolled back onto its side allowing the occupants to
evacuate. The basket was destroyed by fire.
During a touch and go landing, the aircraft veered off the runway. The left wingtip and
propeller struck the ground and the aircraft came to rest outside the gable markers.
During the take-off run, chemical splashed over the windscreen. The pilot rejected
the takeoff, but lost directional control and the aircraft ground looped, causing
serious damage.
It was reported that the glider hit terrain, fatally injuring the pilot.
During winching operations, it was reported that the winch cable snapped and
two crew members fell approximately 16 metres onto the deck of the ship,
seriously injuring both crew members. The investigation is continuing.
On landing, the helicopter’s tail rotor struck a log hidden in the long grass, and
a grass fire started from the helicopter’s hot exhaust. The pilot emptied the fire
extinguisher trying to put out the fire, but it reignited, destroying the helicopter.
As the glider was high on the approach, the pilot attempted to turn away from the
runway to avoid gliders operating on a crossing runway. One wingtip struck the ground,
causing the glider to spin and collide with terrain. Both occupants were uninjured.
Lake Keepit (ALA),
NSW
Nil
Serious
Moorabbin
Aerodrome, W M
2Km, VIC
Essendon
Aerodrome, 025°
M 5Km, VIC
Kojonup (ALA),
147° T 21Km, WA
Nil
Serious
Nil
Serious
Fatal
Serious
It was reported that the aircraft ‘collided with terrain’, fatally injuring the pilot. The
investigation is continuing.
Norfolk Island
Aerodrome
Minor
Serious
It was reported that after multiple missed approaches due to poor weather, the
aircraft became fuel critical & the crew elected to conduct a power-on ditching.
Investigation continuing.
Bathurst
Aerodrome, NSW
Tara (ALA), QLD
Nil
Serious
Nil
Serious
During the initial climb, the engine lost power & the aircraft subsequently hit the
ground.
On touchdown, the aircraft encountered a small whirlwind which caused the
aircraft to lift, rotate, and leave the runway. The aircraft then hit a drain and the
propeller struck the ground.
During the pre-landing checks, the student pilot inadvertently selected the fuel
mixture instead of the carburettor heat, shutting down the engine. The pilot
conducted a forced landing on a nearby school oval.
While landing on a golf course, the balloon’s envelope struck gum trees sustaining
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
Date
2 Oct
First tree contact
Second tree
contact
Fourth tree contact
Wreckage location
Third tree contact
Photo courtesy of ATSB
FSA JAN–FEB10
Issue 72
20
Weighing
up safety
The findings of coronial inquests into two
helicopter accidents, which occurred in 2003 and
2006, reinforce the importance of not exceeding
maximum take-off weights. The first accident took
Approximately 17 minutes after take-off, the
pilot of the lead helicopter, the B206, received
a broadcast from the R44 pilot announcing ‘I’m
going in hard’. The pilot of the Bell immediately
made a tight right turn, and assumed a
reciprocal heading. He then saw a mushroom
cloud of smoke rising from a nearby ridge.
He broadcast a Mayday to Brisbane Centre,
who directed him to look for signs of life near
the wreckage. The B206 pilot could see no
movement, nor could he find a safe place to
land, so he continued to Kununurra.
The first rescue team on the site confirmed
that all four occupants of the R44 had died
– the accident was not considered survivable,
given the impact of the crash, and the fire
which followed the rupturing of the aircraft’s
fuel tanks.
place near Kununurra, in Western Australia on 8 Background
November 2003: the second on 21 February 2006, The R44 pilot, described
about 100km north west of Mount Isa in Queensland.
On 8 November 2003, two helicopters – a Bell 206 and a Robinson
R44, were returning from a fishing charter at Cape Dommett in far
north Western Australia. Both helicopters were single-pilot – the B206
had five persons on board, while the R44 had four. The party had made
an early start, spent the morning fishing, and at 1015 WST, took off for
the return to Kununurra. Before take-off, the passengers decided to
change seating arrangements in the two helicopters.
by his training
instructor as ‘having a common-sense
approach to flying’ and ‘not a risk taker’ had a
CPL, with 15.6 hours on the R44 type, and 8.5
hours as pilot-in-command.
The aircraft itself was maintained as a dayVFR-capable Class B maintenance category
helicopter. Fifteen days before the accident
it had undergone a scheduled 100-hourly
inspection, registering 3018.6 hours in service.
Post-maintenance engine ground runs were
carried out with no defects recorded.
Operating weight
Empty, the R44’s recorded weight was 651.5kg. All heavy baggage,
according to the B206 pilot, was loaded into the Bell to save weight in
the R44. Apparently, the passengers were only carrying small items
such as cameras and fishing reels – allowed for as 2kg per person.
When the accident occurred, fuel on board was estimated at 90 litres –
62.4l in the main (left) tank and 27.6l in the auxiliary (right) tank. The
R44 also carried a standard equipment pack (minus a 5kg water bottle
and a drum fuel pump, normally carried, but off-loaded by the pilot)
– the estimated pack weight, minus these items being 10.9kg. The
weights of the four occupants (established by recent medical records
and description by next-of-kin), plus the pack weight, gave an all-up
weight estimation of 1,117kg for the helicopter at the accident scene.
This exceeded the maximum take-off weight (MTOW) of 1,109kg by 27kg.
Additionally, the longitudinal centre of gravity was calculated as having a
forward arm of 2,334mm, outside the published forward limit.
The ATSB found that this ‘absence of passenger information …
indicated that an accurate calculation of MTOW was probably not
conducted, and the pilot was probably not aware of the helicopter’s
actual take-off weight and centre-of-gravity position’.
Findings
1. The R44 left cruise flight in a descending right turn
approximately 17 minutes after take-off from the Cape
Dommett area.
2. The R44 first struck trees at 36ft AGL.
3. The R44 was approximately 27kg over its MTOW.
4. The helicopter’s centre of gravity was outside the forward
limit of its type.
5. The accident was not survivable.
The second accident
A young pilot of an R44 was undertaking an aerial survey charter in the
vicinity of Mount Gordon, approximately 100km northwest of Mount
Isa. On board were the pilot, and her three passengers – a surveyor, a
mining company manager and an environmental scientist – members
of a larger seven-member team conducting a feasibility study.
On 21 February 2006, the R44 had left Mt Isa at about 0623 and made
Evidence from the GPS navigation unit shows
this flight departed at about 0703, involved
about 55 minutes of flying time, and landed
back at Gunpowder around 0800. After
refuelling, and a change of passengers, the
helicopter took off again at 0837. At 0915,
a pre-arranged meeting took place at Mt
Gordon, and one of the passengers was
replaced for the second aerial survey flight,
which concluded at Gunpowder airstrip at
about 1041. The helicopter was refuelled, and
a third survey flight carried out, returning to
the airfield at 1248.
The afternoon’s program involved three of
the team continuing the aerial survey, while
the other four of the party would drive to Mt
Kelly, with a rendezvous of the two parties
planned between 1500 and 1530. However,
by 1600, the helicopter had not arrived, and
at about 1930, AusSAR was notified. A nighttime search was conducted with no success,
resuming at first light the next day. Finally, at
around 1115 on that next day, 22 February, the
burnt wreckage of the helicopter was located
about 10km west of the Mt Gordon mine on
an isolated hill in steep, rough terrain. All four
on board had died.
Investigation findings
After the crash, fire caused by ignited fuel
spilling from ruptured fuel tanks made it
difficult to establish the exact cause of death.
Given the destruction of the aircraft because
of the impact and the post-impact fire, a
thorough and conclusive assessment of the
helicopter’s pre-crash airworthiness was not
possible. However, ATSB engineers found
no mechanical defects or abnormalities,
and maintenance records showed that all
applicable maintenance requirements had
been met.
The coroner also concluded, on the evidence,
that ‘fuel quality did not contribute to this crash.’
21
WEIGHING UP SAFETY
Prior to take-off for the return flight to Kununurra, the passengers
had decided among themselves to change seating arrangements for
the return flight. Despite the charter company’s operations manual
requiring a cargo/passenger list and flight note to be complied, the
flight note left at Kununurra did not detail passenger names or weights,
nor were the changed seating arrangements and passenger details
recorded prior to take-off for the return flight.
a 28-minute flight to Gunpowder airfield. Three
members of the survey team who were not
weighed, nor questioned about their weight,
then boarded the aircraft at the Gunpowder
airstrip in the R44 for the first aerial survey
flight of the day.
Environmental factors
Increases in the operating altitude and/or
the temperature diminish the capacity of
helicopters to operate and hover. Increases
in altitude, temperature or humidity, or
a combination of all three factors, can
have a detrimental effect on engine output
and rotor efficiency, and therefore the
helicopter’s performance and its ability to
fly/hover safely.
Mt Gordon is at an elevation of 312m or
1025ft, and the ambient air temperature at
the time of the crash was estimated to be
38°C, significantly warmer than for the first
flights in the morning.
‘Overpitching’ occurs when a pilot adjusts the
collective so that the main rotor blades are
set to a high angle of attack, but the power
required to drive the blades in that formation
is greater than the power available in the
The issue of whether the aircraft was overloaded was less straightforward,
with some confusion as to the exact amount of fuel onboard, its weight,
and the corresponding calculations for the out-of-ground-effect (OGE)
hover performance of the aircraft. However, in the view of the coroner,
the ‘totality of the evidence supports the conclusion that at the time of the
accident, the aircraft exceeded its OGE hover weight’.
In this case, the passengers were not weighed, nor were they asked
their weight. There was also no evidence, according to the coroner, of
the operator’s pilots calculating fuel weight as a standard procedure
or practice.
Therefore it is likely that the pilot only discovered she did not have
hover performance when attempting to manoeuvre in the vicinity of
Mt Gordon, unlike earlier in the day when cooler temperatures and
a different load allowed such performance. Given her inexperience,
newness to survey work, the fact that she was operating at low
altitudes, and possibly fatigue and high workload, she may well ‘have
not responded appropriately’, the coroner concluded.
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S1473
FSA JAN–FEB10
Issue 72
22
Overpitching & hover
weight
prevailing conditions, thus decreasing the main rotor RPM. With
prevailing conditions of higher ambient temperature and elevation,
and a heavier aircraft, overpitching is more likely. Moreover, ‘recovery’
from overpitching by applying more throttle and lowering collective
pitch to reduce drag, according to the ATSB report, may be ‘counter
instinctive to the pilot of a descending helicopter at low altitude’. This
led the coroner to say, ‘I can confidently conclude the helicopter would
have been operating out of ground effect.’
Lessons to be learned
In April 2009, Robinson issued a revised safety notice which stated:
‘There is a misconception that aerial survey and photo flights can be
flown safely by low-time pilots. Not true.’ Robinson also stipulated that
aerial survey pilots should have a minimum 500 hours experience
in command and 100 hours experience on type, and be trained
extensively in low RPM and settling with power recovery techniques.
While there is currently no requirement for operations manuals to
contain such safety notices, CAOs 82.3 and 82.5 now require operators
to establish a safety management system to identify and manage risks.
The management of risks includes manufacturers’ safety notices and
airworthiness directives.
Under CAR 138, it is an offence for a pilot to operate an aircraft contrary
to a requirement, instruction, procedure or limitation concerning the
operation of the aircraft which is set out in the aircraft’s flight manual.
The performance limitations of the helicopter in different weather
conditions and at different altitudes are set out in the performance
charts contained in the flight manual for the relevant aircraft.
CASA surveillance activities frequently focus on the standard of preflight notes taken by the pilot-in-command as one measure to ensure
maximum take-off weights are not exceeded. Reliable flight notes
provide the basis for determining that the pilot-in-command has made
an informed decision regarding the safe take-off weight of the aircraft.
Operations manuals must be written to ensure that there are no
contradictory statements or alternatives to a MTOW–this also applies
to aircraft with seven or fewer seats. Smaller aircraft must also adhere
to more specific weight measuring procedures.
This is not an exhaustive list. However, it does
reinforce the fact that regulations require
pilots-in-command to consider a number
of factors when they are determining the
correct weight of an aircraft. These include
the aircraft type, operations to be carried
out during the flight, the performance of
the aircraft in the configurations in which
it is likely to be flown, and the prevailing
meteorological conditions at the aerodrome
at which the aircraft is to take-off or land.
Pilots should never underestimate the effect
that excess weight can have on the safe
operation of an aircraft.
23
‘Pilots should therefore
ensure that they comply
with the hover performance
limitations of the helicopter
as set out in the relevant
performance charts.’
BOB TAIT’S AVIATION THEORY SCHOOL
Hangar N Wirraway Drive, Redcliffe Airport. QLD 4021
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
WEIGHING UP SAFETY
All pilots must be familiar with Civil Aviation Regulations (CAR) 234
and 235 which provide measures to ensure maximum take-off weights
are not exceeded. CAR 235 covers ‘Take-off and landing of aircraft’
and is supported by 235-1(1), ‘Standard passenger baggage weights’.
Under CAR 233 pilots-in-command must
not commence a flight until they have taken
such action as necessary to ensure that the
gross weight of the aircraft does not exceed
maximum take-off and landing weights.
g
g
n
n
i
i
y
y
SSttaearrtt
aalle
Issue 72
FSA JAN–FEB10
alert
alert
24
G holsigtht
F
In the world of aviation, there are few things more concerning to a
pilot than the thought of becoming incapacitated at the controls of the
aircraft with a load of passengers relying on you to deliver them safely
to their destination. Hypoxia is a quiet but deadly foe.
In July 2009, two people on board a Beechcraft C90 came as close
as anyone would like to get to surrendering to the affects of hypoxia
and entering the history books as a second ‘ghost flight’ across the
Australian outback.
On Thursday, 16 July, the pilot and his passenger took off from their
home base bound for a small mining town. The two-hour flight was
planned to be conducted IFR at FL210 (21,000 ft).
The pilot completed his ground checks prior to take-off. All systems
appeared to operate normally.
After take-off the pilot climbed to his designated cruise altitude, carrying
out climb checks at 5000 ft and transition checks at 10,000 ft. The
climb, although uneventful and with no abnormal indications, was in IFR
conditions with moderate turbulence, rain showers and cloud.
The pilot levelled the aircraft at FL210. After they had been flying
for about nine minutes, the pilot became concerned that he had an
unexpectedly low ground speed. He requested weather information
from air traffic control, and after being advised that they had no
reports of adverse or unusual weather in his area, the pilot requested
and was approved, to descend to FL190.
‘ the
Beechcraft
C90 came
as close
as anyone
would like
to get to
surrendering
to the effects
of hypoxia
and entering
the history
books as
a second
‘ghost flight’
across the
Australian
outback ’
Another five minutes passed. The pilot advised ATC that his instruments
were indicating ‘100 knots on the nose’, and then requested permission
to descend further to FL140 where the winds might have been more
favourable. ATC approved the descent, and interestingly, advised the
pilot that they were seeing winds between FL140 and FL190 as coming
from 290 degrees, directly behind the aircraft. Shortly after, the pilot
requested confirmation of his approval to descend to FL150. Following
a short discussion with ATC to clarify his requested altitude, clearance
was given for FL150. The difference, change or confusion in flight level
was not noticed.
The pilot’s actions and his radio transmissions seemed normal;
however, he was already suffering the effects of hypoxia.
The aircraft continued at FL150 until the top of descent where he
became aware that the pressurisation system had failed, and descended
to 10,000 feet, made appropriate checks and landed without incident.
It was apparent that due to the affects of hypoxia, the pilot had
misinterpreted the GPS indication of distance to destination as ground
speed, reading, for example, 140 miles as 140 knots. It was this
confusion that saved the lives of the pilot and his passenger. Had he
not been ‘programmed’ to expect certain indications such as ground
speed, he may never have requested a lower altitude, and consequently,
would have succumbed to the lack of oxygen.
STAYING ALERT
re th e le sso n s in th is
ha t aare
wwhat
SoSo
the lessons in this
cid en t?
in incident?
25
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Professor James Reason’s ‘Swiss cheese model’, which describes a
model of organisational risk management involving various defensive
layers, is well known.
Defences, barriers, and safeguards are critical to risk management:
they serve to protect potential victims and assets from hazards. Mostly,
they do this very effectively, but there are always weaknesses.
Most systems have many defensive layers: some are engineered; some
rely on people; while others depend on procedures and administrative
controls.
In an ideal world, each defensive layer would be complete; however,
they are more like the illustrative slices of Swiss cheese with many
holes. And unlike our hypothetical cheese, these ‘holes’ are continually
opening, shutting, and shifting. While the presence of holes in any one
‘slice’ does not normally cause an accident or incident, when the holes
in several slices momentarily line up, the opportunity for an accident
or incident occurs.
In this incident, the holes in the defensive layer lined up and almost
resulted in a fatal outcome.
landed wit
So what are the defensive layers in this incident? As described before,
some are engineered, such as an aircraft’s design and safety systems;
others are based in operational procedures;
while some rely on pilots to complete their tasks
accurately. The items listed below provide some
of the layers in the system to ensure aircraft
operate safely in accordance with their intended
purpose:
during transition to altitude above 10,000 feet.
In this incident, the pilot noted a cabin rate of
climb of approx 350 ft per minute; however,
he did not note the cabin altitude. It is likely
that the cabin altitude gauge would have been
indicating aircraft altitude at that time.
The aircraft is designed to operate at altitude;
The C90 is fitted with a cabin altitude warning
system that consists of an amber annunciator
light in the instrument glare shield to activate
between 10,000 and 12.500 feet (depending
on the serial number of the aircraft). Following
inspection, the barometric switch was found
to be incorrectly installed, and so it did not
activate the annunciator warning light to
alert the pilot of the abnormally high cabin
altitude.
The pilot is trained and endorsed on the
aircraft type;
The manufacturer describes operational
checks of the pressurisation system in the
flight manual;
The operator has procedures for pressurised
aircraft;
The registered operator of the aircraft is
required to ensure that the aircraft is properly
maintained.
FSA JAN–FEB10
26
The manufacturer requires periodic
maintenance of the cabin altitude warning
system in the maintenance manual;
Issue 72
The aircraft is fitted with a cabin altitude
warning system and cabin altitude pressure
gauge;
SOSoWwhat
HA T went
W ENwrong?
T W RO N G
The Beech C90 is designed to operate at
altitude, but the system relies heavily on
human interaction and the diligence of the
pilot to complete his checks and checklists
accurately and on time.
The pilot was trained and endorsed on
type. However, it is evident that he did not
pay attention to the reading of the cabin
altitude gauge as the aircraft transitioned
above 10,000 feet. Was this as a result of
complacency, workload or some other factor?
This is difficult to determine – but, we know
humans are fallible and such errors occur even
with the best trained and diligent person.
The flight manual requires an operational
check of the pressurisation system as part of
the pre-flight checklist. However, the check
only indicates that air is being supplied to
the cabin by closing the pressurisation safety
valve. This check does not guarantee that the
pressurisation system will operate correctly.
The company’s operations manual required
checks of cabin rate of climb and cabin altitude
The manufacturer’s maintenance manual
requires an operational check in accordance
with the flight manual, and a test of the cabin
altitude warning pressure switch at 12-monthly
intervals. The maintenance manual also
requires a test of the switch and aircraft
system whenever the switch is changed. In
this case, the test was not performed when
the switch was changed in 2007, nor at the
12-month interval.
The registered operator maintains the aircraft
to the Beech C90 maintenance schedule. The
company employs the services of a professional
maintenance control organisation, and a
computer maintenance tracking system to
assist in monitoring and planning maintenance.
Through an oversight, on this occasion the
12-monthly test was not entered into the
maintenance control system, and therefore was
not carried out.
analys is
Analysis
Investigation into this incident identified an
incorrectly adjusted squat switch as the cause
of the pressurisation system failure. The
switch was adjusted to activate so close to the
very end of the undercarriage oleo’s extension
that on this occasion it did not activate. The
aircraft system therefore determined that the
aircraft was still on the ground and kept the
pressurisation safety valve open. The aircraft
cannot pressurise in this configuration by
system design.
You may ask: ‘how many slices of cheese is
enough?’ It’s not the number of slices that is
most important, rather the quality of each
slice and the number of holes in it. More slices
of less quality cheese (defences) does not
necessarily mean improved safety. The real
benefits come from good quality defences.
Many factors contribute to a safe system,
yet they all have failings, which is why it is
so important to analyse the risks, develop
strategies to mitigate those risks and ensure
the people who do the tasks are well trained.
Poorly-developed defences are usually never
enough, as the active failures (unsafe acts
committed by people) and the latent condition
(infectious agents lying in wait) are too
numerous, and have a dangerous potential to
come together.
LEARNED
BElearned
TObe
sson s to
le
Lessons
The major lesson to be learned from this
incident is that complacency has no place
in aviation.
This applies whether it is
the registered operator ensuring that an
appropriate maintenance schedule is in place;
that all maintenance is carried out when it is
supposed to be; that computer maintenance
tracking systems are properly loaded with all
maintenance requirements; that engineers
carry out maintenance in accordance with the
maintenance manual; or that pilots conduct
their flight checks diligently.
A number of other lessons can be learned
for those closely related to, but not directly
involved in this incident.
The operator of the aircraft has a duty of care
to ensure that pilots are not fatigued and are
capable of conducting safe operations. In this
example the pilot was a senior manager in the
The pilot himself has a responsibility to be
aware of and acknowledge cockpit workload
issues and take appropriate measures to
ensure that they do not detract from his
ability to operate the aircraft safely. Pilots are
generally diligent and generally don’t put their
own lives at risk; however, pressure can result
in unusual behaviours and decisions.
The maintenance organisation has a
responsibility to ensure that maintenance
tasks are completed no matter how onerous,
difficult or costly they may be to the company
or aircraft owner. Cultures where engineers
bypass crucial checks for expediency and a
‘she’ll be right’ attitude must be managed and
eliminated.
Effective and thorough cross-category
communication when undertaking multiple
category maintenance is critical. Engineers
must foster such communication and ensure
that tasks are not simply left for someone else
to complete because they are seen as being
‘not my category’.
Each link in the chain of safety is important.
Their small part may seem insignificant for
operators, pilots, engineers, maintenance
organisations and everyone else in the chain;
and that small deviation from the established
path may seem inconsequential, but the
chain is only as strong as its weakest link. A
seemingly inconsequential deviation may just
move a latent failure into the right position
to line up with another - and suddenly, all
the holes in the Swiss cheese line up. How
many times have we thought of something
in hindsight, only to realise we could have
prevented it?
Darren McDonnell is a CASA airworthiness
inspector based in Western Australia.
27
STAYING ALERT
In this case, the maintenance manual
procedure for testing the switch when it was
changed was not carried out; the 12-monthly
test was not carried out, even though the switch
was changed over 18 months before; the cabin
pressure annunciator light did not illuminate
when the cabin pressure went above 10,000
feet; and the pilot did not recognise that the
cabin altitude was abnormally high.
company and head of aircraft airworthiness
and maintenance control. Did the workload
and stresses of these other responsibilities
affect the pilot’s ability to perform effectively?
The fact that this is possible highlights the
importance of human factors and fatigue
management.
not
free-for-all
Glenn Bl akiston’s drop zone
guide
for fellow pilots
It’s the silly season again. The
weather has turned for the bett
er;
aviators dust off the headsets, and
once again take to the air to enga
ge
in the joys of aviation.
Issue 72
FSA JAN–FEB10
Issue 72
28
However, this is also the time whe
n things get really interesting for
skydive pilots who operate in thei
r busy little pieces of sky allowing
those who choose to descend to
terra firma minus aircraft to do so.
In my role as the senior pilot for
Melbourne Skydive Centre (MSC),
safety of the operation is one of our
major concerns. MSC operates out
of Lilydale airport in the beautiful
Yarra Valley. This area of operatio
n,
and the little piece of sky we call
home, poses a number of significa
nt
operational challenges.
Contrar y to popular belief and
the skydivers’ definition of a pilo
t,
(pilot: n. a taxi driver with an elev
ator endorsement), jump flying
is
not simply jumping in and going to
height, opening a door, and coming
down. Jump flying can be, and freq
uently is, very challenging, and can
involve very high workloads and
dangers not usua lly found in norm
al
GA operations. Jump flying requires
the ability to handle multiple task
s
simultaneously, in a very busy
environment, in a condensed time
frame. The few minutes prior to ope
ning the door are particularly busy
times for a jump pilot. Workloa
ds can vary for the pilot depend
ing
on the location and the types of
operations conducted there. MSC
operations are solely tandem-orie
nted, but at other drop zones ther
e
can be a mix of tandems, accelera
ted free fall (AFF ), sports jumpers
and other work.
Our drop zone is located at Lilyd
ale airport, so we face some uniq
ue
airspace issues that converge
in and around the Yarra Vall
ey.
Approximately 3nm SE of Lilydale
is Coldstream airport. Both Lilydale
and Coldstream conduct recreati
ona l aviation, charter, IFR and
GA
flight training, and bounding Lilyd
ale is the eastern VFR transit lane
through the Kilmore Gap. Glass G
airspace is 0–4500ft, and then the
airspace goes to Class C, throwin
g regular public transport (RPT),
commuter, IFR and transiting traffi
c to/from Melbourne, Essendon
and Moorabbin into the mix. One
of the major issues for most jum
p
pilots, and in particular for MSC
operations, is that the Lilydale/ Yarr
a
Valley area is a major transit area
for multitudes of aircraft tracking
to and from Essendon, Moorabbin
and places further afield. Combine
this transiting traffic with traffic from the
local private strips, and the intense flight
training conducted at both airports during
the summer, and the area gets busier than a
gnats’ nest.
This poses one of the biggest problems for
jump pilots: building a mental map of all the
potential conflicts for the drop. It’s not unlike
what air traffic controllers do on a daily basis,
but we don’t have radar to assist us. The
second major issue is to identify conflicts and
communicating with the identified traffic.
ZON
E
Imagine you are planning your nav. You see
the little red parachute symbol, but in the
grand scheme of things it may be something
you don’t place high on the priority list, or
regard as critical to your flight. You take off,
and approach a known and active parachute
drop zone. You tune to the CTAF, but believe
you are at a position where you don’t need
Before jump pilots can allow jumpers to exit the aircraft, they must
be satisfied that there are no conflicts which can endanger the exiting
jumpers, or pose a conflict for the descent. After disgorging their load,
jump aircraft generally waste no time in making their way down to the
ground, so they will be descending at speed. Again, these high rates of
descent pose more potential for conflict.
However, transiting aircraft which fail to communicate, aka ‘bandits’,
are more common than you think. Routinely, aircraft track through
the drop zones completely oblivious of the activity and the very real
danger around them. They have failed to plan for this segment of the
flight, and do not recognise the need to communicate their intentions
and position to anyone. This issue is heightened when there are cloud
operations at a drop zone. The jump pilot must have an intensified
level of situational awareness to ensure the underlying airspace is
clean. If the jump pilots can’t contact transiting traffic, they are forced
to discontinue the drop and go around until the area is clean again.
So you should take a number of precautions when flying through,
around, or into a known active drop zone so that you can avoid
unexpectedly meeting new aviation-oriented people mid-air.
Situational awareness is critical in making a safe transit of, or entry to,
an active drop zone.
Ensure you are well informed. Understand the route you are taking
and if it is marked with a parachute symbol, make notes and decide
on a course of action before approaching the area.
Plan well in advance, so that you know the requirements of jump
operations.
Before allowing jumpers to exit, jump pilots must make appropriate
broadcasts on the required frequencies. Due to the hive of activity,
MSC makes four-minute and two-minute calls on CTAF and radar
frequencies; and additional calls as required if a new contact is
picked up.
Make sure your transponder is on! Think ahead and get ready.
COMMUNICATE clearly, accurately and LISTEN OUT.
To allow us to protect you it is critical you communicate
29
FREE FALL
D RO P
To operate safely, MSC has developed strong
working relationships with the Australian
Parachute Federation to improve pilot
training standards; with CASA, who have
been proactive in improving pilot training and
safety; and also with Airservices Australia.
Airservices’ ML radar team are absolutely
fantastic in assisting us to operate in our very
own designated flight area while dodging all
the through traffic that they have to deal with.
Part of the service they offer us is to advise of
potential traffic down to the ground to assist
in monitoring conflicts. ML Radar is vital in
assisting us to locate potential conflicts, as
they provide traffic advisories all the way
down to circuit height, even though it is in
Class G airspace. This service provides an
important additional safety layer which helps
pick up any wayward transiting traffic which
blunders through the area unannounced,
unaware of the impending danger they are
exposed to, and the potential disruption that
this can cause.
to make any broadcasts. Or maybe you just forget. Suddenly out of
nowhere there is a parachute right in your face. How would you react?
Or even worse, you suddenly pick up additional passengers midflight. When skydivers are in free fall, they are essentially partiallyguided missiles travelling at or in excess of 200kph, depending on
the jump being conducted. Thankfully, this scenario is unlikely, but it
has happened.
DR
OP
ZO
NE
accurately. This includes current position, aircraft type, callsign,
height and intentions, including direction of track.
Scan the area while transiting, or operating in the area. Parachutes
are relatively easy to spot if you are looking for them.
A helpful general rule of thumb: most, if not all, jump runs are
made into wind, so knowing the area winds for that region will
help you work out in which direction the jump aircraft will be
tracking on the jump run. If the jump pilot identifies you as a
conflict, they will attempt to contact you and advise the best
course of action. If in doubt, ask the jump aircraft to assist.
There are a number of things to consider when flying through or
around a jump area.
Be aware of how many canopies will be in the air (this is included
in the calls).
Jumpers can sometimes misjudge spots, which can result in an ‘out
landing’: the parachutist has strayed from where they should be.
Jump aircraft routinely conduct multiple drops from varying heights
on one sortie. So canopies can be out, but more are on their way they also open at different heights.
FSA JAN–FEB10
30
Issue 72
Malfunctions can and do occur. This will mean that a jumper may
be outside the usual drop zone boundaries due to the failure; but
it also means that somewhere up there is a canopy floating down
wistfully in the wind just looking for your prop to engage with.
Also at some drop zones, such as MSC,
multiple aircraft operate together, so you
shouldn’t assume there is only one jump
aircraft operating.
When you’re flying in the vicinity of an active
drop zone, the best plan is to skirt the area so
you don’t come into conflict. If you need to
land at an airfield conducting such operations
and you are unfamiliar with it, ring and get
information from the landing area operator.
Avoid overflying it at all costs.
sh a red
rk ing in a
o
w
l
l
a
e
r
‘W e a
during
E specia lly
a irspace.
a n b ec o m e
ome of it c
e
s u mme r , s
. So th at w
conge s ted
to
d
e x tremely
e
a l l ne
s a fely, w e
it
e
r
a
h
s
ed.
ca n
nd inform
repa red a
be fully p
e of the
, ignor a nc
e
If w e don’t
nt ca n h av
en v ironme
jump zone
ence s.’
s c o n s eq u
d a nge r ou
Pull-Out Section
Improve
safet y– d
through
defect
report
s!
31
AIRWORTHINESS
Following the popularity and success of our last SDR competition
(May-June 2009), it has been suggested that CASA run another
competition.
We understand that workshops are busy places, and that the last thing
you may want to do at the end of a long shift, or after releasing an
aircraft to service after a difficult day, is to sit in front of a computer
screen and fill out SDR forms.
However, it is widely acknowledged that the benefits of submitting a
defect report include:
focusing attention on the key elements of the ‘how, why, what and
when’ of the defect prompting you to think about how to stop it
happening again
timely airworthiness control and advice action for Australia’s
aircraft fleet
long-term improvement in design, manufacturing and maintenance
standards.
Thousands of defects are investigated and corrected every day as a
matter of normal safety management and cost-efficient maintenance
and operation. However, every so often, a defect which fits the
definition of a ‘major defect’ comes up. These defects should also
be reported to CASA for further assessment and possible action
to prevent recurrence, and also, to provide a record in the SDR
database to help detect trends. Pull-Out Section
The SDR database can be an effective tool in helping to achieve these
aviation safety goals, but only if the information provided is accurate,
comprehensive and timely. As the common phrase has it, if there’s
‘rubbish in’, then it’s likely to be ‘rubbish out’: the effectiveness of
the SDR system relies heavily on you, as professional operators and
engineers who are experiencing the problems.
FSA JAN–FEB10
Issue 72
32
It is quite difficult and time consuming for CASA to assess defect
reports which only have ‘it broke’ details. Accordingly, this competition
will have a slightly different emphasis. Not only are we hoping to
encourage the submission of SDRs online, but more importantly, in
this competition, the focus will be on the accuracy and excellence of
service difficulty report content. That being said, brevity is still good.
How do you want me to change the way I complete SDRs? Very
little change, really–just more attention to detail, and isn’t that what
aviation safety depends on? For starters, all the information you need
to include when submitting a defect report can be found in CAR 52A.
As well, Civil Aviation Safety Authority Publication (CAAP 51-1(1)
provides information on what needs to be included in an SDR. If you
follow the guidance, not only will your SDR be a more useful defect
report to you and to CASA, you will also have a greater chance of
winning the prize.
All entries will be assessed on how well they comply with CAR 51 to
52B. So what hints can we give you for submitting a prize-winning
defect report? Look at CAR 52A a little more carefully. For example:
Describe the defect CAR 52A (2) – as has been said before, CASA
often receives a very brief ‘it broke’ report and little else, or a
very detailed report on what happened as a result of the defect, a
description of the kind of weather, what Fred said, damage to the
propellers and engines, but amazingly – completely omitting a
description of the defect found to have caused the problem, and,
no opinion on what is thought to have caused the problem.
Set out the circumstances in which the defect was discovered. CASA provides general guidance in the form of tick boxes for all
the usual suspects, such as in the climb, taxiing, during free fall,
maintenance and a free text box for the unusual. Often the tick
boxes, even in combination, do not tell the whole story. This can
be written in the report. Defect reports often fall short of identifying the safety implication
of the defect as required in the SDR reporting form. What is
appreciated here is something along the lines of ‘had this (defect)
remained undiscovered, loss of control of the aircraft’ or ‘engine
failure’–could have resulted’.
Defect reports very often also fail in describing the corrective and
preventive action taken and an opinion as to the cause of the
defect. For example, CAR 52A (2), where it is a requirement to
Continued on page 40
SELECTED SERVICE DIFFICULTY REPORTS
AIRCRAFT ABOVE 5700KG
Airbus A320232 Flap power control unit
malfunctioned. Ref 510009367
During descent, aircraft experienced ‘F/CTL
FLAPS FAULT’ message. Flight crew performed a
flapless approach, landing without further incident.
Investigation determined the flap/slat power control
unit (PCU) was unserviceable.
P/No: 786A000012. TSN: 11,002 hours/5,791 cycles.
Airbus A320232 Rudder servo control bearing
housing scored. Ref 510009256
Rudder servo control bearing housing scored. Found
during bearing replacement.
P/No: 810A000005.
Airbus A320232 Wing skin corroded.
Ref 510009507
LH and RH wing top skin panels corroded beyond limits.
Found during inspection iaw SB A320-57-1155 Rev 00
and SB A320-5701154 Rev 00. (2 similar occurrences)
Airbus A330201 Hydraulic power systems
check valve low torque. Ref 510009439
During cruise, hydraulic ‘yellow’ system low–ECAM
warning. Fault finding found the ‘yellow’ system HP
manifold right-hand wheel well check valve lockwire
broken and hand tight. Check valve removed and
found the back-up ring damaged.
Airbus A330202 Landing gear system brake
failed. Ref 510009306
Brake system failed at runway holding point.
Investigation continuing.
Airbus A330202 Rudder safety valve union
leaking. Ref 510009291
Yaw/rudder safety valve union packing leaking. Loss
of hydraulic fluid.
Boeing 717200 Engine thermal anti-ice valve
malfunctioned. Ref 510009375
During cruise, caption ‘ENG L A-ICE DISAG’
illuminated. Following ground investigation, the LH
engine thermal anti-ice valve was replaced.
P/No: 32157082.
Boeing 737376 Fuselage frames and bulkhead
failed splice inspection. Ref 510009287
Fuselage frames and bulkheads failed splice
inspections. Numerous cracks evident.
(5 similar occurrences)
Boeing 7373YO Fuselage structure keel beam
corroded. Ref 510009260
Keel beam corroded in several areas along the upper
and lower flanges of the ‘T’ chord. Corrosion located
at stations 673–727 was outside limits.
(1 similar occurrence)
Boeing 737476 Aircycle machine leaking oil –
fumes in cockpit. Ref 510009435
Fumes detected in cockpit during aircraft turnaround–
smells of Jet 2 oil. Fault finding identified the LH pack
air cycle machine (ACM) leaking oil.
P/No: 22051702. TSN: 36,716 hours. TSO: 349 hours.
(2 similar occurrences)
Boeing 737476 Air conditioning pressure
controller failed. Ref 510009402
Aircraft pressurisation controller failed during climb.
Pressurisation controller replaced on ground and
pressurisation system tested serviceable.
(7 similar occurrences)
Boeing 737476 Elevator position sensor faulty.
Ref 510009405
Autopilot B system dropped off twice on approach
and was subsequently disconnected. Built-in test
equipment detected an elevator position sensor fault
in the digital flight control system. Sensor replaced
and the autopilot B system tested serviceable.
P/No: H504B. (1 similar occurrence)
Airbus A330303 Aircraft oxygen system PSU
faulty. Ref 510009503
Seat 60JK passenger oxygen system Passenger
service unit (PSU) would not drop due to gap less than
2mm (0.078in).
Boeing 737476 Escape slide failed to deploy.
Ref 510009443
Door 1R escape slide failed operational deployment
check by twisting vertically. Slide deployed in four
seconds, temperature 22 deg C (71.6 deg F) and
pressure 16 Kpa (2.34 psi). Lights operated normally.
P/No: 737M25651013. TSN: 55,026 hours. TSO: 1,763
hours. (11 similar occurrences)
Airbus A330303 Flight deck slight electrical
burning smell. Ref 510009450
On descent, slight electrical burning smell on flight
deck. Extensive ground checks carried out but unable
to locate source of smell. (1 similar occurrence)
Boeing 737476 Mach trim actuator jammed.
Ref 510009487
Mach trim actuator jammed in extended position.
P/No: 2A7200A. TSN: 52,540 hours. TSO: 27,878
hours. (7 similar occurrences)
Airbus A330303 Windshield arcing evident.
Ref 510009295
R1 windshield anti-ice system faulty. Arcing evident, and
controller also inoperative. Investigation continuing.
Boeing 737476 Trailing edge flap switch faulty.
Ref 510009478
Trailing edge flap ‘Up’ switch S245 had high
resistance between pin 20 D5983P and ground
causing autopilots to disconnect when flaps selected.
P/No: 426EN108. (2 similar occurrences)
Airbus A380842 Landing gear wheel cracked.
Ref 510009373
Aircraft landed overweight. Upon inspection of No.19
unbraked wheel assembly, a crack approximately
25.4cm (10in) long was found in the wheel
circumference.
Boeing 737476 Weather radar failed. Ref
510009403
Weather radar generated weak returns with scatter
all over the screen during flight. The system was
reset several times, but would only work for around
ten minutes each time. Weather radar transceiver
replaced on return for a suspected mount blower
assembly defect.
P/No: 6225132106. TSN: 537,455 hours. TSO: 23,182
hours. (2 similar occurrences)
Boeing 7377Q8 Cockpit window frame cracked.
Ref 510009336
RH No1 cockpit window frame cracked.
(3 similar occurrences)
Boeing 737800 Fire detector faulty. Ref 510009406
On climb, the right wing/body overheat detection
system master caution light illuminated. System
was reset, and flight continued after consulting
engineering services. Upon touchdown at destination,
the light illuminated again. Maintenance investigation
resulted in removal and replacement of the wing/
body overheat control module and the system was
subsequently ground tested serviceable.
P/No: 355992255. TSN: 148 hours. TSO: 148 hours.
Boeing 73782R Pneumatic systems HPSOV
malfunctioned. Ref 510009352
The No 2 engine bleed air circuit breaker tripped on
two occasions when selected in flight. Fault rectified
with the replacement of the high-pressure, shut-off
(HPSOV) valve (P/No 107484-7) and regulator (P/No
3214446-4). P/No: 1074847.
Boeing 737838 APU faulty – fumes in cabin.
Ref 510009390
Crew report fumes in cabin at top of descent. Ground
investigation found that fumes mainly occurred during
engine start and shutdown–a period of large load
changes to the APU load compressor. The APU was
inspected and replaced. Investigation continuing.
P/No: 38007021. TSN: 1,224 hours.
TSO: 1,224 hours. (1 similar occurrence)
Boeing 737838 Air conditioning pressure
controller faulty. Ref 510009446
When taxiing for departure, louder than normal
air-conditioning air vent noise was experienced on
flight deck and in cabin. Noise continued during takeoff, and climb associated with loss of temperature
control and no cabin rate of climb. Manual control of
pressurisation possible. Air turn back was decided
due to low cockpit temperatures and pressurisation
issues. During fault finding, the pressure controller
and temperature controller were replaced.
P/No: 7121-19971-01AC. TSN: 20,582 hours.
TSO: 20,582 hours.
Boeing 73786N Elevator pitot system
inoperative. Ref 510009457
During flight the left-hand elevator pitot warning
light illuminated. Left-hand elevator ‘feel’ pitot probe
was replaced and aircraft returned to service. P/No:
0851HT1.
Boeing 7378BK Engine anti-ice valve failed.
Ref 510009354
RH engine had an amber thermal anti-icing indication
with engine anti-icing selected off. Subsequent
replacement of the cowl thermal anti-icing valve
(CTAIV) rectified the problem.
P/No: 32156184. (10 similar occurrences)
Boeing 7378BK Pitot head contaminated.
Ref 510009267
RH pitot probe contaminated with wasp nest.
33
AIRWORTHINESS
Airbus A330201 Nose landing gear retraction
fault warning. Ref 510009410
After takeoff, the landing gear up lever was selected
and all gears started to retract. Then a fault message
LEG-NLG was displayed with no indication of nose
gear position. Crew selected all gear down and locked
and aircraft made an uneventful landing. Fault was
unable to be replicated on the ground. NLG oleo strut
was serviced and aircraft returned to service.
BAC 146200 Slideraft failed to deploy.
Ref 510009485
R2 door slide failed to deploy automatically or
manually during test. Investigation continuing.
(1 similar occurrence)
Pull-Out Section
1 October – 30 November 2009
Pull-Out Section
FSA JAN–FEB10
Issue 72
34
Boeing 7378BK Pneumatic systems–bleed air
duct split. Ref 510009469
Flight crew observed bleed air duct pressure readings
to be outside limits. Maintenance discovered split
in bleed air duct. The 450 degree thermostat was
replaced. P/No: 1296942. (1 similar occurrence)
4 cm (1.5 inches) long emanating from a single crack
initiation point. Further inspection revealed that the
insulation blanket covering the bulkhead had a patch
repair in exactly the same location as the bulkhead
cracks. Damage was repaired in accordance with the
structural repair manual.
Boeing 7378FE APU failed to start.
Ref 510009281
APU failed to start inflight, but started normally on
the ground. Investigation continuing.
P/No: 1319B. TSN: 6,481 hours/8,769 cycles. TSO:
6,481 hours/8,769 cycles. (9 similar occurrences)
Boeing 747438 Rudder power control module
yaw damper cracked. Ref 510009374
Rudder lower power control module cracked on yaw
damper top cap cavity and bearing, and slide end cap
cavity. P/No: 2417527. TSN: 63,574 hours. TSO: 63,574
hours. (1 similar occurrence)
Boeing 7378FE Captain’s rudder pedal
adjustment jammed. Ref 510009466
Captain’s rudder pedal fore/aft adjustment jammed.
Adjustment subsequently freed and tested
serviceable.
Boeing 767336 Slide failed to deploy during test.
Ref 510009459
Door R1 was only able to be opened two inches during
an operational test. The slide assembly fell onto the
deployment bar, partially unravelling and stopping
the R1 door from opening. The slide did not inflate or
deploy. (2 similar occurrences)
Boeing 7378FE Control column bearings
binding. Ref 510009472
Both control columns not moving freely. Investigation
found flat spots on bearing that coincides with
‘notchy’ feeling through control column. P/No:
KP4FR16FS428. (2 similar occurrences)
Boeing 7378FE Landing gear wheel failed.
Ref 510009365
After landing, the aircraft was found difficult to taxi
and steer. A visual inspection of the RH landing gear
found number four wheel to be on an angle. Wheel
was removed and the inner wheel hub and bearing
mount were found to have broken away from the
wheel assembly.
P/No: 277A6000204. TSN: 9,854 hours/5,711 cycles.
TSO: 1,776 hours/701 cycles. (1 similar occurrence)
Boeing 7378FE Trim actuator motor
unserviceable. Ref 510009463
On approach, the horizontal stabiliser out-of-trim
warning light illuminated. The electric trim was
unserviceable at the time. Trim motor actuator was
replaced and trim system tested serviceable. P/No:
6355B000103. TSN: 16,455 hours/11,790 cycles.
Boeing 747438 Crew oxygen bottle discharged.
Ref 510009292
Lower crew oxygen bottle discharged. Investigation
continuing.
Boeing 747438 Door gust lock collar cracked.
Ref 510009407
The gust lock on left door number 4 was not engaging
during ground servicing. The anti gusting locking
collar was found to be cracked. Collar was replaced
and aircraft returned to service.
(1 similar occurrence)
Boeing 747438 Landing gear rear trunnion
support torque tube sheared. Ref 510009448
During inspection of the RH wing landing-gear rear
trunnion, it was noted that the inboard fixed trailing
edge panel vertical support torque tube/tie rod was
sheared at the lower end. The broken tube had been
resting against the broken flap drive tube and had
removed some paint with minimal damage.
P/No: 65B139129. (1 similar occurrence)
Boeing 747438 Rear pressure bulkhead
damaged. Ref 510009358
During C-check inspection, damage was found on the
RH side of the rear pressure bulkhead between the
tear straps and radial stiffeners at STA 2385 and WL
250. Damage consisted of three separate cracks up to
Boeing 767336 Wing pitch load fitting tension
bolt holes defective. Ref 510009328
Wing aft pitch load fitting forward tension bolt holes
defective. Found during inspection iaw EI 767-54-83
and BSB 767-54-82.
Boeing 767338ER Pitot static system suspect
faulty. Ref 510009322
Pitot/static system suspect faulty. Investigation
continuing.
Bombardier DHC8315 Fuel system accumulator
drain holes blocked. Ref 510009394
During a ‘C’ check evidence of fuel was discovered in
the bilge of the aircraft adjacent to fuel accumulator
installation for field aviation cabin tanks. Drain holes
in the ‘accumulators’ had been inadvertently blocked
by sealant when initially installed to the aircraft.
Bombardier DHC8315 Navigation system cable
short circuited. Ref 510009280
Navigation system coaxial cable short-circuited,
in area approximately 1.2 metres from bulkhead
connector 3455-P10. P/No: 345511C5.
Bombardier DHC8402 Aircraft door handle
partially open. Ref 510009453
During take-off/climb the crew experienced an aft
baggage door insecure warning. Ground inspection
found the aft baggage door handle to be slightly
extended from the fully stowed position. Handle was
re-positioned to fully stowed position & could not
fault the operation of the door locking mechanism.
Suspect handle incorrectly stowed when door closed.
Personnel/maintenance error. (12 similar occurrences)
CVAC 340 EDC seal leaking oil. Ref 510009429
During cruise, the engine-driven compressor (EDC)
oil temperature rose and pressure dropped. EDC was
disconnected electrically by crew. Fault finding found
oil loss past the shaft oil seals. EDC replaced.
TSO: 938 hours.
Dornier DO328100 Navigation transponder
faulty. Ref 510009438
Anomalous transponder behaviour following
introduction of AMSTAR radar.
Dornier DO328100 Pilot’s side window outer
pane shattered. Ref 510009377
During pre-flight inspection, pilot’s side window outer
pane was found cracked/shattered.
P/No: 001A561A0000218. TSN: 23,919 hours/21,615
landings. (1 similar occurrence)
Embraer ERJ170100 Aileron cable worn.
Ref 510009369
RH wing lower outboard aileron cable worn in area
behind the outboard spoiler.
P/No: 17005828401. (5 similar occurrences)
Embraer ERJ170100 Fuel leak from outboard of
flap fairing. Ref 510009492
Fuel leak from LH wing outboard of outboard flap
fairing. Leak stopped after loss of approximately
250 kg of fuel. Pressure relief valve and vent float
valve checked serviceable. Investigation could not
determine cause.
Embraer ERJ170100 Hydraulic shutoff valve
failed. Ref 510009491
RH hydraulic firewall shutoff valve failed in the ‘Open’
position. P/No: 9752875. TSN: 2,244 hours/2,244
cycles. (3 similar occurrences)
Fokker F28MK0100 Aileron outer balance panel
hinge corroded. Ref 510009468
LH aileron outer balance panel aft hinge corroded
causing hinge halves to separate. Found during
scheduled 4000FH check.
Fokker F28MK0100 Captain’s brake pedal feel
spring disengaged. Ref 510009335
Captain’s RH brake pedal feel spring detached from
roller. TSN: 28,374 hours/26,176 cycles.
TSO: 31 hours/14 cycles.
Fokker F28MK0100 Nose landing gear wheel
unserviceable. Ref 510009359
During ground inspections, the LH nose wheel tyre
appeared to be down on pressure. Closer inspection
revealed one tyre was completely deflated and one
wheel hub retaining bolt was missing. In addition,
several other retaining bolts were also found to
be loose. P/No: 50081331. TSO: 1,359 hours/860
cycles/860 landings.
Fokker F28MK0100 Speed brake malfunctioned.
Ref 510009467
On landing approach the speed brakes were selected
out as required and worked normally. When selected
in they failed to retract. The speed brake selector
lever was recycled a few times and the speed brakes
eventually retracted. Investigation continuing.
Saab SF340B Aircraft lighting ballast
overheated – smell/smoke in cabin Ref
510009361
During climb, smoke and a metallic burning smell
was detected in the cabin at approximately row 7A.
Aircraft immediately commenced a return to land.
Master warning ‘CARGO SMOKE’ occurred. The
cargo fire extinguisher was discharged, and after
five minutes the ‘CARGO SMOKE’ master warning
went out. Investigation found SAAB SB 33-048 had
not been correctly carried out by a previous overseas
operator. Personnel/maintenance error. Investigation
continuing. P/No: 6524001. (1 similar occurrence)
AIRCRAFT BELOW 5700KG
Beech 200 Landing gear switch wiring faulty.
Ref 510009366
On selecting landing gear up after take-off, the gear
control circuit breaker tripped. The circuit breaker was
reset and immediately tripped again. The landing gear
had not moved and indicated down and locked. The
pilot landed without further incident. The problem
has been isolated to the RH MLG switch wiring.
Investigation continuing.
Beech 300 Electrical power loom rubbing.
Ref 510009261
Wiring loom adjacent to oxygen-filling gauge rubbing
on oxygen fitting. Outer braiding worn through. Two
other aircraft similarly affected. Found during C of A
inspections. TSN: 65 hours/23 cycles.
Beech 200 Main wheel tyre split. Ref 510009381
During daily inspection, main LH inboard tyre splitting
at the shoulder position–tread separation.
P/No: 265F868. TSN: 198 hours/338 landings.
Beech A36 Aileron bracket incorrectly secure.
Ref 510009383 (Photo below)
Pilot reported the aircraft would not stay wings level
with the control column centred. Fault finding found
the LH aileron outboard aileron attachment point
was incorrectly installed. Aircraft had been recently
repainted and that the control surfaces had been
removed and refitted during this process. Personnel/
maintenance error.
Cessna 402C Wing spar cap SUP. Ref 510009393
RH wing main lower spar cap–wrong part fitted at
7796 hrs. Spar cap appears to be a 402B part which is
a lot thinner. Suspected unapproved part. Personnel/
maintenance error.
Cessna 414A Aircraft oxygen system line
corroded. Ref 510009319
Oxygen line located along the LH side of the fuselage
corroded through due to contact with the metal wire
of the air conditioning system scat line. Found during
SIDS inspection.
P/No: 51001095051. TSN: 5,614 hours.
Cessna 441 Nose wheel tyre tube leaking.
Ref 510009303
Nose landing gear tyre pressure low. Investigation
found the tube leaking around a section of the
vulcanised axial seam. P/No: 32246401.
(2 similar occurrences)
Cessna A188B Fuselage stringer cracked.
Ref 510009417
During periodic inspection, the fuselage RH stringer
assembly forward attachment found cracked. Suspect
contributing factors to be continuous ground turning
for agricultural operations and many landing cycles.
P/No: 161200214.
Cessna 172M Aileron cable threaded terminal
failed. Ref 510009411 (Photo below)
During unrelated maintenance behind instrument
panel, the LH aileron cable’s threaded terminal end
was found to have failed. P/No: NAS22835LH.
Diamond DA40 Landing gear leaf springs
corroded. Ref 510009408 (Photo below)
During routine maintenance minor pitting (surface
treatment erosion) was noted to leading edge of
undercarriage leaf springs. A decision to remove
surface treatment revealed major interactive
corrosion between the plating medium and the
surface treatment. There are also striations across
the leaves indicating the possibility of stress
corrosion initiation. P/No: LH–D41321311501
RH–D41321312501R. TSN: 976 hours/36 months.
Piper PA31350 Landing gear electrical system
connector water contamination. Ref 510009278
Landing gear electrical connector located in nose landing
gear bay contaminated with water, causing a short
circuit and preventing main landing gear from extending.
Piper PA31 Landing gear downlock spring &
pivot worn/corroded. Ref 510009279
The microswitch for the gear down and safe light was
not making full contact due to the limited movement
of the spring and downlock. Investigation found
downlock spring and pivot corroded, limiting the spring
movement, and numerous worn bushing and trunnions.
Piper PA36375 Aircraft stabiliser systems
torque tube rusted. Ref 510009313
LH and RH elevator torque tubes corroded (rusted).
P/No: 9805100. TSN: 6,800 hours.
Swearingen SA227DC Engine intake anti-ice
gaskets failed. Ref 510009273
No1 engine intake anti-ice shield gaskets (2off) failed
allowing hot bleed air to leak onto nearby engine fire
detection system thermocouple.
Swearingen SA227DC Engine torque sensor
orifice blocked. Ref 510009455
During a check flight, an intentional engine shutdown
was carried out. During the shutdown it was evident
that the negative torque sensing (NTS) had failed to
activate, and the engine was feathered prior to 30 per
cent RPM/60 seconds. An engine re-start was made
prior to landing, with the same indications of NTS
failure during the re-start. The orifice was removed,
cleaned with compressed air and refitted. NTS ground
check carried out ops normal.
Swearingen SA227DC Passenger door seal
holed. Ref 510009502
Passenger door seal damaged and holed in lower
RH area. Unable to maintain pressurisation. Area is
subject to abrasion from grit and small stones.
P/No: 2724089009. (1 similar occurrence)
ROTORCRAFT
Cessna 208 Trailing edge flap drive coupling
worn. Ref 510009252
Trailing edge flap primary drive coupling failed. P/No:
C3010010211. TSN: 1,538 hours/4,082 landings. TSN:
1,538 hours/4,082 landings/31 months.
Cessna 210M Landing gear support saddle
shock absorbing pad debonded. Ref 510009326
LH main landing gear support saddle shock absorbing
pad debonded and distorted preventing LH main
landing gear downlock from engaging. (1 similar
occurrence)
Cessna 310R Landing gear microswitch
damaged. Ref 510009344
Landing gear down limit microswitch failed. Landing
gear collapsed. P/No: BZ7RT04. TSN: 10,093 hours.
Gulfstream 500S Elevator trim actuator binding.
Ref 510009376
On top of climb pilot noted that the elevator trim had
become difficult to operate. Ground investigation
found that the RH trim actuator was unserviceable.
P/No: 2835YB.
Jabiru J120C Landing gear collapsed.
Ref 510009310
LH main landing gear suspension leg collapsed. Leg
appeared to have delaminated in attachment area.
P/No: 6003093. TSN: 33 hours.
Agusta Westland AW139 Tail boom debonded.
Ref 510009409 (photo below)
During inspection of the tail boom, an area of
debonding in excess of allowable limit for ‘area 3’ was
found on the forward RH upper side, adjacent to a
previous repair carried out following a similar debond.
Debonding is approximately 126mm (4.96in) long by
22mm (0.87in) wide. Found iaw EASA AD 2009-0234-E
R1 Part 1 and BT 139-195 Rev A. P/No: 3G5350A00134.
TSN: 802 hours/1,948 landings. TSN: 802 hours/1,948
landings/24 months. (3 similar occurrences)
35
AIRWORTHINESS
Cessna U206G Cargo door lower sill corroded.
510009363
Cargo door lower sill had evidence of small spots/pin
holes of corrosion. Further investigation found an area
of intergranular corrosion approximately 50.8mm (2in)
square and 1.27mm (0.050in) deep.
P/No: 121165214. TSN: 16,385 hours.
Mooney M20TN Power plant induction tube
cracked. Ref 510009460
Pilot experienced loss of manifold pressure in flight.
Cause of pressure loss traced to a crack in the elbow
joint of the right hand induction tube. The induction tube
has only minor structural support via a baffle between
the turbo charger and the throttle. TSN: 270 hours.
Pull-Out Section
Beech 200 Main wheel tyre split. Ref 510009381
During daily inspection, main LH inboard tyre splitting at
the shoulder position–tread separation. P/No: 265F868.
TSN: 198 hours/338 landings. (5 similar occurrences)
Continental IO520M Engine cylinder piston
broken. Ref 510009384 (photo below)
During maintenance metal was found in filter.
Investigation found No.6 cylinder piston skirt broken
and No.1 cylinder piston skirt cracked. Pistons bore a
‘Made in Italy’ ink stamp when new. Also, the skirts
are shorter by about 5.08mm (0.2in) compared to
the German-manufactured piston of the same part
number. P/No: SA631475. TSN: 732 hours. TSO: 732
hours. (5 similar occurrences)
Bell 206B Main rotor PCL worn. Ref 510009414
PCL lower fork holes were found to be worn out,
causing difficulties with track and balance.
P/No: 206010354005.
Pull-Out Section
Bell 412 Rescue hoist cable tangled. Ref
510009477 (photo below)
Rescue hoist cable tangled on drum. P/No: 42315939.
TSN: 73 cycles. TSO: 2,001 hours.
(1 similar occurrence)
FSA JAN–FEB10
Issue 72
36
MDHC 369F Tail rotor drive shaft coupling
failed. Ref 510009413 (photo below)
Upon landing and reducing throttle input a loud
rattling noise was heard. Investigation found the tail
rotor drive shaft forward flex coupling had failed.
Investigation continuing. P/No: 369D255013.
Eurocopter AS350BA Main rotor control joint
sheared. Ref 510009307
Co-pilot collective control gimbal joint throttle rod
assembly failed due to intergranular cracking in the
case hardening. P/No: 350A27320520.
Continental O200A Engine cylinder valve guide
suspect faulty. Ref 510009343
All inlet valves stuck in valve guides. Caused by
too close a tolerance between valve stem and
valve guide.
Eurocopter AS350B Main rotor mast bearing
lockplate fractured. Ref 510009312
Main rotor mast lower bearing lockplate fractured.
Length of fracture approximately 25mm (1in). P/No:
350A37118322. TSO: 1,349 hours/1,957 cycles.
Eurocopter EC225LP Main rotor head damper
cracked. Ref 510009395 (photo below)
Main rotor head was received with blade dampers
(4off) suffering from excessive cracking in bonded
rubber. Cracks exceeded limitations iaw maintenance
manual.
P/No: 332A31304201.
Robinson R22BETA Main rotor drive belt worn.
Ref 510009452
During servicing, drive belts were discovered worn
down to the sheaves with small cracks on the outside
of joint lines. New belts fitted and aircraft returned to
service. P/No: A1902. TSN: 1,061 hours.
(27 similar occurrences)
Robinson R44 Engine exhaust collector
collapsed. Ref 510009378
During a 100-hourly inspection the LH collector was
found collapsed at joint with muffler. P/No: C1695.
TSN: 894 hours. (15 similar occurrences)
Kawasaki BK117B2 Tail rotor drive shaft
distorted. Ref 510009276 (photos below and top
middle column)
Tail rotor long driveshaft distorted. Forward drive
shaft attachment bracket and rivets loose and
working with one rivet sheared. P/No: 11731521. TSN:
4,768 hours/5,377 cycles/5,377 landings/154 months.
Robinson R44 Main rotor head bearing incorrect
assembly. Ref 510009415
Main rotor hub teeter bearings P/No C648-3 (black
in colour), and blade coning bearings P/No C648-1
(brown in colour), found incorrectly assembled. Four
teeter bearings were installed in blade coning hinge
locations and two blade coning hinge bearings in two
teeter hinge locations.
P/No: C6483. TSN: 1,156 hours. (1 similar occurrence)
PISTON ENGINES
Continental GTSIO520M Engine cylinder
cracked. Ref 510009355
LH engine No1 cylinder cracked in area of spark plug
port. P/No: 655474A8. TSO: 742 hours.
(21 similar occurrences)
Continental IO520L Engine cylinder cracked.
Ref 510009364
During 100-hourly inspection, four cylinders (ECI) were
found cracked through side of cylinder into the intake
port. Following cylinder removal, further inspection
revealed in some cylinders the cracks had started to
crack around the intake valve seat. P/No: AEC631397.
TSN: 1,447 hours. (1 similar occurrence)
Continental TSIO520A Engine cylinder cracked.
Ref 510009388
At a periodic inspection the LH engine’s No.2 and
No. 5 cylinders (ECI) were found cracked. Four other
cylinders have been found cracked in the previous
two periodic inspections–refer to SDR 510009137. All
cracks are in exactly the same location on each of the
six cylinders. P/No: TIST714BCA. TSN: 677 hours.
(21 similar occurrences)
Continental TSIO520A Fuel heater pump
leaking. Ref 510009475
Cabin heater fuel pump failed and leaking. Cabin
fan switch diode A7 failed with terminal breaking
away and short circuiting causing the cabin heater to
operate with the switch in the ‘Off’ position.
P/No: G714769. TSO: 16 hours.
Lycoming IO540K1A5 Engine camshaft worn.
Ref 510009362
Significant metal contamination (a quarter of a
teaspoon) found in the oil filter after 1397.5 hrs total
time in service (TTIS). Upon further investigation,
camshaft found to be wearing on the No 4 cam lobe
and tappet surface. Engine removed from service for
rectification. TSN: 1,398 hours.
(12 similar occurrences)
Lycoming LTIO540J2BD Exhaust turbocharger
turbine sheared. Ref 510009454
During cruise pilot noted deterioration in M.A.P
and accompanying aircraft yaw on RH engine.
Investigation found the turbocharger compressor
impeller and turbine wheel disconnected from each
other–suspect bearing failure initiated shaft failure in
bearing area. P/No: 40678710. TSO: 727 hours.
Garrett TPE33110UF Engine flamed out. Ref
510009360
LH engine flamed out on or just before touchdown.
The engine appeared to shut down normally, but
when taxiing in, flames and smoke were observed
coming out of both intake and exhaust. The crew
fired off both fire bottles to the engine. Engine was
inspected and ground runs could not duplicate the
problem. Aircraft was test flown and released to
service.
P/No: TPE33110UF513H. TSO: 5,956 hours.
Lycoming ALF5071F Engine turbine disc failed.
Ref 510009353
During climb, No 2 engine suffered an in-flight shut
down. On inspection of the engine, approximately
2/3rds of the rear most turbine disc (T4), was
found to be missing. Investigation continuing. TSN:
24,792 hours/13,434cycles/184 months. TSO: 7,000
hours/3,741cycles/29 months.
PWA PW118A Engine fuel filter contaminated.
Ref 510009489
No1 engine high-pressure fuel filter contaminated
with microbiological growth.
PWA PW118 EEC malfunctioned. Ref 510009346
During cruise the left engine abruptly lost power to 40
per cent torque with a loss of T6. Seconds later the
engine returned to the commanded parameters.
EEC replaced. P/No: 3039187.
GE CFM567B Engine fuel filter faulty.
Ref 510009269
RH engine fuel filter bypass light illuminated resulting
in filter replacement.
(8 similar occurrences)
Rolls Royce TRENT97284 HMU malfunctioned.
Ref 510009462
Aircraft arrived with number 1 engine shutdown
due to crew following electronic centralised aircraft
monitor (ECAM) warning ‘ENG 1 CTL SYS FAULT.’
Number 1 electronic engine control (EEC) replaced and
tested serviceable. However, aircraft subsequently
subjected to a rejected take off (RTO) and return to
base (RTB) due to repeat of initial ECAM warning. EEC
replaced again and further inspections undertaken of
variable stator vanes, intermediate pressure turbine
and intermediate pressure compressor. Engine
subsequently failed high power run ground test. Pump
and hydromechanical unit replaced and aircraft tested
serviceable.
GE CFM567B HMU unserviceable.
Ref 510009324
No 2 engine hydro-mechanical unit (HMU) faulty. P/
No: 1853M56P12.
TSN: 14,741 hours/8,507 cycles.
(6 similar occurrences)
GE CT79B Engine failed. Ref 510009302
LH engine failed in flight. Over-temp indication,
chip light and loud ‘pop’ followed by ITT climbing
to 1230 degrees before engine failed (shutdown).
Investigation continuing.
P/No: 6058T82G01. (2 similar occurrences)
IAE V2527A5 Compressor bleed valve retaining
ring missing. Ref 510009391
During take-off, ECAM message displayed, ‘Engine
2 Compressor Vane Fault’. The No 2 engine stalled,
and flames were observed coming from the exhaust
and pilot discharged fire bottle. No 2 engine EGT was
recorded at 740 deg C for 30 seconds. During the
investigation, and whilst lubricating the 2.5 bleed
area, an adrift pin was found belonging to the slave
bleed actuator to 2.5 bleed valve linkage rod end, as
well as the retaining ring which was missing. The EEC
was also replaced.
P/No: MS32152025.
IAE V2527A5 Engine fuel gasket damaged.
Ref 510009486
No1 engine fuel return located at upper pylon
connection leaking. Investigation found the bolts, part
number NAS630309H, securing the fuel return to tank
hose flange were loose. Further investigation found
the gasket, part number 718115-08, damaged and
leaking. P/No: 71811508.
IAE V2527A5 Engine turbine seal cracked.
Ref 510009270
Engine trend monitoring advised of parameter shift
due to possible cracking of the high pressure turbine
second stage air seal. Investigation confirmed the air
seal was cracked in the front snap fillet area. Found
during NDT. Issue being managed iaw SBs 72-0500 &
72-0502. P/No: 2A3596.
PROPELLERS
Hamilton Standard 14SF23 Propeller blade
corroded. Ref 510009470
Light surface corrosion found on seven out of the
eight propeller blades in area of blade shank zone 1.
P/No: SFA13S1POA. TSN: 3,252 hours/612cycles/30
months.
McCauley D3A34C404 Propeller hub cracked.
Ref 510009412 (photo below)
Engine oil leaking at front of engine, and leakage
continued after time expired engine was replaced.
Propeller and back-plate mounting adaptor were
removed and the hub was found cracked. Operator
reports that start of the leak coincided with propeller
overhaul which included hub replacement.
TSO: 657 hours/13 months.
Balloon gas tank deteriorated. Ref 510009488
Balloon 55-litre gas tanks (2off) leaking from weld
seams. Tanks were purchased condition unknown,
and had just completed a 10-year recertification test.
The tanks were then painted and filled. The next day
the owner noticed a smell of gas and the newlyapplied paint bubbling. The bottles were then emptied
and made unusable.
Collins Radio Co CTL62 ADF controller FOD.
Ref 510009347
During the preliminary inspection, and before
commencing repair activity on the ADF controller,
foreign non-metallic material was found adrift inside
the unit, incorrect hardware used to secure transistor
A3Q301 and further FOD (nut, spring washer and flat
washer) stuck to the Humiseal of the rear A5 card.
Personnel/maintenance error.
Kelly Aerospace 4066109020 Turbine disc
incorrect part. Ref 510009314
Turbocharger turbine wheel incorrect part. Wheel is
approximately 7.937mm (0.3125in) smaller in diameter
than correct part number item. Turbine was fitted at
last factory overhaul.
(1 similar occurrence)
McCauley DCF290D7T3 Governor Spring
broken. Ref 510009431 (photo below)
Governor was received into the workshop for
overhaul. After cleaning it was noted there was
excessive backlash between either the drive gear and
idler gear, or between the idler gear and the flyweight
assembly. Stripping the governor revealed that the
flyweight clamping spring had broken in one place.
Refer related similar occurrences–510009430 &
510009432. P/No: B20429. TSO: 1,800 hours.
(3 similar occurrences)
RFD Safety Marine Pty Ltd Life raft (6-person)
relief valve failed. Ref 510009274
Life raft relief valve fractured and broke away from
life raft. P/No: VALV116. (12 similar occurrences)
SAFT America Inc. 23578 Battery cell
discharged. Ref 510009464
During workshop maintenance, near the end of
the final charge cycle before releasing the battery
for service, one cell began self-discharging and
continued to discharge to zero volts in approximately
40 minutes–the battery became quite hot during this
time.
TSN: 2,552 hours/1,588 cycles.
Note: occurrence figures based on data
received over the past five years.
37
AIRWORTHINESS
GE CF680C2 Thrust reverser bolt missing.
Ref 510009323
LH engine thrust reverser inboard reverser upper
latch bracket bolts (3off) missing. Two remaining bolts
loose. Investigation continuing.
COMPONENTS
Pull-Out Section
TURBINE ENGINES
SELECTED SERVICE DIFFICULTY REPORTS
22 October 2009
Part 39-105–Rotorcraft
Beechcraft 1900 Series Aeroplanes
AD/BEECH 1900/3–Wing Fasteners–CANCELLED
AD/BEECH 1900/5–Right Circuit Breaker Wire Bundle
Clamp–CANCELLED
AD/BEECH 1900/30–Electrical Loom Inspection–
CANCELLED
Agusta AB139 and AW139 Series Helicopters
AD/AB139/7 Amdt 1–Tail Boom Assembly
Boeing 737 Series Aeroplanes
AD/B737/360–P5-14 Panel
Bell Helicopter Textron Canada (BHTC) 206 and
Agusta Bell 206 Series Helicopters
AD/BELL 206/179–Main Rotor Pitch Horn Bearing
Boeing 747 Series Aeroplanes
AD/B747/85 Amdt 5–Corrosion Prevention and
Control Program
AD/B747/163 Amdt 4–Fuselage Internal Structure
AD/B747/242 Amdt 1–Trailing Edge Flap H-11 Bolts
AD/B747/388 Amdt 1–Outboard Flap Track and
Transmission Attachment
Part 39-105–Lighter Than Air
Bell Helicopter Textron 412 Series Helicopters
AD/BELL 412/58–Fuselage Left Upper Cap Angle
Eurocopter AS 350 (Ecureuil) Series Helicopters
AD/ECUREUIL/136–Emergency Floatation Gear
Eurocopter EC 120 Series Helicopters
AD/EC 120/19–Emergency Floatation Gear
Hiller UH-12 Series Helicopters
AD/HILLER 12/10–Main Rotor Blades–Inspection and
Modification–CANCELLED
38
Kawasaki BK 117 Series Helicopters
AD/JBK 117/33–Long Drive Shaft Rivets
Issue 72
Pull-Out Section
There are no amendments to Part 39-105–Lighter
than Air this issue
McDonnell Douglas (Hughes) and Kawasaki 369
Series Helicopters
AD/HU 369/85 Amdt 1–Main Rotor Blade Root
Replacement–CANCELLED
FSA JAN–FEB10
Beechcraft 300 Series Aeroplanes
AD/BEECH 300/4–Cabin Door–CANCELLED
Schweizer (Hughes) 269 Series Helicopters
AD/HU 269/14–Battery Support Bracket–Inspection–
CANCELLED
AD/HU 269/16 Amdt 4–Horizontal Stabiliser–
Inspection–CANCELLED
AD/HU 269/18–Tail Boom–Inspection–CANCELLED
Part 39-105–Below 5700 kgs
Airtractor 600 Series Aeroplanes
AD/AT 600/4 Amdt 4–Engine Mount
Consolidated Aeronautics, Colonial and LA-4
Series Aeroplanes
AD/LA-4/8–Fuel Cell Capacity and Security
Inspection–CANCELLED
GAF N22 and N24 Series Aeroplanes
AD/GAF-N22/69 Amdt 6–Ailerons
Pitts S-1 and S-2 Series Aeroplanes
AD/PITTS S-2/6 Amdt 1–Upper Wing Front Spar to
Cabane Fitting–Inspection–CANCELLED
Part 39-105–Above 5700 kgs
Airbus Industrie A330 Series Aeroplanes
AD/A330/108–Thales Pitot Probes
Airtractor 800 Series Aeroplanes
AD/AT 800/9 Amdt 4–Engine Mount
AD/AT 800/12–Rudder-Aileron Interconnect
Cable Shield
Avions de Transport Regional ATR 42 Series
Aeroplanes
AD/ATR 42/27–Multi Purpose Computer with Aircraft
Performance Monitoring Function
Boeing 767 Series Aeroplanes
AD/B767/10–Main Landing Gear Shock Strut–
CANCELLED
AD/B767/11–Main Landing Gear Drag Brace Upper
Spindle–CANCELLED
AD/B767/42–Fuel Tank Access Doors–CANCELLED
AD/B767/64–Fire Protection–Detection–Smoke
Detector Inspection–CANCELLED
AD/B767/155–P37 Panel–Electrical Wire Bundle
Inspection and Protection–CANCELLED
AD/B767/193 Amdt 1–P37 Panel–Electrical Wire
Bundles
Bombardier (Canadair) CL-600 (Challenger)
Series Aeroplanes
AD/CL-600/10–Autopilot Duplex Servo–Installation
of Protective Cover–CANCELLED
AD/CL-600/11–Stick Pusher–Inspection and
Modification–CANCELLED
AD/CL-600/13 Amdt 1–Brake Control Push-Pull
Cable–CANCELLED
AD/CL-600/14–Engine Pylon Fuel Feed Tube
Assembly–Modification–CANCELLED
AD/CL-600/17–Flight Controls–Elevator Cable
Inspection–CANCELLED
AD/CL-600/119 Amdt 1–Power Control Unit Rod
Centering Mechanism
AD/CL-600/120–Angle of Attack Transducer
British Aerospace BAe 146 Series Aeroplanes
AD/BAe 146/137 Amdt 1–Nose Landing
GearApproved Airworthiness Directives AL 11/2009,
22 October 2009
Dornier 328 Series Aeroplanes
AD/DO 328/71 Amdt 1–Wing Lower Inner Panel
Embraer ERJ-190 Series Aeroplanes
AD/ERJ-190/23–Deployment Failure–Escape Slide
Fokker F27 Series Aeroplanes
AD/F27/10–VHF Antennae–Reposition–CANCELLED
AD/F27/21–Aileron Control Wheel–Inspection of
Washers–CANCELLED
AD/F27/26–RPM Control System–Gustlock
Interference System–Improvement–CANCELLED
AD/F27/27–RPM Indicator–Dial Markings–
CANCELLED
AD/F27/31–Ducting in Air Conditioning
Compartment–Support Bracket–Introduction–
CANCELLED
AD/F27/34–Pitot Static System–Modification–
CANCELLED
AD/F27/38–ADF Sense Antenna–Modification–
CANCELLED
AD/F27/46–Autopilot Servo Rod–CANCELLED
AD/F27/62 Amdt 2–Godfrey Engine Driven Cabin
Supercharger Drive Quill Shaft–Modification–
CANCELLED
AD/F27/66–Engine Breather RIP Overheat Detectors–
Modification–CANCELLED
AD/F27/70–Main Pneumatic Line–Modification–
CANCELLED
AD/F27/88–Emergency Light–Modification–
CANCELLED
AD/F27/93–Nose Gear Down Lock Latch–Inspection–
CANCELLED
AD/F27/99–Passenger Door Outboard Lettering–
Emergency Operating Instructions Changed–
CANCELLED
AD/F27/103 Amdt 8–Structural Limitations
AD/F27/104 Amdt 1–Main Undercarriage Drag
Stay–Inspection–CANCELLED
AD/F27/106–Elevator: Inboard Trim Tab Hinge Bracket
and Control Bracket–Inspection–CANCELLED
Fokker F28 Series Aeroplanes
AD/F28/92–Landing gear–Brake Quick Disconnect
Couplings–CANCELLED
Fokker F100 (F28 Mk 100) Series Aeroplanes
AD/F100/96–Landing Gear–Brake Quick Disconnect
Couplings
Part 39-106–Piston Engines
Thielert Piston Engines
AD/THIELERT/11 Amdt 3–Propeller Control Valve
Part 39-106–Turbine Engines
AlliedSignal (Garrett/AiResearch) Turbine
Engines–TPE 331 Series
AD/TPE 331/64–First Stage Turbine Disc
Pratt and Whitney Turbine Engines–PW4000
Series
AD/PW4000/11 Amdt 1–LCF Items–Mandatory
Inspections
AD/PW4000/14–Low Pressure Turbine Disks
Rolls Royce Turbine Engines–RB211 Series
AD/RB211/42–Front Combustion Liner Head Section
Turbomeca Turbine Engines–Arriel Series
AD/ARRIEL/35–HP/LP Pump Metering Unit–Low
Pressure Fuel Pump Impeller Drive
Part 39-107–Equipment
There are no amendments to Part 39-107–Equipment
this issue
Eurocopter BK 117 Series Helicopters
AD/GBK 117/6 Amdt 6–Main Rotor Blade
Part 39-105–Lighter Than Air
Eurocopter EC 135 Series Helicopters
AD/EC 135/21 Amdt 2–Rear Structure / Tail Boom
There are no amendments to Part 39-105–Lighter
than Air this issue
Part 39-105–Rotorcraft
Bell Helicopter Textron 205 Series Helicopters
AD/BELL 205/2–Tail Rotor Yoke–Inspection–
CANCELLED
AD/BELL 205/17–Hydraulic Fluid Temperature
Indicators–Installation–CANCELLED
AD/BELL 205/19 Amdt 1–Transmission Support
Case–Inspection–CANCELLED
AD/BELL 205/32–Main Beam Cap–Inspection and
Repair–CANCELLED
AD/BELL 205/43–Engine Air Inlet Screen–Inspection–
CANCELLED
AD/BELL 205/44–Cyclic Control Cylinder Assembly–
Inspection of Piston Rods–CANCELLED
Bell Helicopter Textron 212 Series Helicopters
AD/BELL 212/28 Amdt 2–Vertical Fin Forward
Spar–CANCELLED
AD/BELL 212/51–Fin To Tail Boom Junction–
CANCELLED
AD/BELL 212/56–Tailboom Doubler–CANCELLED
Bell Helicopter Textron Canada (BHTC) 407
Series Helicopters
AD/BELL 407/32 Amdt 1–Cyclic Control Lever
Assembly Installation
Bell Helicopter Textron 412 Series Helicopters
AD/BELL 412/11–Main Rotor Yoke, P/N
412-010-101-123–Inspection–CANCELLED
AD/BELL 412/19–Emergency DC Bus Number One
Feeder Circuit–CANCELLED
AD/BELL 412/20–Bolts P/N AN4-5A–Pylon
Support–CANCELLED
AD/BELL 412/21–Fuel Cell Interconnect Tube–
CANCELLED
AD/BELL 412/24–Main Rotor Pitch Link to Pitch Horn
Bolt–CANCELLED
AD/BELL 412/25–Main Rotor Flight Control System
Bolts–CANCELLED
AD/BELL 412/26–Bogus Pressure Gauge Emergency
Floats P/N 212-073-905-1–CANCELLED
AD/BELL 412/31–Fin to Tail Boom Junction–
CANCELLED
AD/BELL 412/35–Tail Boom Doubler and Fin Spar
Caps–CANCELLED
Bell Helicopter Textron 427 Series Helicopters
AD/BELL 427/12–Cyclic Control Lever Assembly
Installation
Part 39-105–Below 5700 kgs
Beechcraft 55, 58 and 95-55 (Baron) Series
Aeroplanes
AD/BEECH 55/57–Fuselage Bulkheads FS 257.6 & FS
271.92–CANCELLED
Beechcraft 56TC (Turbo Baron) Series
Aeroplanes
AD/BEECH 56/19–Fuselage Bulkheads FS 257.6 and
FS 271.92–CANCELLED
Beechcraft 95 (Travelair) Series Aeroplanes
AD/BEECH 95/21–Fuselage Bulkheads FS 257.6 & FS
271.92–CANCELLED
Part 39-105–Above 5700 kgs
Airbus Industrie A319, A320 and A321 Series
Aeroplanes
AD/A320/6–Engine/APU Fire Control Panel–
CANCELLED
AD/A320/10–Standby Pitot Line–CANCELLED
Airbus Industrie A330 Series Aeroplanes
AD/A330/32 Amdt 4–Main Landing Gear Retraction
Actuator Piston Rod
AD/A330/109–Pitot Probe Quick-Disconnect Union
Boeing 727 Series Aeroplanes
AD/B727/219–Auxiliary Fuel Tanks
AD/B727/220–Vertical Stabiliser Kickload Beam
Shear Tie and Web Post
Boeing 737 Series Aeroplanes
AD/B737/354 Amdt 1–Fwd Cargo Compartment
Frames and Frame Reinforcements
AD/B737/361–Rudder Feel and Centering Unit
Boeing 747 Series Aeroplanes
AD/B747/80–Equipment Cooling System E30 Cooling
Rack Orifice–CANCELLED
AD/B747/397–Fuselage Section 41 Frames
Boeing 767 Series Aeroplanes
AD/B767/253–Fuel Tanks Ignition Source Prevention
AD/B767/254–Door Mounted Escape Slides and Slide
Rafts
Bombardier (Boeing Canada/De Havilland)
DHC-8 Series Aeroplanes
AD/DHC-8/5 Amdt 1–Fire Bottle Explosive Squib
Wiring–CANCELLED
AD/DHC-8/13–Landing Gear Control System–
CANCELLED
AD/DHC-8/120 Amdt 1–Power Transfer Unit
Overspeed
AD/DHC-8/152–Series 400 Door Stops
Bombardier (Canadair) CL-600 (Challenger)
Series Aeroplanes
AD/CL-600/2–Elevator Inboard Hinge Fitting–
Inspection and Replacement–CANCELLED
AD/CL-600/4–Auxiliary Power Unit Load Control
Valve–Special Check and Adjustment–CANCELLED
Cessna 550 (Citation II) Series Aeroplanes
AD/CESSNA 550/3–Cabin Door Frame–Inspection,
Modification and Replacement–CANCELLED
AD/CESSNA 550/4 Amdt 1–Main Gear Actuator to
Strut Attach Stud–Inspection–CANCELLED
AD/CESSNA 550/5–Elevator and Rudder Trim
System–Inspection–CANCELLED
AD/CESSNA 550/6 Amdt 2–Tailcone Skin and Vertical
Fin Spar Interference–CANCELLED
AD/CESSNA 550/7–Anti-Skid Control Box–
Modification–CANCELLED
AD/CESSNA 550/8–Nitrogen Bottle Installation–
Inspection–CANCELLED
AD/CESSNA 550/11–TKS Proportioning Unit
Connections–CANCELLED
AD/CESSNA 550/12–Elevator Trim Take-Off Range
Marker–CANCELLED
AD/CESSNA 550/13–Bleed Air Check Valve–
CANCELLED
AD/CESSNA 550/17 Amdt 1–Fuel Flow Transmitters–
CANCELLED
AD/CESSNA 550/18–Brake Shuttle Valve–
CANCELLED
Dornier 328 Series Aeroplanes
AD/DO 328/74–Engine Controls–Power Lever Control
Box
Fokker F27 Series Aeroplanes
AD/F27/56 Amdt 1–Rudder Trim Tab–Inspection–
CANCELLED
Part 39-106–Piston Engines
Porsche Piston Engines
AD/PORSCHE/1–Camshaft Oil Feed Pipes–
CANCELLED
Teledyne Continental Motors Piston Engines
AD/CON/90 Amdt 1–EQ3 Cylinders–Inspection for
Cracks
Part 39-106–Turbine Engines
Pratt and Whitney Turbine Engines–JT8D
Series
AD/JT8D/43–Front Compressor Hub
Part 39-107–Equipment
Propellers–Variable Pitch–Dowty Rotol
AD/PR/1–Pitch Lock Cylinder–Modification–
CANCELLED
AD/PR/8–Hub Driving Centre–Modification–
CANCELLED
AD/PR/13–Pitch Lock Assembly–Modification–
CANCELLED
AD/PR/17–Hub Driving Centre Flange–Inspection–
CANCELLED
AD/PR/21–Hub Assembly–Inspection of Blade
Sockets–CANCELLED
Propellers–Variable Pitch–McCauley
AD/PMC/52–Propeller Blade Erosion–CANCELLED
AD/PMC/53–Cracked Propeller Blades
39
AIRWORTHINESS
Bell Helicopter Textron Canada (BHTC) 206 and
Agusta Bell 206 Series Helicopters
AD/BELL 206/100–Main Rotor Blade Retaining Nuts
P/N 206-011-119-1–CANCELLED
AD/BELL 206/101 Amdt 1–Tail Boom to Gearbox
Attachment–CANCELLED
AD/BELL 206/103–Tension/Torsion Strap Fitting–
CANCELLED
AD/BELL 206/119 Amdt 1–Main Rotor Flight Control
System Bolts–CANCELLED
AD/BELL 206/176 Amdt 1–Cyclic Control Lever
Assembly Installation
Kawasaki BK 117 Series Helicopters
AD/JBK 117/34–Rescue Hoist Assembly
AD/CL-600/9–Junction Box No.2–Vertical Navigation
and Glide Slope Relay–Modification–CANCELLED
AD/CL-600/30–Time Limits and Maintenance
Checks–CANCELLED
AD/CL-600/121–Stick Pusher Capstan Shaft
AD/CL-600/122–Thrust Reverser Transcowl Assembly
Pull-Out Section
19 November 2009
Continued from page 32
Set out any action that has been taken,
or that is proposed to be taken
• to rectify the defect; or
• to prevent the defect from recurring, and
Pull-Out Section
set out what the person making the
report thinks is the cause of the defect. FSA JAN–FEB10
Issue 72
40
Upon enquiry we usually find that all the
proper corrective and preventive actions
have been undertaken, but all too often this
information is completely missing in the
report. Again, brevity is good.
Also note the words ‘thinks’ is the cause of
the defect in the extract from the regulation
above. That means, simply offer an informed
opinion on what you think the cause of the
problem most likely (or very obviously) is,
according to the evidence and any other
‘causal factors’ you have observed.
Show me the numbers. The regulations also
require as part of submitting the defect
report, that the aircraft, propeller and engine
or component details be provided. Although
getting the time in service, model, part and
serial numbers may be tedious and difficult,
all this information becomes very useful when
assessing a defect report, and especially when
it turns out to be one of a series of defect
reports from across Australia on the same
aircraft, system or component.
A word on attachments. As they say, a
picture is worth a thousand words, and
the developments in digital photography
and document scanning now provide a
very effective way of adding valuable detail
when attached to the SDR. A few hints
on photography: if possible, zoom in on
the defect area, ensure that the area is in
focus, and the background is contrasting
and not cluttered. Capture the image at a
good resolution – you can do this by setting
the camera on a ‘large-fine’ .jpeg setting,
which should then give a reasonable file
size. Although please note that the SDR
online system can only accept images up
to 2MB. Email images greater than 2MB to
sdr@casa.gov.au quoting the receipt number
of the report.
Service Difficulty Reports
TO REPORT URGENT DEFECTS
CALL: 131
757
FAX:
02 6217 1920
or contact your local CASA Airworthiness Inspector [freepost]
Service Difficulty Reports, Reply Paid 2005, CASA, Canberra, ACT 2601
Online: www. casa.gov.au/airworth/sdr
WIN tools of your choice, to the value of $1000,
courtesy of
Competition outline
The winning reports will be those which are judged as being the most accurate and comprehensive.
To enter the competition, simply submit your SDR via the CASA website. Visit http://casa.gov.au/airworth/sdr/index.htm
and click on the ‘SDR and SUP online form’.
Fill out the form noting carefully that you have provided all the required information above. In the description field of
the SDR enter the word ‘FSA competition’ to be in the running to win.
Remember to fill in the submitter’s details so that we can contact you if verification of any detail is required.
A valid entry MUST
Be submitted online.
Be received on or before the closing date of 09 April 2010.
NOT be from employees, associated agencies or families of CASA or Snap-on Industrial
Additionally
Include some pictures of your example to illustrate the defect finding.
(Pictures and movies can be attached after submitting the SDR, but note files are limited to 2MB for each attachment.)
Points may be awarded for good pictures.
There is no limit to the number of times a participant can enter, but each entry must relate to a separate defect.
CASA reserves the right to verify and investigate information submitted via the SDR system.
The winner will be judged by a panel of CASA Airworthiness experts and their decision will be final.
The best entries will be published in the May-June 2010 issue of Flight Safety with any pictures and description of
aircraft, owner’s or operator’s details removed for privacy reasons.
41
AIRWORTHINESS
or one of 3 pairs of Ray-Ban aviator sunglasses for runners-up.
Pull-Out Section
Competition
Pull-Out Section
NINE easy
easy steps
steps to
to lodge
lodge your
your SDR
SDR online
online
NINE
FSA JAN–FEB10
Issue 72
42
1
2
Go to the CASA website: www.casa.gov.au
To get started, click on the underlined words ‘SDR
and SUP online form’ which are at the top of the
‘Service Difficulty Reports’ page.
4
Select SDR type from the drop down box, the form
will refresh with the applicable sections open for
you to complete.
Required information is marked with an asterisk. Fill
in any other pertinent information by opening the
applicable section and entering details.
This can be done before you select ‘SDR and SUP
Online Form’.
Note: The form description box has a maximum character
limit of 4000 characters - approximately 56 lines. You can
include additional information as an attachment.
5
The ‘occurrence’ and ‘causal factor’ fields are not
required data, but filling in one or more of these will
help us to assess your report.
Initial notification of defect (additional information can
be provided at a later date, i.e. ‘follow-up’ report), or
Note: If ‘Follow-up’ is selected, a tick box field will
appear titled, ‘Follow-up report from an earlier defect
notification’. Click and enter the defect receipt number
of your ‘initial’ report.
7
8
Click ‘Submit’: you will be prompted if any of the
required fields are not complete, i.e. the applicable
field(s) will be coloured and/or a ‘red’ text message
will be displayed
You will be given a receipt number and the opportunity to
attach photos, movies or other supporting documents.
(You can make multiple attachments, but the size of each
must not exceed 2Mb. Files in excess of 2MB can be
emailed to sdr@casa.gov.au)
Note: Record your receipt number, date of occurrence
and submitter’s name for future reference.
Tip for composing your description
So that you don’t waste time on the web, and
give yourself time to research and compose your
description, you can create a temporary MS Word
document, enter your description and then copy/
paste to the SDR description box.
Selection of defect report type:
Follow-up notification (with additional investigation
results).
Go to the QUICK LINKS ‘Information about:’ dropdown menu on the right of the home page, and select
‘Service Difficulty Reports’—it’s the last option in
the list which appears when you click on the dropdown menu. This takes you directly to the SDR page.
3
!
6
9
Finish procedure or submit another defect - there are
three options to continue data entry:
return to a cleared input screen,
return to the input screen with your previously entered
data retained, or
enter a receipt number, including the defect report’s
date of occurrence and submitter’s name, exactly as
shown for that defect report’s receipt number.
If you need further information please refer to the help page, simply click
on the SDR help link at the top right of the SDR page.
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To download a free demo version, go to www.aeroengaus.com.au
Working Together
Aeronautical Engineers Australia P: 1300 232 000 E: eloading@aeroengaus.com.au
43
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’
Articles should be between 450 and 1,400 words. If preferred, your identity will be kept confidential. Please do not submit articles regarding
events that are the subject of a current official investigation. Submissions may be edited for clarity, length and reader focus.
ADVERTISING
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Write to us about an aviation
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ENGIN
E
FSA JAN–FEB10
Issue 72
44
nded to fly the
te
in
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in
rn
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r
la
to
On this particu
irport to Lismore
a
a
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. The aircraft was
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a
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couple of weeks b
Eric Aubort describes an aborted flight
I paid special attention to the daily check, looking for possible airframe damage and fuel
contamination. I also removed the top engine cowl to inspect the engine and the possible
presence of a bird nest. Apart from a little water contamination in the fuel tanks and glass bowl
in front of the firewall, everything appeared to be fine.
I called the tower, taxied the aircraft to the run-up bay, did my pre take-off checks, ran up the
engine to full throttle and checked the magnetos, carburettor heat and mixture control. There
was nothing I could detect which would have brought my attention to an imminent engine
failure.
I received a line-up then a take-off clearance, opened full throttle, and rotated and trimmed
the aircraft to climbing attitude. After lift off while abeam the control tower and just as I was
retracting the flaps, the engine stopped dead abruptly.
My immediate reaction was to lower the nose of the aircraft, apply full flaps and call the tower
with the words, ‘Engine failure!! Landing straight ahead.’
Though I did not give my call sign, the controller replied, ‘Clear to land’. I thought, ‘Man…do I
have a choice?’
As I was gliding towards the end of the runway
with the propeller still rotating, I quickly
glanced at the engine instruments. The tacho
was showing about 800rpm and the engine
oil pressure was normal. The fuel selector was
on both tanks.
I touched down normally and brought the
aircraft to a stop some 20m from the end
of the runway. At that point the propeller
stopped turning.
The controller then asked if I needed some
assistance. ‘Standby, I’ll see if I can restart the
engine,’ I replied. To my surprise, the engine
fired first go and ran sweetly.
I was embarrassed. I couldn’t understand why
the engine had stopped. I called the controller
again for a taxi clearance to the run up bay and
advise my intentions after the engine run check.
The run up was satisfactory as before
departure. I felt even more embarrassed and
for a moment, my thinking started to drift
into fantasy land.
Thankfully, I followed my engineer’s instinct.
As I was taxiing back to the hangar, I put my
thinking cap on and retraced the events from the
beginning. Inlet air blockage? Fuel starvation? I
dismissed the first one as unlikely.
As for fuel starvation, that was quite possible;
but why did the engine restart and run well after
landing? Furthermore, fuel starvation with an
engine fitted with a carburettor would normally
have given me some warning signs. I would have
expected to notice a change of engine noise
simultaneously with a slight rise in engine rpm,
followed by splutters due to an increasingly lean
mixture and finally engine stoppage. All this
would have been in a matter of two or three
seconds. But not this time - the engine stopped
dead in a fraction of a second.
By that time I was back at the hangar, so I
gave up the guessing work and started a
physical investigation. I removed the engine
cowls, and still convinced that this incident
had something to do with fuel starvation, I
removed the air filter and found what the fuss
was all about.
This particular engine installation has a scat
hose connecting the rear cylinders baffle to
the shroud around the exhaust muffler and
from there another scat hose attached at the
back of the carburettor heater box.
Presumably during the heavy rain, the frog
decided to shelter, entered the engine bay,
hopped along the baffle, dropped into the scat
hose, slid past the walls between the shroud
and the muffler, continued down the next scat
hose and ended in the heater box behind the
air valve which was in the cold position. With
nowhere else to go, it dehydrated and died.
45
Then when I cycled the air valve during the
engine run up, from cold to hot and cold
again, the frog moved forward and became
trapped between the air valve and the filter.
During takeoff the airflow inside the box,
compounded with ram air, was enough to
lift the frog and lodge it under the primary
venturi, instantly cutting the fuel supply and
causing the abrupt engine failure.
Why did the engine restart after landing and
not during the glide?
Remember that the propeller was still
windmilling and with the throttle wide open
the negative pressure above the blocked
venturi was enough to hold the frog. After
landing, the propeller stopped rotating and the
frog fell back in the airbox where I found it.
The other ‘what if’ question was, what would
have happen if I had closed the throttle during
the gliding descent?
It’s likely that the frog would have dropped
in the airbox and the engine would have
restarted with the incident repeating itself at
a location where I would not have been able
to land safely.
The next day, I mailed an incident report
to my aircraft surveyor in Bankstown and
included the frog in a padded envelope, just
to make sure he believed my story.
“apply
full flaps
and call the
tower with
the words,
‘Engine
failure!!
Landing
straight
ahead.”
ENGINE CROAKS
My pilot inner voice was telling me, ‘With all
this wet weather, the engine got a cold. It was
just a bad cough! Have another go,’ followed
by my engineer voice, ‘Don’t you dare fly this
aircraft again. This engine quit for a reason.
Find the cause!’
Lying in the bottom of the carburettor
heater box was a dead frog, shrunk through
dehydration, but still in one piece. While I had
figured out that a simple frog was the culprit,
the next part of the investigation was to
determine exactly how the frog managed to
enter the heater box, and why it had stopped
the engine.
by Doug Evans
FSA JAN–FEB10
Issue 72
46
Just because you haven’t heard of something
doesn’t necessarily prove that it doesn’t exist.
I was flying a pretty slick Mooney from
Sydney to Dubbo in western NSW to catch up
with some of our flight service mates working
at the old Dubbo flight service unit. With my
passenger and I both being from the Sydney
flight service unit (FSU), we were current with
all aviation matters and enjoyed our great jobs
talking daily on Australia’s air/ground radios
- both domestic and international. We were
also pilot briefing specialists, so we knew it
all, so we thought - from briefing pilots, to
watching after them in our profession, to
piloting aircraft ourselves.
Anticipating a fun night with the Dubbo
boys, along with a few drinks I suppose, I
commenced a descent from 8,500ft into
Dubbo on this gorgeous CAVOK day.
Some hot Mooneys can absolutely bolt
downhill and nearly embarrass some twins,
so I proudly boasted our racing DME ground
speed and distance to my old mate working
the radios at Dubbo FSU. Lots of joking banter
ensued while other pilots probably queried
this sudden familiarity of private in-house
jokes and non-reg chatter. ‘And received
information India,’ I added. Dubbo replied
with ‘Be advised: the visibility may be reduced
in locusts.’
‘Huh? What did he say? Is he serious?’ I
turned to my co-pilot, another aviation expert
like me. ‘Did he say locusts?’
‘Yes, sounded like it,’ he agreed.
‘Never heard of that,’ I announced, as if that
was the final verdict in the case.
My sage F/O laughed, ‘Me neither. Didn’t
get any NOTAMs about that, hey! Paul’s just
joking. Forget it.’
Daring pronouncements indeed considering
neither of us had ever flown west of the
Blue Mountains, but exercising caution, we
scanned downwards and spied no brown
blanket of flying insects anywhere; only the
lovely sweeping vista of farms comprising
Dubbo’s wheat and cattle grazing belt on the
vast NSW western plains. Nor could we see a
single cloud in the clear blue sky from here
to the endless horizon. CAVOK was surely
named after flying weather like this.
With Dubbo aerodrome fast approaching, I
asked our mate Paul to repeat his remarks. In
sombre tones more suited to an undertaker,
he repeated his locust warning.
Entering the circuit, my dubious flight service
co-pilot glanced down as we joined downwind
for runway 23 at Dubbo. ‘Bull. It looks
completely clear to me. Never heard of this
No w I w
N
ow I waass
!
e
d
u
!
t
ow th e lowes t sa
affee aallttiitude
IFR aanndd 9990ft
9 b elo w
locust stuff. They’ll all have a big laugh at the club tonight. You know
what Paul’s like.’
I did, and agreed competely. Paul was often full of wild tales. Somewhat
like us, perhaps.
At 10ft off the ground and about to flare out, we were suddenly hit
with thousands of machine gun bullets. Well, that’s what it seemed
like. Instantly, the windscreen perspex turned dark brown, then dark
yellow, then black. My visibility was zero. I can assure you it’s no fun to
lose all visibility at this height in a micro-second. At altitude it might be
okay, but here I faced something I’d never imagined and was suitably
stunned; this was red-hot, imminent danger. Now I was IFR and 990ft
below the lowest safe altitude!
I firewalled a dramatic engine roaring go-around after muttering a few
biblical phrases, terrified of the ground so close but now unseen, and
rose above the wall of locusts in seconds. Escaping disaster, we were
soon at 1,500 feet where the view was so grand it seemed we could
again see right to the Indian Ocean. But only out the side windows, not
the front. Our grand entrance to Dubbo was now a scene from a horror
movie, the smirks on our faces duly wiped.
Hundreds of suicidal insects had bespattered our windscreen. Now from
the little I could see, the Mooney’s entire front end appeared splashed
with the blood and guts of recently-departed locusts. Had they blocked
our air intake? Damaged the propeller? Affected the Mooney’s ram
air system - the door of which I had forgotten to close? Or clogged the
undercarriage? I circled west of Dubbo airport, nervously entering a
sort-of holding pattern I now called ‘nightmare’, while we two famous
aviators failed to see the humorous side of this. ‘Damn it, you can’t see
them looking straight down,’ I pleaded to no-one.
Luckily I found I could squint through a small
gap at the side of my perspex windscreen and
could just – barely – see ahead, and we landed
after a while when the locust swarm had
indeed moved away from the airfield. But we
were soon assaulted again in the parking area
as returning dark squadrons of marauding
insects launched their second invasion. As
we exited the aircraft they seemed bent on
revenge for their recently deceased brothers,
engulfing us as we ran for shelter.
Later I showed our locust-besmeared plane to
an unsympathetic local cropduster pilot who
said, ‘So what? Some farmers are losing their
whole crops.’
That night there were laughs aplenty at my
pathetic excuse, as I tried to explain to our
group that I’d never heard of these locust
plagues. ‘We don’t have them in Sydney,’
‘captain know-it-all’ assured them.
Our smiling mate Paul replied: ‘Doesn’t mean
they don’t exist.’
47
PLAGUED
I turned a left base then final, trying to slow down the slippery Mooney
while extending the gear and flaps. At 500ft the visibility was perfect
on this glorious afternoon, no breath of wind fluttered into the limp
windsock. ‘Flaps 40, three greens, on centreline for two-three, can see
entire runway. Let’s land. What locusts?’
‘I told ya about the locusts,’ laughed Paul over
the radio after all the guys in the FSU had
enjoyed watching our exciting go-round. For a
professional radio operator I was speechless as
I checked the engine instruments, then gulped
at the blackened wings’ leading edges. ‘There’s
a plague of ‘em here today. Just arrived,’ Dubbo
FS merrily added, ‘But they might move away
from the field after a while.’
n in A common topic am
Wheu
ong pilots
bt expe
o
do up
speak
Name withheld by reques t
FSA JAN–FEB10
Issue 72
48
f my
rience lev
el (approa
ching a co
licence) w
mmercial
a s t h e s ub
je
c
t of an en
failure af t
gine
er takeof f
in a light
common lo
single. Th
r e w as t h
e
a t y ou s h o
more than
uld turn n
o
30° and la
nd straigh
Never, ev
t ahead.
er, tr y and
turn back
the field.
to
old commercial
l handling’ section of the
I was well into the ‘genera
find out a little
10 hours where you could
licence syllabus. You had
ls. Short field
ane and your own flying skil
bit more about your aeropl
lly whatever your
fs, some aerobatics, basica
landings, short field takeof
Gra ham (name
benefit. For one exercise,
instructor felt would be of
practise forced
and
a
are
g
out to the trainin
changed) sug gested we go
t we could go
odrome. The logic was tha
landings into a disused aer
approach to a
AGL , as we were ma king an
lower than the usual 500ft
more accurate
exercise would give me a far
runway and therefore the
was dirt, quite
e ‘made it’ or not. The strip
feel for whether I would hav
nded by open
treed area otherwise surrou
short and in a moderately
them. Another
e had a rea l outfield feel to
paddocks. Approaches her
was asked if he’d
the school that day and he
commercial student was at
Cherokee that
hp
140
old
us set off in an
like to join us. The three of
ks.
OW with partially fuelled tan
would have been close to MT
continue until he
my instructor told me to
On the second approach
I felt pretty
ed the little Cherokee in, and
told me to go around. I glid
s obvious,
wa
It
approached the treetops.
pleased with myself as we
made the
e
hav
landing, the aircraft would
had this been a rea l forced
crossed
we
as
t
in the available distance. Jus
field and been able to land
with
ely
saf
y
awa
around and we climbed
the fence he told me to go
AGL
ft
400
ut
abo
Cherokee could muster. At
the little excess power the
trol.
con
d
ishe
nqu
and I automatically reli
Gra ham said, ‘Ta king over’
tch
Wa
?
now
t
righ
at if your engine quit
He then simply stated: ‘Wh
ep
ste
a
into
bird
back to idle and flung the
this.’ He pulled the power
‘it wasn’t
even a
matter of
whether
or not
we’d
clear
the
canopy,
we were
going
straight
through
it’
49
WHEN IN DOUBT
e years later
rsed we never spoke of it again. Som
turn to the left. We hadn’t even trave
ll airline, I
sma
a
that the flying as a first officer with
60° of arc when it became obvious
had the
who
one
and we met Graham’s friend, the
rate of descent had become alarming
story.
the
him
and told
more. successful turnaround,
weren’t going to be able to turn any
aft
aircr
the
me that
power He was aghast. He told
Graham slammed the throttle to full
mini
of
sort
e
was som
t the that he had been in
and levelled the wings and at that poin
and could virtually fit
tiny
was
It
r.
race
n
pylo
n of a
nose was aimed straight for the crow
ge room. He said that he’d
er of in someone’s loun
tree. In my mind, it wasn’t even a matt
29 direction at Bank stown
as far taken off in the
whether or not we’d clear the canopy,
ne had quit when he had nothing
through and the engi
as I could see, we were going straight
but the heav y treeline which
the in front of him
it. With moments to spare, Graham lifted
river. He did a U-turn out of sheer
left the followed the
right wing and as we banked to the
and got away with it in this tiny,
the desperation
canopy slipped underneath us. By now
, high performance aircraft, but was
side of very light
stall warning light was flashing on my
by the boys in the control tower that
shook later told
aft
aircr
le
who
the
and
d,
shiel
glare
the
all hit the floor convinced that he
hard they had
hand
his
kept
am
Grah
t.
buffe
stall
with
g to come through the glass. I think
ugh was goin
thro
it
push
to
if
as
lever
ttle
thro
on the
managed to put in on a taxiway, but he
as that he
er,
pow
more
for
it
ng
had
willi
and
the dash
ted, only just. He emphasised that he
and insis
turn
left
the
in
er
ve
furth
belie
sank
dn’t
aft
coul
the aircr
extremely lucky, and
ock been
padd
a
into
ops
an
treet
in
it
the
late
w
belo
emu
dropped
that his old friend had tried to
sed by
full of cattle. Once again, I sat mesmeri
ancient, underpowered Cherokee.
,
again
–
tion
situa
the
of
ality
unre
the seeming
ent?
make it What is there to learn from this incid
I had no doubt about whether we’d
turn
and
try
r
neve
to
s
orce
reinf
going to Firstly, it
or not. It was obvious that we were
ld have
coaxed back at low altitude. Secondly, I shou
am
Grah
But
ock.
crash in this padd
he’d
nt
insta
the
r
ucto
instr
my
d
airflow questione
her through the stall buffet, and as the
de.
altitu
low
our
given
er
pow
the
the stall pulled back
slowly smoothed over the wings and
er and
Perhaps I should have gone furth
.
light went out, we gently climbed away
think
can
I
CFI.
the
to
ent
incid
the
reported
, and
base
read
to
I’ve
back
t
that
rts
fligh
t
repo
silen
ent
y
accid
prett
n
a
It was
of half a doze
Back
ing.
r
noth
othe
said
the
r
that
enge
on
pass
mpti
seat
assu
rearour
where the
aircraft
at the school, he leaped out of the
pilot or pilots knew what they were
ched
laun
and
k,
wrec
ing
burn
a
was
as if it
doing shouldn’t have been made.
s.
etive
expl
l
erica
hyst
near
of
g
into a strin
that in any multissed It all reinforces the point
He never returned. Graham and I discu
an instr uctor and
it’s
if
engine pilot situation, even
the incident. His friend had had an
the right, but
have
you
to land trainee, not only do
failure after takeoff and turned back
your
ice
than also the obligation, to vo
successfully at the aerodrome from less
same. concerns.
500f t. He thought that he could do the
or to
He asked me not to report the incident,
more
aps
Perh
r.
ucto
instr
tell the chief flying
am had
fool me, but I didn’t. However, Grah
re, and
befo
this
like
never done anything
and
skills
his
d
ecte
up to this incident, I resp
and
go
it
let
to
ed
professionalism. I decid
FSA JAN–FEB10
Issue 72
50
Knowledge
GAAP
Before this incident, I had a number
of flying days over six months with
the organisation, and I thought I knew
the GAAP procedures well. We were
flying a PA28 Warrior, a type that I
had flown most of my PPL navigation
training, my night VFR training, and
a fair amount of private flying in.
On the day of incident, I was tasked with joy
flights as part of a flying day. My first flight
of the day was to take three passengers on a
standard local sightseeing flight, expected to
last around 30 minutes.
The take-off and en-route phases of the flight
were normal. On the way back to the airport I
reported inbound at the usual GAAP reporting
point. It was a weekend, so there was a fair
amount of traffic inbound and in the circuit
area. I was advised to maintain an altitude of
1500ft AGL and join ‘upwind’. Overhead the
airfield I was instructed to ‘follow’ another
aircraft. That aircraft was already on midfield
crosswind, and about to turn downwind.
The procedures for this airport required a
sequencing instruction to be received before
descending to circuit altitude. However, as I
had been instructed to maintain 1500ft AGL,
Sud
Name
withheld by
request
ly there wa
‘thduenm
a
p, thusm
p...
I as unsure whether I had the required approval to descend to circuit
height. This was because most of my previous GAAP experience was at
another airport, which didn’t have that requirement for a sequencing
instruction before descending.
I maintained my altitude at 1500ft AGL and immediately turned
crosswind to follow the direction of the other aircraft. At the same
time I queried the tower as to whether I was cleared to descend to
circuit height. However, by the time I had clarified the situation and
commenced my descent, I was almost at the base turning point.
On final I was high and fast; however I continued the approach. I
floated and landed long due to my excess speed and then braked hard
to catch the taxiway mid-way along the bitumen runway, as missing
that one would have meant a long taxi back to the parking area. I
thought I had got away with it until I commenced the right-hand turnoff to the taxiway. Suddenly there was a ‘thump, thump, thump’ noise.
The starboard main tyre had gone flat, and the noise was from the tyre
trying to rotate inside the spat. As I was concerned about damaging
the aircraft by attempting to taxi any further, I advised the tower of my
predicament (as I was still on the runway). The tower sent the aircraft
behind me around, diverted remaining circuit traffic onto the other
runway and advised me to shut down while help was summoned.
Braking so hard, I locked the brakes, and effectively flat-spotted a tyre
which had less than perfect tread and pressure. I then induced the
puncture when making the sharp turn off the runway. As I stood on the
runway next to the aircraft as it was about to be moved, I was horrified
to see the long skid-mark that led to the aircraft. The problems started
further back however, with my incomplete knowledge of procedures
which kept me high, my persistence with an approach that was fast
and long, and finally, my self- imposed desire to catch a taxiway to
ensure operational efficiency.
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
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Multi-Engine Command Instrument Rating Course
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Training on Beechcraft Baron
Includes GNSS RNAV
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51
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The Australian
ATSB stakeholder
comments invited in
response to the
Minister’s Statement of
Expectations
On 6 October 2009, the Minister
for Infrastructure, Transport,
Regional Development and
Local Government, the
Hon Anthony Albanese MP, provided me with his
Statement of Expectations for the ATSB. I have
undertaken to respond by early February 2010. My
response will be in the form of a Statement of Intent,
outlining how the Commission intends to give effect to the
Minister’s expectations.
The Minister’s expectations of the ATSB include that we:
• beanactiveandeffectiveparticipantinthetransport
policy and regulatory framework, working effectively
with industry and other agencies while retaining its
operational independence
• providehighqualitytransportsafetyinvestigationand
research into transport accidents and incidents
• continuetogiveprioritytotransportsafety
investigations that have the potential to deliver the
best safety outcomes for the travelling public
• provideoccasionalassistancetoaccident
investigations in other countries, in accordance with
international protocols
• preparetomeettheCouncilofAustralian
Governments’ commitment for it to be the preferred
investigator of rail accidents
• haveparticularregardtobuildingstrengthened
working relationships with CASA and AMSA.
The full Statement of Expectations is available on the
ATSB website, at <www.atsb.gov.au/about_atsb/
corporate/ministers-statement-of-expectations.aspx>
In addition to the formal consultative processes already
underway, I would welcome any other stakeholder’s
views on the Statement of Expectations, and suggestions
on possible strategies we could consider to achieve these
objectives.
Comments should be sent to <atsbinfo@atsb.gov.au>
by 31 January 2010.
Martin Dolan
Chief Commissioner
Threats and errors in aerial work
and low capacity operations
T
hreat and error management (TEM) is
a method flight crew can use to
identify and mitigate the threats
and errors they encounter during
flight. A TEM ‘train-the-trainer’
course for the general aviation and
low capacity air transport sectors
was run by the Guild of Air Pilots
and Air Navigators (GAPAN) in
November 2007. The ATSB
surveyed the participants of this
course to investigate the sources
of threats and errors faced by those
pilots. This report describes the common
perceived threats and errors as well as threat
and error mitigation strategies that pilots are
encouraged to familiarise themselves with.
For pilots involved in aerial work (who were mostly represented by
pilots in flying training) and low capacity air transport operations, the
most common perceived external threats included adverse weather,
traffic congestion, operational pressure, Air Traffic Control (ATC)
communications issues, maintenance events and malfunctions. Some
ways pilots can mitigate these threats are included in the report. The
most common threat internal to the flight deck was the lack of pilot skill,
knowledge or experience, closely followed by pilot fatigue.
The symptoms and effects of fatigue on performance, such as poor shortterm memory and degradation in communication, are well documented.
Pilots are advised to assess whether they are fit to fly before conducting a
flight as part of their threat management strategy. The report also offers
some suggestions on how pilots can avoid being fatigued in the first place.
It is important that pilots are aware of these common threats that exist in
their flying category, and that they plan countermeasures for them as part
of their pre-flight routine. This pre-flight assessment and planning may
reduce workload during flight if these threats materialise during flight.
Common errors identified included checklist errors, communications
from ATC and other aircraft, non-compliance with standard operating
procedures, and planning errors. The report presents some error reduction
strategies for each of these errors. For example, to avoid checklist errors,
pilots should confirm each item visually and by touching/pointing, and
verbally announcing switch positions. To mitigate planning errors, pilots
should always provide a pre-flight briefing. Even if it is a solo flight, the
pilot should go through each briefing item as he or she would with another
pilot. ■
Aviation Safety Investigator
The dangers of wave turbulence
A
At the time, special weather
reports for severe turbulence
and severe mountain waves
were current for that area.
Wind speeds on the ground
were reported to be 50 kts.
Calculations made using the recorded
radar data and forecast wind showed that
the aircraft had been in cruise flight at
speeds probably greater than its published
manoeuvring speed, prior to disappearing
from radar.
The air traffic controller declared
a distress phase after a number of
unsuccessful attempts to contact the
pilot. At 2003, the Operations Director at
Melbourne Centre declared the aircraft as
probably lost and advised the Australian
search and rescue agency. A search
was begun using a helicopter and an
aeroplane, in addition to ground search
parties. No emergency locator transmitter
signal was reported. At 2147, wreckage
was located by a searching aircraft amidst
the timbered ranges near Clonbinane,
approximately 50 km north of Melbourne.
At about 2200, a ground search party
confirmed that the wreckage was that of
YJB and that there were no survivors. The
aircraft had been seriously damaged by
excessive in-flight aerodynamic forces and
impact with the terrain. It had descended
almost vertically through the tree canopy.
The wreckage and its distribution pattern
were consistent with an in-flight breakup
during cruise flight, with the aircraft
being subjected to rapid and extreme
aerodynamic forces during normal
cruise flight at 7,000 ft. Examination of
the damage to the structure revealed no
evidence of any pre-existing defect, such
as metal fatigue or corrosion. The wing
structure failed in negative overstress. The
symmetrical nature of that failure was
indicative of a breakup in straight flight,
consistent with the radar data, rather than
during a turn or a spiral descent. That
type of failure of the aircraft’s structure
can be explained by either the rapid onset
of an extremely powerful downward gust,
or by forward elevator control application
by the pilot (possibly in response to a
sudden nose-up pitching movement), or a
combination of both.
The investigation found that some
pilots operating the aircraft type are
generally unaware of the applicability
of the aircraft’s manoeuvring speed
during flight through turbulence, despite
the inclusion of relevant
advisory information in the
Operator’s documentation.
There is also a concern
that pilots generally
may not be exercising
as much caution in
forecast severe turbulence
conditions as they would
for thunderstorms, even
though the intensity of the
turbulence can be similar.
As a result of this
investigation, the
Australian Transport
Safety Bureau reissued
the publication Mountain
Wave Turbulence (available for download
at www.atsb.gov.au), and distributed the
investigation report to all Australian
operators of the Aero Commander
aircraft. A safety advisory notice was also
issued to aircraft operators and pilots,
encouraging operators to review their
procedures and to ensure awareness of
the implications of the combination of
aircraft weights and speed, and of the
ambient conditions; in particular, when
flying in, or near areas of forecast severe
turbulence. ■
ATSB investigation report AO-2007-029 released
on 9 November 2009 is avaliable on the website.
53
ATSB
t 1946 Eastern Standard Time, on
31 July 2007, a Rockwell International Aero Commander 500-S,
registered VH-YJB, departed Essendon
Airport, Vic. on a business flight to
Shepparton, carrying the pilot and one
passenger. The flight was conducted at
night under the instrument flight rules,
and the pilot was familiar with the route,
the terrain and the seasonal
meteorological conditions.
At 1958, while in the cruise
at 7,000 ft above mean sea
level in Class C controlled
airspace, radar and radio
contact with the aircraft
was lost when it was about
46 km north-north-east of
Essendon.
Investigation briefs
FSA JAN–FEB10
Issue 72
54
Fuel planning
Tail rotor pitch link failure
Agricultural spraying
ATSB Investigation AO-2009-022
ATSB Investigation AO-2008-068
ATSB Preliminary Investigation AO-2009-060
On 21 May 2009, the pilot of a Piper
PA 31 Navajo, registered VH-WAL, was
conducting a return flight under the
instrument flight rules from Albury, NSW
to Canberra, ACT with one passenger on
board.
On 19 September 2008, during a flight
from Fitzroy Falls to Rosehill, NSW, the
pilot of a Eurocopter AS350 BA helicopter,
registered VH-BUK, experienced the
onset of severe vibration within the tail
rotor controls and made an emergency
landing at Casula High School.
The ATSB has released the preliminary
factual report into a fatal accident that
took place near Wickepin, WA. The
information contained in the preliminary
report is derived from initial investigation
of the occurrence.
Before leaving Canberra, the pilot had
used a computerised flight-planning
program to plan and submit the flight
plan, but did not use the associated
fuel-planning section in the program to
calculate the required fuel uplift. The pilot
checked the aircraft’s fuel records and
gauges, and ascertained that the aircraft
had what he considered to be more than
sufficient fuel, including reserves. The
flight to Albury took less time than
anticipated because of a 25 kt tailwind,
therefore, the aircraft consumed less fuel
during that flight.
Before leaving Albury, the pilot checked
the remaining fuel using the aircraft’s
fuel gauge and fuel calibration card,
and determined that the aircraft had
160 L of fuel remaining. He performed a
mental calculation to ascertain the fuel
required for the flight, but stated that he
inadvertently used the lower fuel flow
figures for the multi-engine Duchess
aircraft that he normally flew, instead
of the figures actually required for the
Navajo.
Approximately halfway through the
flight, the pilot became concerned about
the quantity of fuel remaining and
subsequently conducted a precautionary
landing 50 km south-west of Canberra.
There was no reported damage to the
aircraft or injuries to the occupants.
The aircraft operator has advised the
ATSB that, as a result of this occurrence,
it has implemented a requirement for all
of its pilots to use a documented fuel plan
in all circumstances when flying from one
location to another. ■
Examination of the aircraft revealed that a
tail rotor pitch change link had fractured,
resulting in lateral movement of the tail
rotor and damage to the tail boom and
tail cone. The link had fractured from
fatigue cracking – the result of excessive
play in the heavily-worn spherical
bearing.
Excessive play in the bearing resulted in a
loading condition that originated a high
cycle fatigue crack at one of the outside
corners of the rod end and progressed
through a majority of the section before
failure. A second fatigue crack then
originated on the interior surface of the
rod end and progressed a short distance
before the remaining material failed
through overstress. Endurance test results
provided by the aircraft manufacturer
found that it was probable the bearing
degradation was relatively advanced in
the broken link at the time of the most
recent ‘after last flight’ inspection. The
reason that play was not identified in the
subject link during this inspection was
not determined.
As a result of this incident, the aircraft
manufacturer released Safety Information
Notice 2000-S-65, to highlight the tail
rotor pitch link inspection and
maintenance requirements. CASA
released Airworthiness Bulletins 27-009
Issue 2 (AS 350) and AWB 27-010 Issue 1
(AS 355 and AS 550) to emphasise
inspection requirements relating to the
tail rotor pitch change links and the
importance of frequently checking for
link wear. ■
At about 1130 WST on 3 October 2009,
the pilot of an Air Tractor Inc. AT-502
aircraft, registered VH-ODP, departed
from a paddock on a property about 5 km
north-east of Wickepin, WA to conduct
agricultural spraying operations. A short
time later, the owner of the property
discovered the wreckage of the aircraft,
which had impacted the ground fatally
injuring the pilot.
Debris from the aircraft’s spray boom,
and a substantial number of tree
branches, were found at the base of a
23 m high tree that was located at the
corner of one of the fields that were
intended for spraying. The tree was
significantly taller than the other trees
that ran along the western boundary of
the field. There was extensive damage to
the leading edges of the aircraft’s wings,
consistent with the damage observed to
the tree canopy.
The aircraft impacted the ground about
150 m north of the tree, in an inverted,
steep nose-down attitude and slid
inverted for about 50 m, before coming to
rest. Numerous items of aircraft wreckage
were distributed along the wreckage trail.
The investigation is continuing. ■
QF72 ADIRU spikes
Risk of unanticipated yaw
ATSB Investigation AO-2008-070
ATSB Investigation AO-2008-043
The ATSB has released a second Interim
Factual Report into the Qantas Airbus
A330-303 in-flight upset, 154 km west
of Learmonth, WA, on 7 October 2008.
The aircraft (registered VH-QPA) was
being operated on a scheduled passenger
service (QF72) from Singapore to Perth.
While cruising at 37,000 ft, the aircraft
experienced two uncommanded pitchdown events. The flight crew were able
to quickly return the aircraft to level
flight on each occasion and diverted to
Learmonth for a safe landing.
At 1026 EST on 18 June 2008, a Robinson
Helicopter Company R44 Clipper II
helicopter, registered VH-RYW, departed
Cairns Airport, Qld, to film a residential
development site that was located in the
vicinity of False Cape, about 10 km east
of the airport. On board the helicopter
were the pilot and three passengers.
There has been speculation of a potential
link between the QF72 accident with the
AF447 accident that occurred on 1 June
2009 on a flight from Rio de Janeiro,
Brazil to Paris, France. Although each
of the accidents involved the same basic
aircraft type, there are several important
differences between the two accidents:
The occupants of the helicopter reported
that while conducting the second period
of filming, there was a sudden and violent
movement of the nose of the helicopter
to the right, which continued into a
rapid rotation of the helicopter. The
pilot’s reported attempt to reduce the
rate of right yaw was unsuccessful, and
he entered autorotation and attempted
to reach a clear area. The helicopter
subsequently collided with trees before
impacting the ground, seriously injuring
the pilot and front seat passenger.
• The(airdatainertialreferenceunits)
ADIRUs on the two aircraft were
different models, and constructed by
different manufacturers.
New investigation team
• Theairspeedsensors(pitotprobes)on
the two aircraft were different models
made by different manufacturers.
Despite extensive testing and analysis,
the reason why the ADIRU started
providing erroneous data (spikes) during
the flight has not been identified to
date. Nevertheless, the crew operational
procedures that were provided by Airbus
significantly reduced the chance of
another in-flight upset by limiting the
time that a faulty ADIRU could output
angle of attack spikes. Airbus is also
modifying the flight control primary
computer software used in the A330/A340
fleets to prevent angle of attack spikes
leading to an in-flight upset.
The investigation is continuing. ■
The investigation also identified that
the lack of the nomination of a search
and rescue or scheduled reporting time
for the flight, decreased the likelihood
of a timely response in the case of an
emergency.
In response to this accident, the
helicopter manufacturer advised that
it was considering a revision to the
aerial survey and photography flights
safety notice that was contained in the
R44 Pilot’s Operating Handbook. That
revision would, if adopted, include a
discussion of the risk of unanticipated
right yaw associated with the conduct of
those flights. ■
The ATSB receives around 15,000 notifications of aviation occurrences each year, 8,000 of
which are accidents, serious incidents and incidents. It is from the information provided in
these notifications that the ATSB makes a decision on whether or not to investigate. While
some further information is sought in some cases to assist in making those decisions,
resource constraints dictate that a significant amount of professional judgement needs to
be exercised.
There are times when more detailed information about the circumstances of the
occurrence would have allowed the ATSB to make a more informed decision both
aboutwhethertoinvestigateatalland,ifso,whatnecessaryresourceswererequired
(investigation level). In addition, further publically available information on accidents
and serious incidents would increase safety awareness in the industry and enable
improved research activities and analysis of safety trends, leading to more targeted safety
education.
To enable this, the Chief Commissioner is establishing a small team to manage and process
short factual investigations, the Level 5 Investigation Team.
The primary objective of the team will be to undertake limited-scope factual gathering
investigations, which result in a short summary report. The summary report will be
a compilation of the information the ATSB has gathered, sourced from individuals
or organisations involved in the occurrences, on the circumstances surrounding the
occurrence and what safety action may have been taken or identified as a result of the
occurrence. These reports will be collated and released publically on a periodic basis.
The implementation of these new ‘short’ investigations will start at the end of 2009, but it
will take 6 to 12 months before this new practice is adopted for all accidents and serious
incidents, as resources within the ATSB are built up to perform the function. If you have
anyquestionsorcommentsaboutthisinitiative,pleasecontacttheATSB’s
Director Safety Data, Research and Technical, Julian Walsh on 02 6274 7548 or by email to
julian.walsh@atsb.gov.au ■
55
ATSB
• Thecockpit-effectmessagesand
maintenance fault messages from both
flights showed a significantly different
pattern of events. For example, a
series of maintenance messages that
were transmitted by AF447 prior to
the accident showed inconsistencies
between the measured airspeeds and
the associated consequences on other
aircraft systems. No such messages
were recorded by QF72.
This accident highlighted the risk of
loss of tail rotor effectiveness associated
with the conduct of aerial filming/
photography and other similar flights
involving high power, low forward
airspeed and the action of adverse airflow
on a helicopter.
REPCON briefs
Australia’s voluntary confidential aviation reporting scheme
REPCON is established under the Air
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,
either the reporter or any person referred
to in the report, the personal information
will remain confidential. If you believe it
would be necessary to act on information
about an individual referred to in your
report then you should consider reporting
this directly to CASA. Only de-identified
information will be used for safety action.
FSA JAN–FEB10
Issue 72
56
To avoid doubt, the following matters are
not reportable safety concerns and are not
guaranteed confidentiality:
(a) matters showing a serious and
imminent threat to a person’s health
or life;
(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 Regulations
2003 < www.atsb.gov.au>.
Note 2: Submission of a report known by the
reporter to be false or misleading is an offence
under section 137.1 of the Criminal Code.
REPCON would like to hear from you if
you have experienced a ‘close call’ and
think others may benefit from the lessons
you have learnt. These reports can serve
as a powerful reminder that, despite
the best of intentions, well-trained and
well-meaning people are still capable of
making mistakes. The stories arising from
these reports may serve to reinforce the
message that we must remain vigilant to
ensure the ongoing safety of ourselves and
others.
If you wish to obtain advice or further
information, please call REPCON on
1800 020 505.
Helicopter hot refuelling
R200900034
Report narrative:
The reporter expressed safety concerns
that pilot training should include training
in dangerous goods after witnessing a
helicopter pilot refuelling a helicopter
while the engine was still operating. The
reporter believes that pilots would gain a
better respect for the possibility of static
discharge if they were more aware of the
dangers of fuel that is taught in dangerous
goods courses.
REPCON comment:
REPCON supplied the Civil Aviation
Safety Authority (CASA) with the deidentified report and CASA provided the
following response:
In respect of the comments made about
pilot training we note the Day VFR [Visual
Flight Rule] Syllabus for a Commercial
Pilot (Helicopter) Licence includes flight
standards for managing fuel. The observation does not relate to a dangerous goods
issue.
The regulations make provision for the
refuelling of helicopters with the engines
running in certain circumstances.
The serving of alcohol beverages
in-flight
R200900050
Report narrative:
The reporter expressed safety concerns
about the serving of alcohol beverages
in-flight to passengers. Policy offered by
airlines is not explicit in helping crew
manage this issue e.g. one manual states
‘Not to serve alcohol to any passenger to
the point of intoxication’. The policy or
procedures do not prevent intoxication.
In the event of an emergency situation
or evacuation, an intoxicated passenger
would be a risk to themselves and to other
passengers and crew. A passenger cannot
enter an aircraft in an intoxicated state as
this is prohibited by legislation, but can be
served alcohol to the point of intoxication.
The reporter has observed that each
individual has a different point of
intoxication based on their genetic
makeup. When the cabin crew observe
that a passenger has reached or is
approaching their intoxication point
and the passenger is refused any more
alcoholic drinks, this is where problems
have been seen to arise and some
passengers have become disruptive,
abusive and violent.
The reporter is aware of three incidents
where cabin crew have been assaulted,
and on at least one occasion, where
police were required to intervene when
the aircraft was safely on the ground.
The reporter believes that one in five
Darwin flights have issues relating to the
consumption of alcohol by passengers.
Responsible serving of alcohol is open for
interpretation, resulting in crew making
up their own policies and procedures
due to the absence of anything else
that prevents intoxication. Passengers
often do not show signs of intoxication
at the time of request or delivery. The
reporter believes that there needs to be
set procedures that set out exactly how
many drinks a passenger may be provided
in a set time frame to avoid intoxication
becoming an issue.
REPCON comment:
REPCON supplied CASA with the deidentified report and CASA provided the
following response:
The current Australian aviation safety
legislation addresses concerns related to
intoxicated persons entering and on board
aircraft. Regulation 256 of the Civil Aviation
Regulations 1988 (CAR) provides that ‘[a]
person shall not, while in a state of intoxication, enter any aircraft.’ It is an offence for a
person to do so (penalty: 5 penalty units =
$550).
There is nothing in the civil aviation
legislation governing the service of
alcohol to persons on board an aircraft, or
expressly prohibiting a person from being
or becoming intoxicated after he or she
is already on board an aircraft. However,
CAR 256AA does address the problematic conduct of persons who are or may
be intoxicated, making it an offence for a
person ‘to behave in an offensive and
disorderly manner’ (penalty: 50 penalty
units = $5,500).
Where the conduct of any person (including
a person who is or may be intoxicated)
involves action that (i) interferes with a
crew member of an aircraft in the course
of the performance of his or her duties as
such a crew member; or (ii) threatens the
safety of an aircraft or of persons on board
an aircraft’, this may constitute an offence
under section 24 of the Civil Aviation Act
1988, for which a person may be imprisoned
for up to 2 years.
Having particular regard to the provisions
of CAR 256 and CAR 256AA, as well as
section 24 of the Civil Aviation Act, CAR
309 provides that the pilot in command
of an aircraft, with such assistance as is
necessary and reasonable, may:
• takesuchaction,includingtheremoval
of a person from an aircraft or the
placing of a person under restraint or in
custody, by force, as the pilot considers
reasonably necessary to ensure compliance with the Act or the Regulations, in
or in relation to the aircraft; and
• detainpassengers(orcrewmembers)
for such period as the pilot considers
reasonably necessary to ensure compliance with the Act or the Regulations, on
the same basis.
R200900073
Report narrative:
The reporter expressed safety concerns
that after receiving pushback clearance
from surface movement control (SMC)
and with the aircraft beacon switched on,
a ground crew member approached the
aircraft and opened the forward cargo
door. The crew contacted the person on
the headset to stop this from happening,
but a response was received that ‘nothing
could be done nowadays’.
REPCON comment:
REPCON supplied the operator with the
de-identified report and the operator
advised that it had found some similar
occurrences in its database. A safety
investigation was conducted for each
occurrence, identifying causal factor/s,
and specific safety action was introduced
for each occurrence. The operator also
advised that the statement about ‘nothing
could be done nowadays’ in the report
was not true, but have accepted the report
as a safety indicator, and will strive
even more to improve the safety culture
within ground handling operations. The
operator indicated that it is introducing a
National Training System program which
will provide human factors training to
ground operations staff and this should
be beneficial in reducing these types of
occurrences.
A new form has been released that will make the reporting
processeasierandquickertosubmityoursafetyconcern
to the ATSB.
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,
POBox600,CivicSquareACT2608
Total 2007
117
Total 2008
121
First Quarter 2009
41
Second Quarter 2009
28
Third Quarter 2009
21
October/November 2009
24
What happens to my report?
For Your Information issued
Total 2007
58
Total 2008
99
First Quarter 2009
42
Second Quarter 2009
20
Third Quarter 2009
39
October/November 2009
18
Alert Bulletins issued
Total 2007
1
Total 2008
12
Year to date 2009 #
57
0
Who is reporting to REPCON?
#
Aircraft maintenance personnel
25%
Air Traffic controller
4%
Cabin crew
3%
Facilities maintenance personnel
/ground crew
REPCON supplied CASA with the deidentified report and a version of the
operator’s response. CASA advised that
it had reviewed the REPCON report and
CASA was satisfied with the response
New REPCON Confidential Reporting Form
How can I report to REPCON?
REPCON reports received
1%
Flight crew
35%
Passengers
7%
Others*
ATSB
CASA conducts audits and other surveillance activities to ensure that aircraft
operators have procedures and systems that
are consistent with the legislative provisions mentioned above. However due to
the de-identified version of the REPCON
report, CASA is unable to comment on the
particular circumstances described by the
reporter.
from the operator. CASA advised that
the operator investigated the matter, took
appropriate action and has demonstrated
its commitment to promoting a positive
safety culture within the organisation
through human factors training.
Aircraft pushback procedures
25%
# 29 January 2007 to 30 November 2009
* examples include residents, property owners, general
public
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FSA JAN–FEB10
Issue 72
58
A cheap
accident for
Qantas
Flight Safety writer, Macarthur Job, looks at an almost fifty-year-old
accident which was a wake-up call for Qantas of the day.
The decade of the 1960s did not begin well for Australia’s Governmentowned airlines—at that time Qantas and Trans Australia Airlines
(TAA). On the evening of 10 June 1960, TAA suffered its first and only
fatal accident when its Fokker F-27 Friendship, VH-TFB, the first of the
type to enter TAA service a little over a year before, flew into the sea
off Mackay in darkness after holding in the area for more than an hour
waiting for fog to clear from the airport. All 29 occupants, including
nine schoolboys returning home from Rockhampton for holidays,
were killed. With Australian National Airway’s Amana accident in June
1950, it equalled Australia’s worst airline fatality.
Only 10 weeks later, on 25 August, Qantas, the company least
expected to encounter operational problems—still riding the wave of
public euphoria that its bold introduction of Boeing 707 jets to the
Pacific service had created a few months previously—also suffered a
major blow, this time overseas.
That very same day, the Minister for Civil Aviation, Senator Shane
Paltridge, rose to his feet in Federal Parliament to table Qantas’ 195960 Annual Report, noting that Qantas had flown 148 million miles
since 1948 without a major accident or a fatality. (On 23 March that
year, the Qantas-operated, but British registered Avro Lancastrian:
G-AGLX disappeared over the Indian Ocean while flying between
Colombo and Cocos Island. Five crew members and five passengers
were lost with the aircraft. No trace of it was ever found - see footnote).
WAR TIME ACCIDENT
The art and science of air safety investigation has moved somewhat
since that time. When Senior Aeronautical Engineer in the Department
of Civil Aviation, J.L. Watkins (in years to come Director of Engineering
for TAA), arrived from Melbourne to examine the wreckage of the
wooden aircraft, he was aghast to learn that it had been deliberately
burnt. Queensland’s Senior DCA Aircraft Inspector explained: ‘We
didn’t know you were coming. But you wouldn’t have got anything out
of it anyway -- it was smashed to matchwood!’
All was not entirely lost, however. VH-USE’s fin, intact except for where
it had been torn from its fittings, was found lying where it fell about
Super Constellation
Southern Wave
departs
Just a matter of hours before, Senator
Paltridge was extolling Qantas’ splendid
safety record to his assembled listeners in
Canberra on 25 August 1960, the company’s
Lockheed 1049 Super Constellation, VH-EAC
Southern Wave, was preparing to depart from
Plaisance Airport, Mauritius, for Cocos Island,
on the regular fortnightly service between
Johannesburg and Sydney.
Under the command of Captain E W Ditton,
a former British Commonwealth Pacific
Airlines pilot, and carrying a crew of 12 and
38 passengers, VH-EAC was scheduled to
take off at 5.30pm local time. Light rain was
falling as company staff completed their final
preparation shortly before the passengers
went aboard.
The flight crew started the engines when all
was ready and, at 5.42pm, 23 minutes before
sunset, the aircraft taxied away from the
terminal to the threshold of Runway 13, the
airport’s only runway adequate for the Super
Constellation’s take-off at its all up weight
of 133,000 pounds. The wind was from 110
degrees at 10 to 15 knots, and the temperature
20 degrees C.
After the lengthy run up and pre-takeoff
check customary for Super Constellations,
the captain, in the left-hand seat, began
the takeoff, opening the throttles steadily
to 35 inches of manifold pressure, at the
same time steering with the nose-wheel as
the aircraft accelerated. Following normal
take-off procedure, the flight engineer then
took over the duplicated throttles on his
panel, increasing the power to 57 inches.
The airspeed was rising through 112 knots
but, just as the captain was anticipating the
first officer’s V1 call at 115 knots, the flight
engineer unexpectedly called, ‘Failure No 3!’
59
A CHEAP ACCIDENT
Qantas nevertheless had good reason to be proud of its safety record.
Despite extensive overseas operations since the end of the war, this
mysterious loss occurred a full eight years after the only multi-engined
airline accident the company had previously sustained. Early on the
morning of 20 February 1942, the elderly four-engined De Havilland 86
biplane, VH-USE, left Brisbane’s Archerfield Airport on a scheduled service
to Charleville and Cloncurry. One of several DH 86s Qantas ordered back in
1934 to operate the Brisbane-Singapore section of the air route to London in
conjunction with Britain’s Imperial Airways, VH-USE carried a crew of two
and seven wartime priority passengers. The weather was poor, with rain,
low cloud and bad visibility. Only minutes after the lights of the departing
DH 86 were lost to view at Archerfield, it plunged out of control from heavy
cloud, crashing to destruction amongst trees on the slopes of Mt Petrie on
the outskirts of Brisbane. All on board were killed instantly.
a kilometre away from the crash site. Clearly,
it had become detached from the fuselage
in the air, evidently under a very heavy side
load, suggesting that the aircraft could have
encountered control difficulties while flying in
heavy turbulence.
Immediately the captain pulled off the power, braked hard, and pulled
the reverse thrust levers up and back. The flight engineer meanwhile
feathered the No 3 propeller and pulled the engine’s emergency shutoff valve. Sensing the runway was slippery from the rain and that
the aircraft did not seem to be decelerating as it should, the captain
applied maximum reverse thrust and full braking.
Skidding from side to side as it slowed, but still travelling at about
40 knots, the Super Constellation overran off the end of the runway,
ploughed its way through the grassed overrun, bounced jarringly over
a low embankment, and plunged nose-first into a three metre deep
rocky gully, coming to a violent stop about 100 metres beyond the end
of the concrete.
Though all on board were badly shaken, no one was hurt in the impact;
but through the cabin windows, the wings could be seen to be ablaze
almost throughout their span on either side. The captain at once shouted
‘all out’, and the flight crew ran back into the cabin to help the stewards
evacuate the passengers. Some of the exit doors were jammed, children
were hysterical, and for a time bedlam seemed to reign.
FSA JAN–FEB10
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60
Those who left the burning aircraft through the forward emergency
exit and loading door had to jump eight feet down on to rocks. Those
who went out the rear main door, had not only to jump, but to run
through scrub the aircraft had set on fire. The captain and the first
officer were the last out, leaping from the forward door after they had
ensured no one was left on board.
Meanwhile, the tower controller who had cleared VH-EAC for take-off,
seeing the Super Constellation was in trouble, had alerted the airport’s
four fire-fighting tenders and they were racing to the scene.
Mauritius-based Qantas staff — company
representative J L B Cowan, a former Qantas
flight navigator, and ground engineers DJ
Kennedy and R P Barrett— who were watching
the take-off from a balcony on the terminal
building, heard the scream of reverse thrust,
and saw the aircraft sliding off the end of the
runway. Dashing down the stairs to their car,
they saw a pall of thick black smoke rising
from where the aircraft seemed to have
disappeared.
Speeding down the runway, they passed
some of the airport fire engines on their
way, arriving at the burning aircraft only
three minutes after the crash. On the ground
beneath the rear fuselage they found some
of the crew struggling to lift an overweight
woman passenger clear of the flames. She
had broken her ankle when she fell from the
cabin door.
While Cowen assisted them to move her
away, Kennedy and Barrett courageously
climbed into the aircraft through the open
rear emergency exit. Running the length of
the smoke-filled fuselage, they made a final
check of the first class and tourist cabins to
see that no passenger had been left behind.
With flames already licking in through the
starboard emergency exit, and an ominous
rumbling developing, Kennedy called to
Barrett that it was ‘time to go’. They left the
way they had come.
to
wreckage. Note the damage
Two views of the fire-gutted
the
in
d
ture
rup
the fuel tanks
the wings, set on fire when
y.
gull
y
rock
final impact in the
The cause of it all
: VH-EAC’s No 3 en
gine being salvage
wreckage. Both pro
d from the
peller and engine
were relatively un
been feathered pro
damaged, having
mptly by the flight
engineer after the
failure occurred.
when an engine failure was called shortly
before V1 speed, there was insufficient
runway left in which to stop. A delay on
the part of the flight engineer in calling the
engine failure after the partial loss of power
had contributed to the accident, as had the
captain’s delay in immediately applying full
braking and full reverse thrust. These factors
pointed to inadequacies in both training and
operating procedures on the part of Qantas.
The instantaneous wing fire apparently began
when the port wing tip tank burst on impact.
Fuel pouring on the rocky ground from other
ruptured wing tanks immediately spread and
intensified the blaze.
the crew of Lockheed Super
Skid marks left on Mauritius’ Runway 13 as
nt the aircra ft over-r unning
Constellation VH-EAC tried desperately to preve
burnt out wreck age can be
the slippery concrete. The triple tail fins of the
Lockheed plunged.
seen protruding from the gully into which the
As a result, the 5000 gallons of high octane fuel on board were
ultimately to prove too much for the fire tenders and, except for the
tail section, the Super Constellation burnt to destruction. Even so, the
fire service’s extremely prompt response in temporarily preventing
the fire from engulfing the fuselage undoubtedly contributed to the
escape of all the passengers and crew.
The passengers were brought to the end of the runway, and all but
one put on board a coach and driven to a hotel. The exception was
the woman who had broken her ankle. She was taken to hospital and
later underwent surgery. A six-year-old child who had fractured an
arm, and a number of passengers suffering from burns, abrasions and
bruises, were treated at the hotel by the local Red Cross.
Spared what could so easily have been appallingly tragic consequences
by a frighteningly slim margin, Qantas’ public composure seemed
unaffected. But behind the scenes the accident was a serious affront to
the company’s pride after so many years of accident-free international
flying—especially so in the light of its now expanding jet operations.
The accident, investigated in detail by the Australian Department’s
Lockheed Super Constellation type specialist, Senior Examiner of
Airmen J Brough, was finally attributed to the fact that VH-EAC had
not accelerated in accordance with its rated performance. As a result,
Clearly Qantas did so. For close on 50 years
now the company has flown heavy jets on
an extensive and busy international route
network without losing a single aircraft
hull or incurring a single passenger fatality.
The record is a tribute to all involved in the
company’s operations, and is today the envy of
the aviation industry throughout the world.
Footnote:
Towards the end of the war, con
verted
Con solidated Liberator bombers
, then
Avro Lancastrian s (a ‘civilianised
’
version of the famous Avro Lan
caster
bomber), replaced the ‘double sun
rise’
Catalina flying boats on Qantas’
famed
non stop Perth-Colombo route.
Eve n
after the resumption of the Aus
traliaEngland route via Singapore with
Hythe
flying boats in May 1946, a Lan
castrian
service to London , jointly operate
d by
Qantas and BOAC, was retained
as a
faster alternative—four days of
travel
rather than nine.
61
A CHEAP ACCIDENT
By this time the airport firemen had run out the first hoses and were
playing foam on the fuselage in an attempt to isolate it from the fierce
wing fire that had begun explosively when the fuel tanks ruptured in
the impact. But the nature of the ground beyond the end of the runway
and the rocky gully into which the Super Constellation had plunged
made it impossible for them to reach the forward part of the aircraft
effectively.
Forwarding Mr Brough’s comprehensive
report to Director General D G Anderson,
the Department’s Director of Air Safety
Investigation, C A J Lum, commented: This was
a ‘cheap’ accident for Qantas ... the important
thing is to ensure the company acknowledges the
weaknesses involved in bringing it about and is
made to see it was completely avoidable.
Unmanned ems
Aircraft Syst g
(UAS) Trainin
FSA JAN–FEB10
Issue 72
62
A new training facility in Queensland aims to support the professional
growth of Australia’s burgeoning civil unmanned aerial vehicle (UAV)
industry, by providing an Australasian first, an unmanned aerial systems
(UAS) academy. Launched in November last year, the Australian UAS
Academy will offer its first courses in March 2010. The Academy is a
collaboration between Brisbane company, V-TOL Aerospace; aviation
insurers, QBE Insurance; The University of Queensland; Ipswich City
Council; the Australian Air Force Training Cadets; and Queenslandbased training organisation, the Australian and International Training
Institute.
According to Mark Xavier, the managing director of V-TOL Aerospace,
the Academy will build on existing UAS regulations, namely Part
101 [CASR (1998)], to develop courses for both UAS pilots, payload
operators and engineers. ‘Australia is in a unique position,’ Mark
explains. ‘Having Part 101 gives us the template to work from. The
course will be designed around modules of existing accreditation. This
material will be rounded out, and then there will be the opportunity to
specialise around the basic requirements.’
The Guild of Air Pilots
& Air Navigators (GAPAN)
Griffith University
2010 Postgraduate
Aviation Scholarship
V-TOL will bring their day-to-day operational
experience to the course, as well as using
their new mini-UAV, the Warrigal, as a
training aircraft; QBE will contribute its riskmanagement expertise to the courses; and
the University of Queensland will address
the tertiary-level technical engineering
and ICT areas of the courses such as autopilot development, avionics and software.
The Australian and International Training
Institute (AITI) currently delivers training
courses to groups such as law enforcement
and firefighting agencies in Southeast Asia.
‘These are applications-based programs
designed to skill UAS end-users in the effective
employment of this emerging technology,’
Mark says, ‘so it’s simple to extend that to
what we’re doing.’
Applications are invited for the 2010 scholarship, established
to promote aviation management excellence.
One scholarship will be awarded. This will cover tuition fees
at Griffith University for the Graduate Certificate in Aviation
Management, or the Masters in Aviation Management.
For further details and an application form,
email postgradscholarship@gapan.org.au
Applications close 28 February 2010.
The Academy will offer three streams of UAS training:
Technical training, in conjunction with the University of Queensland
– avionics, software, ICT, GIS, etc
Pilot and payload training – pilot and crew management
qualifications, with full training in the legal operation of UAS, in
accordance with regulation, and
Applications – targeting end-users nationally and internationally,
that is, organisations, and/or individuals wishing to employ UAS
for a variety of applications, such as environmental monitoring,
emergency management, community protection, spatial
information and city and regional sustainability (for example: law
enforcement agencies, farmers wishing to undertake crop or stock
monitoring on their properties).
The Academy, with access to classrooms, function and accommodation
facilities, will be based at Woodlands of Marburg, near Ipswich, in
Queensland, a location which also benefits from relatively close proximity
to the Amberley RAAF Base, 15kms to the south east. This provides onsite
access to 40 square kilometres of RAAF controlled airspace dedicated to
V-TOL’s unmanned aircraft operations and the Academy.
The UAS pilot stream of the course will
follow a similar path to manned PPL and CPL
licensing. There’s the requirement for the
basic aeronautical knowledge (BAK), then
the ground theory associated with PPL, and a
radiotelephony exam. The Warrigal training
variant will be used for the practical flying
training part of the course. Although ‘it is the
most basic UAV we have,’ Mark explains, ‘and
is not much bigger than a large bird, it is made
from advanced materials, and has leading-edge
UAS capabilities.’
Currently, V-TOL requires its UAS pilots to have a
VFR-rated PPL with the ‘visual’ part of the rating
being situational awareness of the local airspace
and ‘electronic line of sight’ to the Warrigal UAS.
V-TOL anticipates that in the future someone
Continued on page 66
63
UAS TRAINING
Air Force Training Cadets will be part of the first intake in March under the
Future Skies™ youth training program, and according to Pilot Officer Frank
Martin, Australian Air Force Cadets, the courses will offer cadets high-end
exposure to UAS technology and a welcome insight to an alternate future
career in the robotics industry. Speaking at the November 2009 launch,
he said that although the course was based in
Ipswich, it was envisaged that it would be taken
nationally, giving cadets the choice to pursue
careers as ‘UAS “pilots” and or UAS engineers’
in our future skies.
r
e
p
a
p
e
t
i
h
w
n
o
i
t
a
i
Av
Presenting Flight path to the future, the aviation policy
white paper released as this issue of Flight Safety went
to press; Transport Minister Anthony Albanese said the
paper ‘sets out the future of Australia’s aviation industry.
It is about providing long-term investment certainty for
the industry, maintaining and improving Australia’s
safety and security record, and providing guarantees for
the users of airports and those who live in communities in
the vicinity of airports.’
FSA JAN–FEB10
Issue 72
64
Given Australia’s role at the forefront of aviation, he said
it was surprising that Flight path to the future was the first
such comprehensive government aviation policy document.
While acknowledging that there were those who warned of
the risk in adopting such a long-term strategy for aviation,
Albanese argued that ‘it was time to do more than make
ad-hoc policy.’ The white paper, he continued, is based on
the premise of the central role aviation plays in Australian
economic development, and its vital role in connecting
Australians with each other and connecting our ‘huge
island’ to the world.
There are over 130 policy initiatives in the four sections
in the paper, which addresses aviation and economic
development; the Government’s ‘number one priorities’:
safety and security; aviation infrastructure; and
sustainable aviation. Albanese discussed the phenomenal
growth of domestic aviation in Australia, which has more
than trebled over the past 20 years, to over 50 million
passenger movements in 2008–09 through more than
180 domestic airports.
White paper at a glance
Aviation & economic
development
International aviation
Moves for a new generation of liberalised air services
agreements with like-minded international partners.
Qantas Sale Act 1992 amendment to remove secondary
foreign ownership limits. However, Qantas to remain
majority-owned by Australians and with its major
operational base in Australia.
Domestic and regional aviation
Retention of Australia’s current deregulated domestic
aviation market.
Improved/better targeted assistance for regional and
remote air services and airports at those routes unable
to sustain commercial operations:
re-focusing of the assistance provided by the
payment scheme for Airservices enroute charges
onto the more remote routes;
consolidate four existing remote aviation programs
(RAAS, RAI, RASP & RAIF) into one.
General aviation
Government commitment to the continued operation
and growth of secondary capital city leased federal
airports.
Airport master plans will maintain a strong focus on
aviation development at secondary airports. Nonaeronautical uses not allowed to compromise future
aviation growth.
Overall direct regulatory service fees to be capped at
current real levels for at least five years.
Continuing development of sport aviation through
CASA’s proposed establishment of a Sport Aviation
Office.
Encouragement of Australia’s aircraft and component
manufacturing
industry:
mutual
recognition
arrangements with key trading partners including the
USA and Europe, to lower the regulatory burden for
Australia’s aircraft and parts exporters. Targeted Govt
export assistance programs.
Industry skills and productivity
Expanded role of Industry Skills Councils, and
development of the aviation training package.
Expanded access to financial assistance through
vocational education and training (VET) FEE-HELP.
Consumer protection
Airlines encouraged to develop corporate charters
outlining how they will deal with complaints
Airline industry ombudsman to better manage
complaints not resolved by airlines.
Provide better compensation payments to air crash
victims and their families; cut red tape for industry
(1999 Montreal Convention).
Improve carriers’ liability arrangements; strengthen
the mandatory insurance arrangements for damage
caused by aircraft to third parties on the ground.
Government, industry and consumer working group on
disability access to aviation services..
Encouragement of airlines and airports to develop
and publish Disability Access Facilitation Plans
– information and access to services available to
passengers with disability.
Safety & security – the
highest priorities
Air traffic management
Airspace reform – closer alignment of Australia’s
airspace administration with ICAO’s airspace system.
Harmonisation of civil and military air traffic
management
Aviation safety regulation and
investigation
New governance arrangements for CASA and the ATSB.
CASA’s resourcing base will be secured through
appropriate industry cost-recovery arrangements as
the industry grows. All funds raised through the current
aviation fuel levy will continue to be returned to CASA
for safety regulation.
Aviation security
Reform of the prohibited items list; more consistent
targeting of security measures to higher-risk aircraft such
as larger turbo-propeller aircraft and charter services.
Streamlined background checking of aviation workers,
while maintaining frequency of background checks.
Enhanced security of air cargo to meet ongoing
international demands.
Airport planning & development
Airport master plans will be required to provide
better transparency about future land use at airports,
including for non-aeronautical purposes.
New planning coordination forums will improve
planning coordination between major airports and
all levels of government, including the implications of
developments for local traffic and public transport.
Major airports will be required to establish community
aviation consultation groups.
Economic regulation of airports
Improved regulatory oversight of leased federal
airports, by introduction of a tiered approach to price
and service quality monitoring.
Existing airport pricing regime maintained, including
price monitoring by the ACCC of aeronautical
services, and car parking at the five major airports.
Self-administered, scaled-down monitoring will apply
to Canberra, Darwin, Hobart and Gold Coast airports.
Future aviation needs for the
Sydney region
Federal and NSW governments will work together to plan
for the Sydney region’s future airport infrastructure,
including road and rail transport systems. Increased
emphasis on inclusion of ground transport plans in
airport master plans.
Sydney-Melbourne domestic route seventh busiest in
the world – highlights the need for a second airport for
the Sydney region. Badgery’s Creek ruled out as a site.
Aviation & sustainability
Manage aircraft noise through maintaining existing
curfews and aircraft movement caps, and phasing out
the operation of older, noisy aircraft. Focus on effective
noise management strategies, including periodic review
of the need for a curfew at Brisbane.
Establishment of a noise information and complaints
ombudsman.
The full text of Flight path to the future is available online
www.infrastructure.gov.au/aviation
65
AVIATION WHITE PAPER
Strategy for the increased use of enhanced air traffic
management infrastructure, including satellite
technology, to further improve safety and meet future
air traffic capacity demands.
Aviation infrastructure
Continued from page 63
whose career is ‘flying’ a more capable UAS beyond line of sight for hire
and reward under a UAS Operating Certificate will require a qualification
similar to a CPL-IFR rating. A UAS pilot with an unrestricted licence might
eventually ‘fly’ 100km beyond the line of sight, and perhaps at night.
Eligibility for certification as UAV controller
1. Only an individual is eligible to be certificated as a UAV controller.
2. A person is eligible to be certificated as a UAV controller if he or she:
A. qualifies for the issue of a radio operator’s certificate of proficiency; and
B. has been awarded a pass in an aviation licence theory examination (other than a flight radio operator’s
examination);and
C. has been awarded a pass in an instrument rating theory examination; and
D. h
as completed a training course in the operation of the type of UAV that he or she proposes to
operate, conducted by the UAV’s manufacturer; and
E. has at least 5 hours experience in operating UAVs outside controlled airspace.
A. a flight crew licence with a command instrument rating; or
C. an air traffic control licence, or a military qualification equivalent to an air traffic control licence; is
taken to satisfy the conditions in paragraphs (2) (a), (b) and (c).
FSA JAN–FEB10
66
Issue 72
3. A person who holds or has held:
B. a military qualification equivalent to a licence and rating mentioned in paragraph (a); or
Part 101.295
Warrigal mini-UAS
The Warrigal is a mini-unmanned aircraft capable of imaging and
sensing the environment for Earth Observation™ monitoring over
regional and urban* areas.
*When certified and approved to do so.
Features include
Intelligent autonomous flight control
GPS waypoint navigation
Autonomous takeoff and flight
Fuselage & wings manufactured from a form of polypropylene
Live video streaming to >5km
Specifications
Wingspan – 1500mm (60 inches)
Length – 1200mm (47 inches)
Weight – 1-5kg
Cruise – 30kts
Max speed – 60+ knots
Electric power (Li-Po)
Endurance – 60–90 mins
AVQUIZ
FLYING OPS
1. At or near ground level, a sudden change in wind direction
accompanied by a rapid increase in wind speed and a
drop in temperature, resembling a small cold front, can be
associated with a thunderstorm
(a) in the mature or dissipating stage, when strong
downdrafts are occurring.
(b) in the mature or dissipating stage, when strong updrafts
are occurring.
(c) only in the mature stage, when strong updrafts are
occurring.
(c) t raining persons other than by the owner.
(d) only in the mature stage, when strong downdrafts are
occurring.
2. ADF coastal refraction error will be zero when the bearing
from the aid to the receiver
(a) crosses the coast at right angles.
(b) is parallel to the coast.
(c) only crosses fresh water.
(d) crosses the coast at greater than 70 degrees.
(a) cloud base consists of stratus at 1200ft, so no VFR alternate
is required.
(b) cloud base consists of stratus, and a VFR alternate is
required.
(c) cloud is on the ground.
(d) ceiling is 1200ft.
4. Runway lead-on lights immediately beyond stop bar lights are
(a) on at all times, regardless of the status of the stop bar
lights.
(b) t urned off when the stop bar lights are on.
(c) flashing when the stop bar lights are extinguished.
(d) flashing when the stop bar lights are on.
5. Ignoring compressibility, the calibrated airspeed (CAS) is the
(a) indicated airspeed (IAS), corrected for instrument and
position error.
(b) indicated airspeed, ignoring position error.
(c) t rue airspeed, corrected for instrument error.
(d) t rue airspeed, corrected for position error.
6. A VH-registered light sport aircraft as defined by CASR 21.186,
cannot be used for
(a) glider towing.
(b) charter operations.
7. When a pilot nominates a time for the initiation of a SAR
action, it is called a
(a) S AR and the correct terminology for cancellation is ‘cancel
SAR’.
(b) S ARWATCH and cancellation is based only on arrival
reports.
67
(c)SARTIME and the correct terminology for cancelling is
‘position/location cancel SARTIME’.
(d)SARTIME and the correct terminology for cancellation is
‘position/location cancel SAR’.
8. If you departed on a planned track of 270(m) with a flight
planned heading of 280(m) and after travelling for 30nm were
5nm right of track, your actual drift
(a) would be 10 degrees right.
(b) would be 10 degrees left.
(c) would be zero.
(d) could not be determined from the given information.
9. With regard to aircraft loading systems, the datum point is the
position
(a) o f the forward limit of the centre of gravity.
(b) o f the centre of gravity at the basic empty weight.
(c) o f the centre of gravity when loaded.
(d) f rom which the moment arms are measured.
10. If cleared to cross a stop bar and enter a runway, but the stop
bar remains illuminated
(a) you can cross the stop bar.
(b) you can cross the stop bar subject to ATC confirmation.
(c) you can cross the stop bar subject to confirmation by ATC and the illumination of the runway lead-on lights.
(d) you cannot cross the stop bar.
CHANGE
ME
QUIZ
3. An area 30 forecast states ‘PROB30 0617/0621 0500 FG BKN ST
1200 ’ for the Kilmore Gap (elevation 1200ft). This means that
the
(d)ab-initio training.
MAINTENANCE
1. 5. In an axial compressor of a jet engine, the stator blades form a
(a) divergent duct in which pressure reduces.
Hydrogen embrittlement is
(b) divergent duct in which pressure increases.
(a) a consequence of a plating process.
(c) convergent duct in which pressure reduces.
(b) a consequence of a plating process and is eliminated by
passivation.
(d) convergent duct in which pressure increases.
(c) occurs on high carbon steels as a function of age.
(d) occurs on low carbon steels as a function of age.
6. The electrolyte specific gravity reading of a nickel-cadmium
battery
(a) increases with the state of charge.
2. An AN4 steel bolt has a nominal diameter of
(c) decreases with decreasing temperature
(b) ¼” and a rated yield strength of approximately 3,100 lbs.
(d) does not vary with the state of charge.
(c) ½” and a rated yield strength of approximately 14,100 lbs.
(d) ½” and a rated yield strength of approximately 5,900 lbs.
3. The thread on an AN aircraft bolt is formed by
(a) rolling, in order to provide residual compressive forces, and
thus better fatigue resistance.
FSA JAN–FEB10
Issue 72
68
(b) decreases with the state of charge.
(a) ¼” and a rated yield strength of approximately 1,300 lbs.
(b) rolling, in order to provide residual tensile forces, and thus better fatigue resistance.
(c) machining, in order to produce a more accurate thread
profile.
(d) machining, in order to form a more rounded thread root with
higher fatigue resistance.
4. The plating on an AN series bolt is
(a) passivated zinc, to minimise corrosion to the bolt.
(b) passivated zinc, to avoid electrolytic corrosion when in
contact with aluminium alloys.
(c) cadmium, to minimise electrolytic corrosion when in
contact with aluminium alloys.
(d) cadmium or zinc, to minimise electrolytic corrosion when in
contact with aluminium alloys.
7. Water should not be added to a nickel-cadmium battery
installed in an aircraft because
(a) t he correct water level can only be determined when the
battery is fully discharged.
(b) t he specific gravity should be adjusted each time water is
added.
(c) a gassing charge is required in order to mix the electrolyte
uniformly.
(d) t he electrolyte level varies with the state of charge and
electrolyte loss may thus result.
8. When carrying out magnetic particle inspection of a rodshaped ferrous component, cracks parallel to the long axis are
detected by
(a) circular magnetisation in which a current is passed through
the part.
(b) circular magnetisation in which a current is passed through
a coil around the part.
(c) longitudinal magnetisation in which a current is passed
through the part.
(d) longitudinal magnetisation in which a current is passed
through a coil around the part.
9. A hardness test of a metal based on the surface area of the
impression made by a one-centimetre diameter hardened steel
ball under a standard load is termed
(a) Rockwell.
(b) Brinell.
(c) V ickers.
(d) Izod.
10. When negative torque is sensed on a turboprop engine with a
negative torque system, the
(a) f uel is trimmed back.
(b) bleed valves are opened.
(c)blade angle is increased.
(d) blade angle is decreased.
IFR OPERATIONS
4. An IMC departure
Considering an IMC departure from RWY 35 at Canberra (YSCB)
via the Bindook Two departure SID in a Cessna 310, what
minimum rate of climb would be required to meet the gradient at
120 kts T.A.S. and an average headwind of 20kts for the climb?
1. a) 800 FPM throughout
You are about to depart from Mildura (YMIA) from RWY 27 in
an IFR BE36 Bonanza operating category B, equipped with
ADF and VOR, but no RNAV. Considering a return to YMIA in
the event of an abnormal operation, for example an alternator
failure, what would be the lowest minima for departure?
a) 300ft ceiling/2km vis
b) 800 FPM to 3400ft, then 400 FPM
c) 660 FPM throughout
d) 660 FPM to 3400ft, then 330 FPM
5. b) 513ft ceiling known QNH/2.4km
c) 513ft ceiling known QNH/3.5km
d) 613ft/3.5km
2. You are about to depart from Essendon (YMEN) RWY 26 in
an IFR BE58 Baron operating single-pilot category B and
equipped with ILS, VOR and ADF. You determine that in
the event of an engine failure you have the performance to
proceed to Moorabbin (YMMB) where the weather is above
I.A.L minima, or return to YMEN as an option.
a) Continue outbound on the departure TR to BIK, attempting
to become visual for an approach to land at a suitable
aerodrome.
b) Return to YSCB via the 13 DME ARC to position for the RWY
35 ILS.
What is the lowest minima for departure from YMEN?
c) TR to TALAG for the YSCB RWY 17 VOR/DME approach
accepting the slight tailwind for landing.
a) 251ft ceiling known QNH/1.5km
c) 300ft ceiling/2km
6. Unless an IFR departure is via a S.I.D. or under instruction from
ATC, (for example radar vectoring), then an aircraft must be
established on track within how many miles?
a) the circling area for the aircraft category
b) 5nm
c) 10nm M.S.A.
d) 25nm M.S.A.
a) 1000ft ceiling/5km for a visual return
b) I.A.L. minima for YPCE
c) 300ft ceiling/2km
d) Pilot discretion, as no information is given.
7. An IFR aircraft may only be operated below the MSA or LSALT
during the necessary climb after departure when levels are
being assigned by ATC in a radar environment. True or false?
a) True
b) False
CHANGE
ME ME
CHANGE
QUIZ
3. You are about to depart from Pooncarrie (YPCE) (Refer ERC
L2) in an IFR category B Cessna 340. Since it is a remote
aerodrome from alternates with instrument approach
procedures, you consider a return in the event of an
asymmetric operation. What would be a suitable minima for
departure?
69
d) Return to YSCB, diverting to intercept a TR of 117 for the
SECTOR C DME or GPS arrival.
b) 490’ft ceiling known QNH/1.9km
d) I.A.L minima for YMMB i.e. 570ft ceiling known QNH/2.4km
During the departure from RWY 35 at YSCB on the SID in the
previous question, an engine fails at 10 DME. You conduct your
emergency drills and ascertain that the aircraft can maintain
4700ft on QNH as a maximum. In declaring your emergency,
what would be a prudent course of action based on ATC
advising current YSCB weather of ‘wind 350/5, cloud broken
3400, visibility 3000m in rain’?
8. You are about to depart Moorabbin (YMMB) runway 17 LEFT
in a Piper PA31 Chieftain tracking via Cowes (CWS) enroute
to Launceston (YMLT), and climbing to a planned level of A090
(below CTA steps). It is an IMC departure. Your departure
brief considers the manoeuvring to be established on track,
and return options in the event of an emergency. Which of the
following would be a safe and practical technique?
a) Become airborne, climb to overhead the NDB and only after
passing the MSA of 2200 set course. Return via the 3000ft
or 4000ft NDB in an emergency.
b) Become airborne, climb to overhead the NDB and only after
passing the 10nm MSA of 3600, set course. Return via the
3000ft or 4000ft NDB in an emergency.
c) Become airborne, intercept track whilst climbing to above
LSALT of 2100ft (no terrain or obstacle issue). Return via
the SECTOR A GPS arrival (Aircraft equipped/ you are
endorsed).
FSA JAN–FEB10
Issue 72
70
9. You are about to depart Merimbula (YMER) runway 03 in a
Piper PA60 Aerostar enroute to Canberra (YSCB) and climbing
to a planned level of A080 via ‘PEAKE’. It is an IMC departure.
Considering again the departure and emergency return
brief, which of the following would be a safe and practical
technique?
a) Become airborne, turn to set course whilst climbing to
planned level. Return via the NDB approach.
b) Become airborne, climbing right turn to overhead the NDB
and not below 10nm MSA of 4200ft before setting course.
Return most expedient via the GPS or DME arrival (Aircraft
equipped and you are endorsed).
c) Become airborne, climbing right turn to overhead the NDB
and not below LSALT of 5900 to ‘PEAKE’ before setting
course. Return via the GPS or DME arrival.
10. During a departure of an IFR aircraft from a controlled
aerodrome, the term ‘VISUAL’ will be used by ATC if a heading
instruction and/or assigned level is given that is below MVA
(minimum vectoring altitude) or MSA/LSALT. True or false?
a) True
b) False
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Vol 63
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For pilots and aircraft owners.
In this months issue:
>> Who’s talking on the radio?
>> Barry Schiff flies a Lockheed Electra
>> Our disappearing airports - More bad news
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Who’s
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TRA
LIA
QUIZ ANSWERS
1. (a)
2. (a)
3. (c) cloud in ARFOR is
AMSL; VFR alternate
is based on forecast at
destination.
4. (b) AD 1.1-26
5. (a)
6. (b) only private ops,
training or glider towing
(CAR 262APA).
7. (c) AIP ENR 1.1 para.
67.2 and GEN3.4-28.
8. (c) track error would be
the same as the planned
drift.
9. (d)
10. (d) ENR 1.1 5.2.1.
Maintanance
1. (a) to avoid it, heat
treatment must occur
within a short time after
plating.
2. (b)
3. (a)
4. (c)
5. (b)
6. (d)
7. (d)
8. (a)
9. (b)
10. (c)
IFR Operations
1. B - AIP ENR 1.5–27 A
return via the runway
09 VOR approach with a
circling to RWY 27 gives
the lower circling visibility.
2. C - AIP ENR 1.5–27
NOTE 4 More prudent
perhaps to return to
YMEN via the RWY 26
ILS–fewer track miles in
the emergency.
3. A - AIP ENR 1.5–27 Para
4.4.2 Remember too, that
the abnormal op does not
have to be asymmetric–it
could be something such
as you smell smoke or a
fuel tank venting etc.
4. D - DAP (E) YSCB SID,
PLATE DAP 2-1 Gradient/
rate graph based on
100kts groundspeed
5. D - DAP (E) YSCB
approach plates,
intercepting the
DME/GPS arrival at
MSA of 4600 can be
accomplished. It is safe
inside 10nm to 4000 and
has the visibility minima
for circling to land.
6. B - A.I.P. ENR 1.1-15 Para
7.3 ENR 1.1-82, Para 59.2
7. A - A.I.P. GEN 3.3- 16
Para 3.6 CAR 178, Para 4(b)
8. C - Departing along TR is
sensible if terrain permits
(study all information
available from D.A.P plates
and charts–VTC/ WAC/
VNC) The GPS arrival steps
involve fewer track miles
and therefore time for a
return.
9. B - Comments above
apply. Note that in some
cases the MSA can give
more flexibility than
LSALT.
10. A - AIP ENR 1.1-14
Para 6.2.2
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Licence No. 2TA4424
10/9/09 5:41:19 PM
QUIZ ANSWERS
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Flying Ops
71
A SPECIA
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FSA JAN–FEB10
Issue 72
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Licence No. 2TA4424
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Inside next issue
flightsafety
… essential aviation reading
Our feature looks at fatigue risk management
Flash Airlines accident
Nanotechnology and aviation
And... more of the ever-popular ‘Close Calls’
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There has never been a better time
Issue 72
to be with good people.
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