jul-aug2012

87
July–August 2012
Unmanned aircraft | a civil discussion
Sneaky leaks | pinhole corrosion
a civil discussion
Unmanned
aircraft

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CONTENTS
Issue 87 | July–August 2012
08
62
20
FEATURES
08 Unmanned aircraft
The realities and challenges of
a rapidly growing aviation sector –
and they aren’t drones!
20 A hard-headed look
at helmets
If you don’t need a head, you
don’t need a helmet?
22 Aerodrome safety survey
The results are in
25 A hands-on approach
Never give up flying the aircraft
28 In plane sight – hazard
ID and SMS
The vital connection between
the two
31 Sneaky leaks
The problem of pinhole corrosion
40 A game of many parts
Technology, reporting and safety
44 Sharing the sky … gliders
Part three of this series looks at
the joys of soaring like an eagle
58 Pride before a fall
The fatal combination of a confused
captain and a timid first officer
62 Watch out, whales about!
Flying neighbourly during the
migration season
44
REGULARS
02 Air mail
Letters to the editor
03 Flight bytes
Aviation safety news
16 ATC Notes
News from Airservices Australia
18 Accident reports
18 International accidents
19 Australian accidents
31 Airworthiness section
34 SDRs
39 Directives
46 Close calls
46 Hot and shaky
48 Live, learn, survive and be happy
50 Taking control
52 ATSB supplement
News from the Australian Transport
Safety Bureau
66 Av Quiz
Flying ops | Maintenance
IFR operations
70 Calendar
Upcoming aviation events
71 Quiz answers
72 Coming next issue
72 Product review
CASA’s new Maintenance Guide
for Owners/Operators

02
AIR MAIL / FLIGHT BYTES
Aviation safety news
AIR MAIL
Dear Editor
I enjoy reading and digesting Flight Safety Australia, a most
informative and professional journal. Besides the useful
safety information contained, I appreciate the culture of open
communication fostered by the editors.
I read with interest the article on cabin crew training (‘The cabin
connection’) in the March-April issue, and present a dilemma
for consideration by all cabin crews of commercial airlines.
As far as I can recall, every time I choose to travel on a large
passenger aircraft I am frustrated by loud, inattentive passengers
who ignore the emergency procedures briefing before takeoff.
While I can accept that not every passenger views this as
important to them, their inconsiderate actions can limit others
from hearing and understanding this information.
As a passenger I feel uncomfortable in asking these people to
refrain from talking during this important presentation by the
cabin crew. I have yet to witness any of the cabin crew make
an attempt to advise passengers of their inconsiderate
behaviours, which could, in rare circumstances, lead to unsafe
actions during an in-flight emergency.
I believe that strategies for addressing this issue could usefully
be incorporated into cabin crew training in the near future.
Gary Allan
Several callers responded to the story Pad not paper, in issue 86,
May-June 2012. All approved of using tablet computers as an
aid to conventional flight planning, but those from tropical parts
of Australia pointed out that tablet computers and smartphones,
such as the Apple iPad and iPhone, often black out when left in
a hot aircraft cockpit. They remain blank until they cool down,
which can take up to half an hour. Apple lists 0 to 35 degrees C
as the operating air temperature range for iPhones and iPads and
says other symptoms of overheating include the display going
dim, the mobile signal strength fading and the device stopping
charging. ‘It’s nice to have, but that’s why I don’t rely on it, ‘said
one caller.
Director of Aviation Safety, CASA | John F McCormick
Manager Safety Promotion | Gail Sambidge-Mitchell
Editor, Flight Safety Australia | Margo Marchbank
Writer, Flight Safety Australia | Robert Wilson
Sub-editor, Flight Safety Australia | Joanna Pagan
Designer, Flight Safety Australia | Fiona Scheidel
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Flight Safety Australia
Issue 87 July–August 2012
03
FLIGHT BYTES
Correction
In the May–June issue of FSA the date listed for the free
‘Aviation access all information areas’ aviation safety education
forum at the University of NSW in Sydney was unfortunately
incorrect. The forum will be on 22 August from 0900 to 1630
and prospective attendees need to register as soon as possible
on www.casa.gov.au/avsafety
Book now for the Brisbane safety forum!
The free ‘aviation - access all areas’ forums are a joint
venture between CASA, Airservices, the ATSB, the BoM and
the RAAF to share vital aviation safety information with all
interested parties, with an emphasis on human factors,
as well as on accessing information on tablets and
smartphones. The Brisbane seminar is on 28 July, and you
can register for it, or for future seminars around Australia,
at www.casa.gov.au/avsafety
Having trouble finding
aviation information
www.casa.gov.au/avsafety
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04
FLIGHT BYTES
Aviation safety news
Centralising carriage and discharge of
firearms approvals
If you are one of the small number of pilots or aircrew (such
as police, or those who fly over crocodile-infested swamps)
who need to carry a firearm on an aircraft, or the even smaller
group of people (professional shooters) who have a legitimate
reason to shoot from an aircraft, this one is for you. CASA
is centralising its application and approval process for the
carriage in, and discharge of firearms from, aircraft.
Two permits will be available, one to carry a firearm on an
aircraft, and the other to carry and discharge a firearm from
an aircraft, for feral animal shooting. The permits apply to,
and are required for, both fixed- and rotary-wing aircraft.
The new permits cover all firearms, making no distinction
between handguns, rifles and shotguns
The permits will be valid for three years, or until the applicant’s
firearms licence expires, whichever is soonest.
An online application form will be available on the CASA
website in July.
ADS-B rolling out over the U.S.A.
More than 60 per cent of the required ground stations for the
satellite-based automatic dependent surveillance-broadcast
(ADS-B) network have now been completed in the U.S.A., with
428 ADS-B radio stations already built. The current plan is for
700 stations to be deployed: 647 in the continental U.S., 41 in
Alaska, nine in Hawaii and one each in Guam, Puerto Rico and
the U.S. Virgin Islands.
The FAA initially plans to use the network to provide ADS-Bin
data to its air traffic control facilities. This means ADS-B
eventually can replace radar as a surveillance source for
controllers. Aircraft operators must equip for ADS-B-in by
2020. The ADS-B-out service, which provides surveillance and
other data to aircraft cockpits, will be rolled out later.
The FAA has been using ADS-B for traffic control at four initial
sites and this year plans to begin using the ADS-B feed at up to
a dozen additional facilities.
Interestingly, in Australia, all operators of aircraft flying above
FL290 will have ADS-B equipment installed and operating
correctly by 12 December 2013, with over 70 per cent of
international flights in our FIR currently using it.
After December 2013, non-ADS-B-equipped aircraft will have
to operate below FL290 in Australian airspace, and risk any
resultant delays and reduced flexibilty.
Sources: Aviation Week and Flight Safety Australia
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Flight Safety Australia
Issue 87 July–August 2012
05
Easier process for small aviation businesses
Small aviation organisations will be able to use a new
simplified and streamlined process to comply with important
drug and alcohol management requirements.
CASA is introducing the simplified drug and alcohol
management processes for aviation organisations with seven
or fewer employees engaged in safety sensitive activities.
The new simplified processes do not apply to any aviation
organisation engaged in or providing services to regular public
transport operations.
Aviation organisations eligible to use the new drug and alcohol
compliance processes will use a standard drug and alcohol
management plan provided by CASA. Full details of eligibility
requirements are on CASA’s web site.
Organisations will also use a CASA e-learning package
to educate and train their employees in drug and alcohol
responsibilities.
Director of Aviation Safety, John McCormick, said the
new drug and alcohol compliance processes for small
organisations recognised that the existing requirements could
be unnecessarily onerous for these operations.
‘We are making life easier for small aviation organisations by
streamlining the process of drug and alcohol management
while maintaining high safety standards,’ McCormick said.
‘Small aviation organisations will no longer have to develop
their own drug and alcohol management plans.’
‘By using CASA’s new drug and alcohol management plan and
new on-line training small aviation organisations will save time
and resources and still be confident they are meeting all the
regulatory requirements.
“CASA has listened to the concerns of the aviation industry
about the impact of drug and alcohol management plans on
small organisations and found a solution that is simpler and
protects safety.’
Small aviation organisations using the new processes will still
be required to report to CASA every six months on their drug
and alcohol management performance and CASA will continue
to check on compliance.

06
FLIGHT BYTES
Aviation safety news
A caffeine gum hit
The Israeli army is supplying aviators and special operations
forces with a caffeine-charged chewing gum that dramatically
enhances their ability to cope with fatigue on missions lasting
more than 48 consecutive hours.
The food supplement gum is part of ongoing efforts to curb
fatigue-related injuries and deaths and is also included, along
with other foodstuffs designed to increase vigilance and
endurance, in the ‘First Strike Rations’ issued to U.S. field units
on high-intensity combat operations in Iraq and Afghanistan.
Before introduction of the gum, soldiers often chewed on
freeze-dried coffee to stay awake during night operations.
A standard pack holds five cinnamon-flavoured pieces that
contain 100 milligrams of caffeine each. This is absorbed from
the circulatory system five times faster than caffeine in coffee.
‘There are no side effects, except for the disgusting taste.
It improves the soldiers’ alertness and their cognitive
performance. The pilots are amazed to discover that it simply
works’, said a senior Israel Air Force officer.
Despite their satisfaction with the gum’s performance, the
Israelis are not taking any chances. Troops sent on 72-hour
missions are also issued with Modafinil, a prescription drug for
treating an assortment of sleep disorders.
Source: Yedioth Ahronoth
No in-flight calls please – we’re British
According to a recent poll, 86 per cent of British travellers
are opposed to the use of mobile phones on flights. The poll
follows Virgin Atlantic’s announcement that it will become the
first British airline to allow passengers to make calls on their
own mobiles.
Respondents said they would object to passengers making
voice calls, mainly because ‘it’s annoying to listen to other
people’s conversations’.
Almost half said they would use the service, but only to send
text messages. A further 10 per cent said they would send
emails, but only six per cent said they would make or receive
voice calls.
Sam Baldwin, Skyscanner’s travel editor, said: ‘In a world
where we are now almost always on call, it seems people
don’t want to say goodbye to their last sanctuary of nonconnectivity.
Flying allows us to switch off for a few hours,
both from our own calls, and other people’s. However, Virgin’s
move is the beginning of the end of the no-phone zone.’
Virgin will launch the service on flights between London and
New York, but wants to make it available on at least nine more
routes before the end of the year. Calls are still not permitted
during take-off or landing, and American laws mean it has to
be turned off 250 miles from U.S. airspace.
Source: Daily Telegraph U.K.
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Flight Safety Australia
Issue 87 July–August 2012
07
Non-destructive testing seminar
The National Aerospace NDT Board will hold a Quality and
Testing in Aircraft Maintenance seminar in Sydney on
14-15 November 2012. The themes include NDT but extend
beyond it to capture the quality and compliance issues that
underpin any effective inspection and quality program in
aircraft maintenance.
Australian and international presenters will cover subjects
such as quality management, SMS, human factors, regulatory
compliance (including CASR Part 145), training, NDT
inspections, composites, ageing aircraft and much more.
This event is targeted at the aircraft maintenance professionals
from general aviation, executive transport, regional operators
and the airlines who are responsible for quality, inspection,
maintenance, audit, NDT and compliance. There will also be
an inspection equipment and services exhibition.
As an incentive to join them in Sydney, the board will
maximise the value to attendees and their employers by
generously subsidising registration costs. Seminar and
registration details can be found www.ndtboard.com
“Spidertracks real-time tracking is an extremely
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all over Australia and Papua New Guinea.”
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Oxygen bottle fire forces diversion
An OLT Express Poland Airbus A320 made an emergency
landing in Sofia, Bulgaria on May 17 after suffering cabin
decompression and, subsequently, a fire in the cabin.
The aircraft was en route from Warsaw to Hurghada, Egypt
when cabin pressure was lost at cruising altitude and the
oxygen masks deployed. The cause of the decompression
has not yet been determined.
The fire was caused by a short circuit in an oxygen generator,
which then fell onto the cabin carpet during the oxygen
mask deployment. It ignited the carpet, but the cabin crew
immediately extinguished the fire.
The captain decided to make an emergency landing in Sofia.
The aircraft landed around noon, and all 147 passengers and
eight crew evacuated via the escape slides with no injuries.
Source: Flightglobal
Go East cabin crew
As China’s major airlines expand flights across the globe
they are looking for foreign cabin crew in a bid to become
more international. The main reason for this, they say, is that
international passengers prefer to be served by cabin crew
from their own countries, and more foreigners than ever are
now working, living and travelling in the People’s Republic
of China.
Ryan Cornish, a British expat who regularly flies between
Europe and China, said: ‘While I don’t mind Chinese-speaking
attendants, if there’s ever a problem on board it helps to have
a native English speaker. For foreign cabin crew, working for a
Chinese airline is likely to provide very valuable experience.’
However, applicants may also need to be fluent in Mandarin,
plus at least one of the other major spoken languages of China.
Major carriers Air China, China Southern Airlines and China
Eastern Airlines have all said they plan to increase their
recruitment of foreign cabin crew.
Industry figures show that Chinese airlines are flying more
foreign passengers as they expand their international reach.
According to Air China’s annual report, it carried more than
seven million international passengers last year. It also added
eight new international and regional routes.
China Southern Airlines recently flew its maiden voyage
from the city of Guangzhou in south China to London, and is
targeting passengers wanting to travel between Europe and
Australasia. There will be three flights on the new route a week,
with the flights also expected to benefit Asian passengers
heading to the Olympic Games this summer.
Source: The Telegraph

08
FEATURE
Unmanned aircraft
Flight Safety Australia, in light of the recent media
buzz on UAVs, looks at what is arguably one of the
fastest growing sectors of aviation
Unmanned
aircraft
a civil discussion

‘They’re being used now,’ she
explains, ‘and in certain situations
are the mainstay’.
Flight Safety Australia
Issue 87 July–August 2012 09
Scan any newspaper today, and you’re likely to find reports of
activity by ‘drones’, a term unmanned aircraft systems (UAS)
insiders decry as negative, with its connotations of monotony,
menace and inflexibility. (The word drone is said to have
derived from the name of one of the first unmanned aircraft,
the de Havilland Queen Bee, a radio-controlled variant of the
Tiger Moth biplane.)
Even the most respected media take a melodramatic tone.
When The Wall Street Journal visited the subject, the headline
asked ‘Could we trust killer robots?’ Likewise The Australian
in a recent feature summed up the subject as ‘Drones, lives
and liberties’, and declared ‘as civilian use of unmanned
aerial vehicles (UAVs) grows, so does the risk to our privacy’.
The story invoked George Orwell’s 1984 in its discussion of
how police use of ‘drones’ may affect civil liberties. It did not
mention the potential uses for UAS until the sixth of its eight
columns, nor, for that matter, the ubiquitous ground-based
CCTV cameras increasingly watching over urban dwellers.
Hollywood can take much of the credit, or blame, for this
sinister image of what are more accurately, and less emotively,
known as remotely piloted aircraft (a part of unmanned aircraft
systems [UAS] or UAV, to use the older term). Reece Clothier,
senior research fellow at the Australian Research Centre for
Aerospace Automation (ARCAA) also points a finger at the
silver screen. ‘What most people know about UAS is what
they’ve seen in movies like Stealth, the Terminator series,
Eagle Eye and Mission Impossible. The movie images are of
killing machines rather than machines that can make aviation
safer,’ he laments.
The reliance on such vehicles for military surveillance and
intelligence gathering, and increasingly as weapons platforms,
in war zones such as Afghanistan (since 2001), Iraq (since
2002), Yemen (since 2002), Pakistan (since 2004) and Gaza
(since 2008) also contributes to a public misapprehension
about the benefits, purpose and safety of UAVs in civil use.
While civilian UAVs (also classified by the International
Civil Aviation Organization [ICAO] as remotely-piloted aircraft
[RPAs], to emphasise the fact that there is a human pilot in
control) have obviously benefited from military research and
development, they have also been described in the same dark
and often inaccurate terms.
This frightening portrayal is emerging as a challenge for
what is arguably the fastest-growing and most dynamic
sector of aviation.
CASA’s UAS specialist, Phil Presgrave, says there are now
19 certified UAS operators/organisations (UOC holders) in
Australia, comprising a mix of fixed-wing (8), rotary (6) and
multi-wing (4), and one airship, with 30 anticipated by the
end of 2012, and enquiries growing daily.
It is a technology which is ‘not coming, but here’ says
Peggy MacTavish, the Executive Director of the Association
of Unmanned Vehicle Systems Australia (AUVSA). ‘She
describes UAS in a memorable phrase, they’re ‘not the
leading edge any more, but the bleeding edge’. They have
moved well beyond the incubator of academic research and
into mainstream aviation use. ‘They’re being used now,’
she explains, ‘and in certain situations are the mainstay’.
Peter Smith, vice-president of AUVS-Australia, says ‘in three
years we will almost routinely be flying UAVs in selected
situations to provide information about the position, movement
and severity of bushfires. It will be done at night, at low
altitude, using sensors like synthetic aperture radar to look
through the smoke.’
A paper presented at a recent UAS conference identified
over 650 applications for UAS.

10
FEATURE
Unmanned aircraft
UAS—the safety case
But the payoff is huge: they do dull,
dirty, dangerous and demanding jobs
without putting the pilot at risk
Some Australian
examples of UAS use
Surveillance – fishing
Law enforcement
Noxious weed identification; for example,
Siam weed in northern Queensland
Aerial photography
Powerline monitoring
Animal population monitoring – counts of
migratory whales; feral animals in northern
Australia
Crop monitoring
Crop and noxious weed spraying
Search and rescue
Customs/border surveillance
Meteorology
Emergency services support – firefighting.
Paul Martin, a CASA-licensed UAS operator, as well as a
manned helicopter pilot, has been using UAVs in his aerial
photography business since 2008. ‘I think UAS will have
a huge effect on safety. At the moment they’re incorrectly
categorised as being a safety risk. But the payoff is huge:
they do dull, dirty, dangerous and demanding jobs without
putting the pilot at risk,’ he says.
Peter Smith says UAS can take the risk, and the corresponding
moral dilemma, out of scientific research and mercy missions.
By using UAS, the question of scientific breakthrough versus
loss of human life no longer arises. ‘Nobody in their right
mind would go into a hurricane and fly below 1000 feet, but
we flew an Aerosonde into a hurricane and got down to below
100 feet,’ he says.
‘The result was to confirm what science had suspected—
that there are surface friction and low-level atmospheric
effects. We got the aeroplane out of that one. You can do
stuff that morally you could not expose a flight crew to.’
Smith says UAS can benefit from 100 years of safety
development in manned aviation. ‘UAVs are different but
they’re not unique,’ he says. ‘They’re part of a spectrum of
air vehicles and need to be put into context. We don’t have
to invent a brand new wheel: there are elements of existing
systems that can be used.
There are a huge number of issues about privacy, safety
and other aspects but none of them seem to me to be more
demanding than those surrounding manned aircraft.’
After a government employee was killed in a helicopter crash,
the Queensland Government has decided to use UAS more
widely to avoid placing employees at risk. A trial to monitor
fishing off North Stradbroke Island (illegal fishing costs
the industry hundreds of thousands of dollars) using UAS
was the first known flight of a UAS in class C airspace, and
demonstrated that UAS could do the job at least as well as a
manned aircraft, while collecting terabytes of valuable data.

Flight Safety Australia
Issue 87 July–August 2012
11
Sharing the skies
Currently, Australian UAS operations are limited to visual
line-of-sight operations in visual meteorological conditions
(VMC) below 400ft AGL. However, CASA’s Phil Presgrave
says the long-term goal, based on the growing competence
and sophistication of the UAS industry, is to allow routine
operations beyond visual line of sight in VMC/IMC in all
classes of airspace by the end of 2017.
To do this safely, UAS will need reliable and increasingly
sophisticated safety systems. Dr Duncan Campbell, who
heads the Australian Research Centre for Aerospace
Automation (ARCAA) says ARCAA is working with global
industry partners on four main areas around this broad theme.
The first focuses on the development of advanced systems
for navigation, automating airspace management, and
importantly, on dynamic and static ‘detect and avoid’. There
will be a progression towards greater onboard computational
intelligence and autonomous mission replanning, dynamic path
planning, and as the highest priority, an automated emergency
landing system. Secondly, another research area focuses on
developing aviation risk management frameworks and tools
relating to UAS, and appropriate regulation. (Australia led the
way in UAS regulation with its Civil Aviation Safety Regulation
[CASR] Part 101, which is ten years old this year. Only one
other country, the Czech Republic, has formal UAS regulation,
since last year.)
A third research area is focusing on multidisciplinary design
and optimisation, especially human-machine interaction
around multi-UAV mission command. ARCAA is working
with Telecom Bretagne in France and Thales on several
related projects.
And finally, ARCAA is working on advanced sensing for
specific UAS applications.
Peter Smith sees particular potential in the development of
sensors for UAS. He says that as an IT-based technology
UAS have benefited from Moore’s law—the rule of thumb
that says computing power (defined by the number of
transistors on a chip) roughly doubles every two years, with
corresponding benefits in size and cost. ‘It’s happened with
the military already and when civil volume is added, I think
we will get to the point where Moore’s law really shows us
what can be done.
CASA has a full program of planned
training, licensing, certification changes
and education over the short-, mediumand
long-term, from now to 2030:
Integrating remotely-piloted aircraft (RPA)
into airspace
Further developing the rule set—reviewing and
updating CASR part 101, and releasing a suite of
eight advisory circulars: general UAS, training and
licensing, operations, manufacturing and initial
airworthiness, and continuing airworthiness
Regulatory oversight—for CASA, flying RPA safely
is paramount. Illegal operations will be penalised
Education: of the UAS sector, the aviation industry
and the general public.
‘When I first came into the industry ten years ago, the only
sensors were lipstick cameras like the ones fitted to Formula
One cars—they cost a few thousand dollars each and you
could just about see something on the ground from 3000
feet. Then there were infrared sensors, and all you could
see with them was a white blob on the ground. Since then
the resolution of those sensors has roughly doubled every
18 months, to the point where you can carry a useful suite
of sensors in a small UAV. The latest Aerosonde for the US
military allows the operator to differentiate between a shovel
and a weapon in a person’s hand.

12
FEATURE
Unmanned aircraft
UAS enablers
Although UAS are not new, having precedents from
before the Wright Brothers, such as the pilotless
balloons used in the Austrian bombardment of
Venice in 1849, a number of factors have enabled
their increasing take-up in aviation. These include:
The widespread civilian use of GPS, following
the U.S. decision to end selective availability of
the system in 2000
Powerful lithium ion batteries have made
practical small RPAs possible, particularly in
conjunction with brushless electric motors
Development of microelectronics made
sophisticated flight control systems and
lightweight sensors possible
Advances in robotics, which brought artificial
intelligence and self-learning computer software.
Some RPAs can now analyse their previous flight
paths and fly more accurately on their next pass
Development and commercialisation of strong
lightweight materials, including carbon-fibre
composites.
At the same time, the weight of the system has halved every
18 months. Now on a 35kg aeroplane you can have daylight
video, nighttime video and probably low-light TV as an
intermediate. All of that in a six-degree-of-freedom gimbal
mount. Prices have remained quite high, but bang for buck has
gone asymptotic (exponential).’
ARCAA is working on the next level of UAS ‘detect and avoid’
technology—dynamic detect and avoid, which encompasses
a seamless automated process of threat detection, evaluation
and avoidance. In recent trials with a vision-based system
fitted to a Cessna 172, the sensor was able to ‘see’ a small
RPA at 10km, far beyond human visual range.
Peter Smith says when it comes to the avoid part of ‘detect
and avoid’ even experienced engineers, himself included, have
fallen into the trap of thinking that a UAV must behave like a
manned aircraft. He realised his error in what he describes as
an Isaac Newton moment.
‘What you need to create is a system on the aircraft that
can detect something unusual, and in a very few seconds,
calculate the likelihood of a collision and take action to avoid.
‘I was driving and drove towards some piping shrikes. One of
them wasn’t looking and I almost got him, but he just threw
himself sideways. This bird was thinking, “forget the laws of
aerodynamics—I’ll recover later”. I suddenly thought, “That’s
it”. The Aerosonde is designed to take 25 G because it is
recovered in a net. You could never subject human beings to
that sort of force, but with a UAV you don’t have to. You can
do the tightest turn that the good Lord ever saw, and get out of
the way. As soon as I mentioned it to one of our researchers
he said, “of course”.
‘We have the potential to give the aircraft a considerable ability
to protect not just itself, but other aircraft’, Smith says.

Flight Safety Australia
Issue 87 July–August 2012
13
‘You have to think of communication
on several levels when you operate
a UAV: how you control your vehicle,
how you talk to the world and how
you talk to your ground crew’
But technology is only one aspect of safe operations.
The importance of communications emerges as a common
theme among UAS developers.
‘You have to think of communication on several levels when
you operate a UAV: how you control your vehicle, how you talk
to the world and how you talk to your ground crew’, says BAE
Systems’ technology and development program engineering
manager, Nelson Evans.
‘We decided to speak openly about what we were doing so
there were no surprises for any parties’, he says.
BAE Systems operates the Kingfisher unmanned aircraft
system at its flight test and development centre in West Sale in
Victoria, within RAAF East Sale’s airspace. ‘We operate under
a CASA agreement, during daylight hours in a pre-defined flight
zone, NOTAMed when we operate. We’ve operated with mixed
traffic without issue; that is among RAAF training, general
aviation, trike operators and the like,’ Evans says.
‘One of the early lessons was that communication with the
broader community was highly valuable. We talked to all
the operators, the council and the farmers about what we
were doing. Eight years ago, UAVs were rare and not always
discussed in positive terms.’
Future challenges
What particularly worries the UAS sector of aviation is
what happens when the reality of RPA operation and its
public image literally collide.
UAS operators emphasise the operational discipline and
technological redundancy they must have in order to fly,
but several say this is not always reciprocated by manned
aviation. One researcher said that ‘although UAS operations
must advise their presence with a NOTAM, in practice many
general aviation and recreational pilots either do not read the
NOTAM, or having read it, on several occasions decided to
fly into UAS operating areas “to have a look”.’
Another explains what he described as the ‘Florida problem’
put to them by the U.S. Federal Aviation Administration.
An Australian UAS operator had to walk away from a lucrative
contract for highway surveillance in the southern state.
‘The problem is the state is full of rich retirees and a significant
number of airport condominium developments. You have
80-year-olds with their 40-year-old Piper Cherokees parked
outside their houses. Your danger with a UAV in Florida is
somebody like that is going to whack into our aircraft one day.’
A third UAS insider was brutally succinct: ‘We have triple
redundancy in our systems—they have the mark one eyeball.’
There are also some specific, and immediate, technological
challenges for UAS.
Peter Smith says: ‘The reliability level of UAVs is not yet
as high as CASA would want for completely autonomous
operations in densely populated areas.’
Malcolm (Mac) Robertson, technical airworthiness manager
with BAE Systems, sees two distinct challenges. ‘GPS or any
satellite-based system is not reliable enough for use in UAS.
The response in military research is to look at navigation
through feature-recognition systems, revisiting the technology
of inertial navigation and using magnetic field detection.’

14
FEATURE
Unmanned aircraft
Another challenge is radio frequency spectrum allocation.
‘The radio frequencies allocated to UAS need to be secure.
It’s a question of bandwidth, which will increase as UAVs and
their sensors become more sophisticated, and of integrity.
There needs to be sufficient bandwidth for future operations,
and that part of the spectrum needs to be free from
interference by other radio users.’
‘We can check every engine’s power
usage at any time ... Every single
flight you do is recorded and can’t
be deleted.’
Recently, BAE Systems successfully demonstrated a UAV
recovery to an airfield unfamiliar to the aircraft’s mission
system and without GPS. This was achieved exclusively
through on-board sensors and a single geographic location of
the airfield.
The intermittent reliability of GPS navigation systems for UAS,
and the threat of their communication links being jammed,
could result in catastrophic consequences, regardless of
built-in redundancies and INS (inertial navigation system)
back-up. BAE Systems has developed technology that would
improve the safety of UAS missions and negate the reliance on
GPS for safe, accurate navigation. According to Brad Yelland,
BAE Systems’ head of strategy and business development:
‘This new technology … provides that extra capability for
UAV operators to make emergency landings to non-surveyed
airfields, especially in high-impact airspace where the
operational situation changes continuously.’
Security and potential misuse are concerns Yamaha takes on
with usage restrictions on the R-Max unmanned helicopter
they plan to use for aerial applications in Australia. Yamaha
Sky Division pIans to introduce the R-Max into Australia
early next year, with projections for 36 R-Max to be in
operation in the first 12 months. But the UAV helicopter will
only be allowed to be leased, not bought outright, and only
to approved and licensed operators. Yamaha Sky Division
business development manager, Liam Quigley, says its GPS
system incorporates a geo-fence, which disables the R-Max
if any attempt is made to operate it outside a pre-agreed area.
Even within the agreed zone, any attempt to tamper with the
R-Max’s digital flight recorder will prompt its flight control
computer to shut down, rendering the aircraft inoperable.
However, not all RPAs are as sophisticated. Some operators
look with dismay at what has been referred to as ‘the toy-shop
end of the industry’.
‘There’s a lot happening that’s literally under the radar,’
Clothier says. Unlicensed operators are using recreational
model aircraft to take pictures and video, blurring the line
between UAS and model aircraft in the public mind. Again,
the mainstream media are no help. A recent feature in
The Australian Financial Review carried the standfirst: ‘Get
ready for some adrenalin-pumping fun with a drone of your
own’, and went on to describe how the writer blithely lost
a $349 iPhone-controlled quadcopter ‘drone’ and ‘found
it dangling from a branch hanging perilously out over the
freeway below’.
Stories like these infuriate commercial quadcopter operator,
Paul Martin. His German-made Microdrones Systems aircraft
use the same grades of carbon fibre as military aircraft
(because they were originally military aircraft) and cost up to
$100,000. For a working helicopter that can earn an income
from aerial photography and survey that’s not as expensive as
it sounds, he explains.
The MD-4 400 and MD-4 1000 aircraft incorporate safety
and flight-recording systems more sophisticated than airline

Flight Safety Australia
Issue 87 July–August 2012
15
transport aircraft, he says. ‘We can check every engine’s
power usage at any time, its rpm, vibrations, efficiency, thrust
percentage of load—that’s just the motors. It even plots
your flight plan on Google Earth. Every single flight you do is
recorded and can’t be deleted.’
But Martin is dismayed that other operators, with much less
sophisticated equipment, and a less conscientious attitude to
regulations are devaluing his investment, damaging the image
of the industry and putting the public at risk.
‘We are deeply concerned that our ability to expand the
envelope of what we can do in future will be inhibited
significantly by those who don’t do the right thing and cause
problems. It happens in many industries, I suppose, where
the few wreck it for the many.’
‘I have had to knock back jobs that could not be done in
compliance with the regulations, only to find out other
operators have taken them on,’ he says.
‘The problem is that cheap equipment, almost overnight, has
become readily available. While it sort of works most of the
time it’s only a matter of time before these components fail.
Internet operator forums for these machines tell the real story,
he says. ‘They’re full of comments like “ it just crashed”
or “it flew away, I couldn’t control it”, and “it just does massive
circles in the sky”. Everyone’s asking everyone else how
to fix it.
‘Our machine is almost self-governing. It uses GPS to hover
automatically within a cubic metre. If anything goes wrong
we have the information to show what was happening,
and that information is generated by the machine not by us.
It’s impartial data.’
Aviation requires the best, he says. ‘When you go to the
airport you don’t see anything other than a Boeing or Airbus.
You don’t see half-price or quarter-price Chinese copies.
That’s not because airlines don’t want to save money—they
would buy them in a heartbeat. It’s because people’s lives are
at stake and only the best will do. I think that’s an appropriate
standard for all aviation.’
BOOK EARLY, LIMITED AVAILABILITY!

ATC notes
ICAO flight
notification changes
The changes to provisions for flight planning triggered by ICAO Amendment 1
to the PANS-ATM will soon be implemented.
When filing a flight plan, you will need to
understand the NEW format descriptors used in
Item 10 and the allowable indicators for Item 18.
The most noticeable change will be an
upgrade of the NAIPS web interface and
back-end processing as well as to the Flight
Notification Form. This will result in flight plans
and flight movement messages being created
and generated in the NEW format. Note that
NAIPS will be configured to accept only NEW
format descriptors.
Some of the key changes are as follows:
• Ability to file detailed communication,
navigation and surveillance capabilities by
use of new alphanumeric descriptors
• Filing an ‘S’ in Item 10a will indicate
carriage of VHF, VOR and ILS but will no
longer include ADF. An ‘F’ will need to be
filed separately to indicate carriage of ADF
• Only certain indicators will be allowed in
Item 18 STS/. This means that some of
the commonly used indicators like MED1,
MED2, SARTIME, VIP, etc will be invalid.
Alternative indicators and/or procedures will
be notified in AIP
• SARTIME details will be submitted in the
same format but in RMK/ rather than in STS/
Flight plans will be accepted up to five days in
advance but must include a ‘Date of Flight’ in
Item 18 (in format DOF/YYMMDD) if filing more
than 24 hours in advance.
Further information and links to key ICAO
documents can be found at
www.airservicesaustralia.com/projects
Information will also be made available through
AICs and AIP Supplements.

Check your flight notifications
The lodgement of a flight notification is
a critical step in safety of the airways
system. Whether you are planning a
multi leg IFR commuter flight or a weekend
getaway with a SARTIME notification,
completeness and accuracy of the notification
is crucial.
Lodging flight notifications via computer
or mobile devices has added a level of
convenience and safety that was not previously
available. However, as with many software
applications, what the operator thinks they
have input may not necessarily be what is
transmitted. For example, there have been
instances of pilots believing they have filed a
SARTIME, but because of the software on the
device they were using, the SARTIME field was
depopulated prior to sending.
The user interface of small devices can also
contribute to incorrect data being entered.
Remember, small screens and big fingers do
not go well together.
When a notification is submitted, NAIPS
replies to the originator with a copy of what
was received. Always check that the flight
notification NAIPS sends back to you is
correct, and is what you intended to submit. If
in doubt, call Airservices national briefing office
on 1800 805 150 or 07 3866 3517. This simple
cross check could save you time, money, or
even your life

18
Accident reports
International accidents | Australian accidents
International accidents/incidents 20 April – 3 June 2012
Date Aircraft Location Fatalities Damage Description
20 Apr Boeing 737-236 2.5km SW of Benazir
Bhutto Int. Airport,
Pakistan
21 Apr Curtiss C-46F-I-CU Santa Cruz Viru-Viru Int.
Airport, Bolivia
127 Destroyed Passenger aircraft (first flight 1984) destroyed on approach
to Islamabad, after a Bhoja Air inaugural flight from Karachi.
The plane crashed, broke up and burned in a rural area,
killing all on board, in weather described as poor, with limited
visibility, thunderstorms, rain and the possibility of wind shear
or a microburst.
3 Written off Cargo plane (first flight 1945) crashed about 200m from the
northern end of the runway during a go-around shortly after
take-off. Three crew members were killed, one survived.
25 Apr Pilatus PC-6 30km from Muara, Borneo 2 Destroyed Aircraft crashed at the edge of a ravine a few minutes after
the passenger sent a text message reporting a fuel problem
and anticipating an emergency landing. Both the passenger
(an aerial photographer) and the pilot were killed.
28 Apr Antonov 24 Galkayo Airport, Somalia 0 Written off Passenger aircraft sustained substantial damage in a landing
accident. A witness said that ‘its tyres blew out, then it leaned
to the right side until it broke into two pieces’. Fortunately,
there were no fatalities.
30 Apr ATR-72-212A Dhaka-Shajalal Int. Airport,
Bangladesh
2 May Cessna 208B
Grand Caravan
9 May Sukhoi Superjet
100-95
10 May Super Puma
EC225
0 Substantial A Royal Thai Air Force aircraft sustained damage in a
runway excursion while landing. It came to rest against a
concrete barrier, causing substantial damage to the RH wing.
Two passengers reportedly suffered minor injuries.
Yambio Airport, S. Sudan 0 Substantial UN World Food Programme aircraft (first flight 1992) hit a
drainage channel on landing and flipped over. One pilot
and a passenger suffered non life-threatening injuries.
75km S of Jakarta,
Indonesia
40km off the coast of
Aberdeen, UK
14 May Dornier 228-212 5km SW of Jomsom
Airport, Nepal
45 Destroyed New aircraft on a demonstration flight destroyed when it hit
the side of a mountain in poor weather. It is suspected that
the aircraft had deviated from its planned flight path and lost
altitude before crashing. The manufacturer says that there
have so far been no indications of any failure of the aircraft’s
systems and components.
0 Unknown Helicopter carrying workers to two offshore oil rigs ditched
after an oil pressure warning light came on. Investigations
revealed a crack in the bevel gear shaft, and suggested a
possible ‘manufacturing defect’. All 12 passengers and two
crew were rescued, with no major injuries.
15 Destroyed Passenger aircraft (first flight 1997), on a flight from Pokhara
destroyed when it struck the side of a mountain, killing two
pilots and 13 passengers. Five passengers and the flight
attendant survived. The pilot had apparently told ATC that he
was returning to Pokhara moments before the crash.
17 May ATR-72-212A Munich Airport, Germany 0 Substantial Shortly after take-off the pilot of a passenger aircraft (first flight
2001) reported smoke in the cabin and decided to return to
Munich. On approach the pilot reported engine problems and
feathered no. 2 prop. After landing, the aircraft ran into the
grass and its nose gear collapsed. One passenger suffered
minor injuries.
18 May Antonov 2T Gödöllõ Airfield, Hungary 0 Substantial Biplane (first flight 1980) damaged in a fire on the ground.
Flames spewed from the engine during a test run and the RH
lower wing caught fire and burned out.
2 Jun Boeing 727-221F Accra-Kotoka Airport,
Ghana
3 Jun McDonnell Douglas
MD-83
near Lagos Int. Airport,
Nigeria
12 Destroyed Cargo aircraft (first flight 1982) suffered a runway excursion on
landing. All four crew members survived, but 12 people were
reported killed when the aircraft hit a minivan and a taxi. The
aircraft had been cleared to land during a thunderstorm but,
after landing in a pool of water, ran off the end of the single
runway, through a perimeter fence and into the vehicles.
~153+10 Destroyed Passenger aircraft (first flight 1990) destroyed when it crashed
into a residential area of Lagos, killing everyone on board
and at least 10 people on the ground. Just after take-off the
crew reported that they had lost power in both engines before
the plane clipped a power line and crashed into a two-storey
building north of the runway.

Australian accidents/incidents 01 April – 28 May 2012
Date Aircraft Location Injuries Damage Description
01 Apr PZL - Bielsko
50-3 Puchaz
11 Apr Ayres S2R-G10
Thrush
Flight Safety Australia
Issue 87 July–August 2012
Ararat Aerodrome, Vic Fatal Destroyed During initial climb, the tow line broke and the glider collided
with terrain. The two people on board were killed.
Moree Aerodrome, 313°
T 36km, NSW
Fatal Destroyed While conducting a ferry flight from St George, Queensland to
Moree, NSW the aircraft collided with terrain and burnt.
The investigation is continuing.
12 Apr Cessna 310R Marlgawo (ALA), NT Minor Substantial On final approach, at about 50ft AGL, the aircraft encountered severe
windshear and landed heavily. The investigation is continuing.
13 Apr Mooney M20J Yarrawonga Aerodrome,
Vic
Nil Substantial The aircraft landed with the landing gear retracted.
13 Apr Helicopteres
Guimbal Cabri G2
18 Apr Cessna 210M
Centurion
21 Apr Cessna 172R
Skyhawk
Camden Aerodrome,
NSW
29 Apr Cessna 150M Bourke Aerodrome, 047°
M 55km, NSW
01 May Piper PA-25-235/
A9 Pawnee
03 May Cessna 172R
Skyhawk
20 May Amateur-built
Hornet AG
Minor Substantial During jammed pedal recovery practice, the helicopter collided
with the ground and rolled over. The investigation is continuing.
Nyirripi (ALA), NT Serious Substantial On approach, the aircraft encountered gusting winds resulting in
loss of control. The crew were unable to regain control and the aircraft
collided with terrain. One of the two crew members onboard was
seriously injured. The investigation is continuing.
Archerfield Aerodrome, Nil Substantial During landing, the aircraft ran off the runway.
Qld
Leongatha Aerodrome,
018° T 13km, Vic
Camden Aerodrome,
NSW
near Gloucester (ALA),
NSW
28 May Cessna 172 Wentworth Aerodrome,
WSW M 10km, NSW
Fatal Destroyed During mustering the aircraft collided with terrain.
The investigation is continuing.
Fatal Destroyed It was reported that the aircraft collided with terrain.
The investigation is continuing.
Nil Substantial The aircraft landed hard, resulting in substantial damage.
Minor Substantial During cruise, the engine lost power and subsequently failed
during the return to Gloucester. An engineering inspection revealed
that the reduction drive gear box had failed.
Fatal Substantial The aircraft collided with terrain, killing the pilot.
The investigation is continuing.
19
Australian accidents
Compiled from the Australian Transport Safety Bureau (ATSB).
Disclaimer – information on accidents is the result of a cooperative effort between the ATSB and the Australian aviation industry. Data quality and consistency depend on the efforts of industry
where no follow-up action is undertaken by the ATSB. The ATSB accepts no liability for any loss or damage suffered by any person or corporation resulting from the use of these data. Please
note that descriptions are based on preliminary reports, and should not be interpreted as findings by the ATSB. The data do not include sports aviation accidents.
International accidents
Compiled from information supplied by the Aviation Safety Network (see www.aviation-safety.net/database/) and reproduced with permission.
While every effort is made to ensure accuracy, neither the Aviation Safety Network nor Flight Safety Australia make any representations about its accuracy, as information is based on
preliminary reports only. For further information refer to final reports of the relevant official aircraft accident investigation organisation. Information on injuries is not always available.

20
FEATURE
Helmets in aviation
A hard-headed look
at helmets
The law says you need a
helmet to ride a bicycle
in Australia—and a life
jacket if you board a
boat—but you are free to
fly in any type of aircraft
with a bare head.
That’s not going to change; CASA is not
planning to make helmets compulsory. To
wear a helmet, or not, is every individual’s
decision. But that decision should be an
informed one.
Most research and documentation on
the usefulness of helmets comes from
military helicopter aviation. The results
are unambiguous.
When the US Army evaluated the
effectiveness of its SPH-4 flight helmet,
it found unhelmeted helicopter cockpit
occupants were 6.3 times more likely to
suffer a fatal head injury and 3.8 times
more likely to have a severe head injury
than helmet wearers. The analysis looked
at severe accidents that were at least
partially survivable. Unhelmeted occupants
in the passenger or freight area of the
helicopter were even more likely to be
injured if not wearing a helmet.
They were 5.3 times more likely to suffer a
severe injury and 7.5 times more likely to
have a fatal head injury.
The author of the US study, John S.
Crowley, extended his conclusions
to civilian flying. ‘Although much civil
helicopter flying is obviously different
from tactical military aviation (controlled
airspace, high altitude, busy airports),
some civilian flying is very similar … it
does appear reasonable to apply these
military data to civilian helicopter scenarios
with similar flight profiles,’ he wrote.
A guide for US government employees
quotes some impressive examples of
helmeted occupants of helicopters who
escaped serious injury. They include an
occupant who suffered two rotor blade
strikes to the helmet but escaped without
permanent head injury. In another case, a
helicopter hit the ground inverted and the
seatbelt failed: the survivor had no head

Flight Safety Australia
Issue 87 July–August 2012
21
injuries. Another helicopter came
down on its left side after a 100-foot
fall—without serious head injuries to
the helmeted survivors.
In 2009, an agricultural helicopter pilot
wearing a helmet and a four-point harness
survived a wirestrike near Albury, NSW that
destroyed the Bell 206 he was flying.
Some types of aviation obviously carry
elevated risk. Agricultural flying, aerial
firefighting, powerline work and mustering
come to mind. But for helicopters in
particular, activities often thought of
as fairly safe are prominent in accident
statistics. When the Australian Transport
Safety Bureau looked at light utility
helicopter safety, it identified private flying
and flying training as the second and third
largest categories of accident flights after
aerial work, (which included mustering).
For Australia’s most popular helicopter, the
Robinson R22, private flying and training
each produced about six times as many
accidents as aerial agriculture. In short:
elevated risk does not always announce
itself by being high-G and low-level.
By keeping you conscious and allowing
you to escape from the cockpit of a
crashed aircraft, a helmet can save you
from burning to death or drowning—there
are many examples of this—and many
other cases where incapacitated aircrew
died who might have lived had they been
wearing helmets.
A less well-known safety benefit of helmets
comes from how their visors protect the
face. The US Army found that in 25 per
cent of accidents to helmeted aircrew, it
was the visor that prevented or reduced
injury. In 22.2 per cent of accidents the
visor prevented injury. The study found:
‘crewmembers who wore their visors
down sustained minor injuries—caused by
the visor in many cases (often due to the
visor edge striking the cheek)—but there
were fewer fatalities among them.’
The ATSB noted in its report into a 2006
helicopter crash, where both the pilot and
feral animal shooter were wearing helmets,
and survived, that the pilot might have
been protected from facial and eye injuries
had his visor been down.
While not demanding it, CASA encourages
helmet wearing. For example, advisory
circular 21-47(0) on flight-test safety, of
April 2012, says: ‘For the early flights of
an experimental or major developmental
program, and for any flight in which there
is a chance that the aircraft may be subject
to a loss of control near or on the ground,
or may have to be abandoned while
airborne, a protective helmet should also
be worn.’
Some sectors of aviation have
unreservedly adopted helmets.
‘The Aerial Agriculture Association
of Australia strongly recommends all
application pilots wear helmets during
operations,’ says AAAA chief executive
Phil Hurst. ‘We have been teaching this
for years, it is included in the Aerial
Application Pilots Manual—and has almost
universal adoption within the industry.’
In Hurst’s opinion, the relevance of helmets
to the wider GA community depends on
the risk and the nature of the operation.
‘As a helmet or protective clothing is
classified as “PPE” —personal protection
equipment—it is on the bottom rung of
risk management. The highest order of risk
management is of course not to be there—
to eliminate the risk,’ he says.
‘While this is not possible in many ops—
and therefore the need for other mitigation
measures—it is certainly the case for
any GA pilot who might be tempted to
undertake low flying “for the fun of it”.
They simply shouldn’t put themselves in
the hostile, low-level environment.’
‘Of course, helmets and other PPE are just
another means of trying to get the odds on
your side for a favourable (safe) outcome
to every flight.’
Like most things in aviation, flight
helmets are not cheap. They can cost
up to $2000, although a small financial
mercy is that they can be inspected and
refurbished for further use, unlike, for
example, motorcycle helmets, which can
be equally expensive but are recommended
for destruction after a certain lifespan.
Sport aviation helmets are available for
hang glider, trike and three-axis ultralight
occupants.
Nobody plans to have an accident: nobody
wants to have an accident. All sensible
pilots take precautions with their aircraft
and how they fly it, so they do not have an
accident, or minimise its effects. Wearing
a helmet is one such precaution that has
been shown to work. The decision to wear
one is yours. On your head be it.
Further reading
1991 US Army helicopter crew helmets study
www.ncbi.nlm.nih.gov/pubmed/1890485
Helmet use: What message are we sending to
patients? Ted Ryan, Beth L. Studebaker, Gary
D. Brennan Air Medical Journal Volume 13,
Issue 9, September 1994, Pages 346–348
Helicopter Safety Vol. 24 No. 6 November-
December 1998 Flight Safety Foundation,
Alexandria, VA, USA
ATSB investigation reports: 2006—
200606510, and 2009 B206 Albury wirestrike

22
FEATURE
Aerodrome safety
A big thank you to the 242 certified and registered aerodrome operators
who completed the Aerodrome Safety Questionnaire in September 2011.
This valuable feedback equated to a 76 per cent response rate.
The 2011 survey provided a picture of the scope and size of
certified and registered aerodrome operations. Close to one fifth
of all aerodromes see only one flight or less on average per day,
while 50 per cent have between 10 and 100 flights per week.
The majority of aerodromes (68 per cent) are operated by
local government organisations. Twenty per cent of the aerodrome
operators are private enterprises for profit.
Almost half of all aerodromes reported employing only one
or no full-time staff to run the aerodrome. The largest
aerodromes, representing five per cent of the total, employ
60 per cent of all full-time airport operator staff.
10% 2%
The survey collected information regarding aerodrome
operations such as:
the turnover of key personnel
the ability to hire staff for key positions
20%
Responsibility for
daily operations
68%
changing workload conditions across the industry.
This sort of information regarding industry stability
provides important insights into potentially increased risk
associated with change.
Turnover rates for the aerodrome manager, head of operations
and head of safety are all relatively similar, with around 25 per
cent of current managers holding their positions for less than
a year. The head of airfield maintenance position seems to be the
most stable, with 60 per cent having held their role for more than
five years.
Other
Private enterprise not-for-profit
Private enterprise for profit
Local government

Flight Safety Australia
Issue 87 July–August 2012
23
Threat species by climate zone
4
6
te zone
Number of aerodromes
One third of the respondents stated that foreign object damage
(FOD) control is the sole responsibility of airport operators
or local council personnel, whilst 25 per cent see FOD as the
responsibility of everyone working airside.
Just under half of the responding aerodromes have a runway
safety program in place.
Airport runway safety program
45
40
35
30
25
20
15
10
5
0
Very small
0–1000
annual movements
Small
1000–5000
Medium
5000–20,000
Yes
No
Unknown
Large
more than
20,000
34
30
20
14
28
Kangaroo/Wallaby
5
7
11
21
Galah
8
18
13
11
2
5
9
Lapwing/Plover
3
7
8
Flying Fox/Bat
1
4
Kite
10
25 30 35
One section in the questionnaire was dedicated to wildlife
unt of eight or more management. The majority of respondents indicated that their
aerodrome has a wildlife hazard management plan. Around 30 per
cent of the smaller airports (those with fewer than 5000 annual
aircraft movements) do not have such a plan. When these figures
are ranked according to aerodrome type—registered versus
certified—only 20 per cent of registered aerodromes have a wildlife
hazard management plan, as opposed to 80 per cent of the certified
aerodromes. Almost 80 per cent of aerodromes that carried out a
risk assessment said they had a wildlife hazard management plan.
Most respondents rated the risk of wildlife on their airport as
low, with the larger aerodromes often reporting a medium risk
(46 per cent). Generally, tropical and subtropical area aerodromes
rated their wildlife risk as higher than the operators in more
temperate regions.
Respondents who rated the risk of wildlife as medium or high were
asked to indicate the specific species that posed the highest risk on
their aerodrome. A maximum of three species could be selected.
The results are shown opposite, broken down by climate zones.
13
Ibis
1
4
6
9
Duck
Magpie
Note: flying-fox/bat–only species with a count of eight or more
are displayed
Tropical and Equatorial
Subtropical
Desert and Grassland – hot
Desert and Grassland – temperate
Temperate and Alpine
2
7
4

24
FEATURE
Aerodrome safety
Most aerodrome operators selected kangaroos and wallabies
as problematic species throughout all climate zones.
Although the actual number of animal strikes is low, there is
a relatively high possibility of aircraft damage arising from
animal/marsupial strikes compared to bird strikes.
While the lapwing/plover and flying-fox/bat species are the
most common bird/mammal types struck in Australia, they
only come fourth and fifth respectively in the ranking of
risk species as identified by the aerodrome operators. The
highest single bird species struck is the galah, making up a
significant proportion of bird strikes in New South Wales, the
Australian Capital Territory and South Australia. The survey
results support this finding; the majority of aerodromes rated
the galah as the highest-risk bird type, in all climate zones.
Galahs are known to have flocking tendencies, which may
lead to multiple bird strikes. Flocking behaviour may also
explain why ten aerodromes rated ducks as a hazard.
There are some significant differences in problematic
species by climate region. In the hot desert and tropical
areas, kite species pose the most significant wildlife risk for
aerodromes, whereas temperate areas face most difficulties
with galahs and ibis.
Operators were asked to rate a list of possible risks to
aviation safety as high, medium or low. The majority of
aerodromes rated the presented risks as low or no risk.
Certified and registered aerodromes showed a very
similar pattern in their risk rating.
Aerodrome operators were more likely to rate
organisational risks as high or medium than operational
risks. A lack of funds, closely followed by the inability
to attract skilled staff and the age of facilities were most
often identified as medium- to high-risk issues.
The Aerodrome Safety Questionnaire also gave operators
the opportunity for feedback about their perception of
CASA. Almost 70 per cent of participants reported that
CASA had been helpful, or very helpful, in identifying
important safety issues that their organisations had not
previously been aware of. Similarly, over 80 per cent of
aerodrome operators found the CASA website helpful.
Operators’ responses have given CASA a wealth of
valuable information relating to many potential aviation
safety issues.
Operational risks
Wildlife
Emergency
Fuelling safety
Runway safety
Inadequate maintenance of airfield
Vehicular safety
Transport/storage of dangerous goods
Debris in operational area
Use of alcohol and other drugs
Signs and markings
%
0 10 20 30 40 50 60 70 80 90 100
No risk
Low risk Medium risk High risk

Flight Safety Australia
Issue 87 July–August 2012
25
A Hands-on Approach
Two flights, more than sixty years apart, have much to
teach about the importance of pilots staying involved and
never giving up, as an airline pilot reveals
Long before it was given a name, crew resource management
and the flying skills of First Lieutenant Lawrence M. DeLancey
brought a B-17 bomber back to Nuthampstead air base, in
England. It was November 1944 and flak over Germany had
blown the B-17’s nose off and damaged its hydraulic system.
The bombardier was killed by the flak burst, but ‘Larry’
DeLancey and his co-pilot Phil Stahlman saved the rest of the
aircraft’s crew. Their reward was life. DeLancey lived until 1995
and Stahlman went on to a 40-year career as an airline pilot.
A report on the landing described how the pilots sat stunned
in the cockpit afterwards and how DeLancey was able to walk
only a few paces before ‘he sat down with knees drawn up,
arms crossed and head down.’
Decades later, in a peaceful European sky, Turkish Airlines flight
TK1951 began its approach to Schiphol airport, Amsterdam.
Within a minute of touchdown the approach became a
disaster—in still, clear air, the Boeing 737-800 stalled and
crashed. The links in this accident chain have been disclosed
in the Dutch Safety Board report, in exquisite detail. I have no
new revelations, but merely pose some questions to give pilots
something to think about.
With 20/20 hindsight, the proper actions are obvious—they
always are. Why did the captain, who was a senior instructor,
not take over manually and hand-fly the approach? He had
already identified that the aircraft had diminished functionality
with impaired and defective systems.

26
FEATURE
Flying operatiions
If not then, why did he not take over when the
localiser was intercepted, late, at a tight 5.5nm
and 2000 feet?
When I flew into Schiphol, I recall that the
approach controllers preferred a quiet, idle
thrust, constant descent, approach with little
or no chance for a level period to comfortably
capture the glide slope, especially approaching
from the north and east of the airport. That’s
how it was more than ten years ago.
It is a common occurrence around the world
for an aircraft to be vectored too close and too
high to the runway, forcing the glide slope to
be captured from above. The steep descent,
on a non-precision approach, adds to a crew’s
already high workload.
Automatic flight systems, such as autopilot
and autothrottle, increase fuel savings, reduce
crew workload, and give more opportunity
for situational awareness, but may also make
pilots too complacent, too comfortable, lazyminded,
and out of practice when hand-flying
becomes necessary. Underlying systems
malfunctions could be masked, especially when
the crew lacks a complete understanding of the
automated systems’ interactions. Automation
can set deadly traps for a crew not on top of
their game.
To this add training that is perfunctory and
uninspiring, that is inadequate, outdated, and
lacking standardisation between one instructor
and the next. Combine it with non-existent
or poor CRM, and watch the problems in the
cockpit swell.
Turkish Airlines TK1951 crash site
We know from the accident report that the radio altimeter gave the autopilot
false information. This forced idle thrust and, uncorrected, led to the stall. But
this accident was completely preventable, had the captain taken control and
manually flown the approach.
At what point would it have been prudent for the captain to take physical
control of the aircraft? In the performance of his pilot monitoring duties, the
captain was not proactive in his support of the first officer, who was pilot
flying. Was the captain too comfortable with his first officer’s handling of
the aircraft, the fact the weather was not too threatening and that the aircraft
was being flown on autopilot? Did he just assume, because the approach
procedure was one he had done a hundred times before, that there would
be no drama that day? We have all fallen into that trap, regardless of how
disciplined and professional we think we are.
Had the captain been vigilant, as he was supposed to be as pilot monitoring,
had he been calling out the flight mode annunciations on the primary flight
display (PFD), and monitoring engine instruments, such as abnormally low
N1 (low-pressure compressor rpm) and fuel flow, he would have immediately
realised that there was something abnormal about the profile and the aircraft’s
automation. (Editor’s note: See the feature article in Flight Safety Australia
March-April 2012 for a discussion on the difficulties and poor definition of the
pilot monitoring role.)
Typically, when I was flying the Boeing 737NG, on final approach, after gear
down and flaps 15, I would call for ‘flaps 30 - landing checklist’ at about 1300
feet. I would let the aircraft re-stabilise, disengage the autothrottle, checking
that N1 was approximately 57 per cent, then disengage the autopilot and
hand-fly the approach from 1000 feet to landing rollout. Maybe this technique
allowed me to dodge the bullet that brought down TK1951. Maybe I was
just lucky.
As a pilot, I would like to get something out of every flying day that reminds
me I am still a pilot. Taking manual control of the aircraft to hand-fly is a rare
opportunity that I really enjoy, whether as captain or first officer. It is also
an opportunity to refresh my hand-flying skills, which I may still need for
a visual circuit when the autopilots have failed, or if I have a simulator
proficiency check.

Flight Safety Australia
Issue 87 July–August 2012
27
Loss of control has become one of the largest contributors to aircraft
accidents, and it is not just a problem for commercial transport-category jets.
It affects every category and class—agricultural pilots making uncoordinated
turns, seaplanes attempting take-off on glassy water, helicopters that lose tail
rotor authority from a steep downwind approach, or from extreme manoeuvres
(cowboying the aircraft) during cattle mustering. Helicopters self-destructing
due to ground resonance, a medium twin in severe turbulence, a turboprop
airline crew that failed to recognise icing, a corporate jet hitting wake
turbulence from a Boeing 757, (surprise, surprise), a transport category jet
with a rudder hard over––all loss of control.
1st Lt. Lawrence DeLancey’s crippled B-17 at Nuthampstead
October 15, 1944
In all preventable loss-of-control aircraft accidents
the common denominator is the crew’s response—
or lack of response—to an event.
The solutions are well known, but easier to list
than implement. Meaningful initial and recurrent
training (this means more than playing ‘stump
the dummy’ in the simulator), crew vigilance,
discipline and professionalism are the keys to
preventing future loss of control accidents.
For the pilot all this boils down
to two principles: always stay
mentally engaged and never give
up flying the aircraft.
I learned this from a personal experience on the
simulator. During a recurrent training session a
few years ago, I was paired with a captain who
had been trained by a large Asian airline. Both
of us were captains for the same airline, on
the same fleet. I was in a supporting and pilot
monitoring role, in the right-hand seat. While
flying upwind, the aircraft ended up inverted.
The captain said, ‘That’s it, we’re dead’, to
which I replied, ‘*** **** ** ***!’ I took
control, immediately applied full thrust and
pushed forward on the yoke, to climb while
inverted. I rolled the aircraft shiny-side-up at
about 3000 feet. Then I asked him, ‘Are we
dead?’ I transferred control and said, ‘Never
give up flying the aircraft!’
I flatter myself to think that Larry DeLancey,
who was 25 when he made his epic flight,
would have approved.
Extra 500 Turboprop
luxury business tourer
– Carries more
– Flies farther
– Costs less
– Compare for yourself
For more information on a demonstration flight in your region please contact
John Rayner on 0418 311 686 or john.rayner@aviaaircraft.com.au
www.aviaaircraft.com.au

28
FEATURE
Hazard ID
In plane sight –
hazard ID and SMS
PASSENGER
CITIZEN / JOHN MR
DATE
JULY 2012
CARRIER
CITY AIR
CASA safety systems
inspector, Leanne
Findlay, and ground
operations inspector,
David Heilbron, look at
the vital role hazard-
ID plays in safety
management systems
Operational safety
Aviation companies have different safety-related procedures. A ‘keeping-it-simple’
approach assumes a basic understanding by all staff (including subcontractors),
across all areas of the operation, of the hazard identification processes and
procedures available to them.
You can use The SHEL model (sometimes referred to as the SHEL[L] model) to help
visualise the relationships between the various parts of an aviation system. This model
emphasises individual human interfaces with the other parts of the aviation system, in
line with International Civil Aviation Organization (ICAO) standards.
The process of hazard identification never stops. Every flight is different, every
passenger and combination of passengers is different, and new technology and its
effects on the various combinations of interfaces can create new hazards and, in turn,
risks. Many organisations are now developing safety management systems, which
ideally reflect an ability to continually review and improve processes and procedures
to adapt to change.
Introducing any change to an operation should elicit more safety reports, and this
additional data can be analysed, acted upon and monitored to mitigate risk. Change
might include the fine-tuning of procedures, new equipment, a reduction or increase in
personnel, or turnover of personnel. During these changes, everyone with the ability to
report hazards and identify their potential risks needs to understand the many forms
hazards can take.

Flight Safety Australia
Issue 87 July–August 2012
29
CANBERRA ² BRISBANE
CBR ² BNE
FLIGHT
FSA87
BOARDING TIME
2030
GATE
8
SEAT NO.
12B
PASSENGER
CITIZEN / JOHN MR
FLIGHT
FSA87
When designing training, consider the target audience:
What do staff need to know?
What do staff need to look for? (e.g. baggage size and weight, able-bodied
passengers, oxygen bottle types, medical requirements.)
Why are these identified as hazards, or potential hazards?
Why do staff need to report hazards?
Will operational staff know what a hazard is if they do not understand the concept?
Why are identification and reporting important, even if the hazard does not cause
an incident or accident?
Anything noticed (smelt, seen, heard) and identified as a hazard has to be reported
to someone who can address the issue and prevent a possible incident or accident.
Operational staff need to know that their contributions to the safety reporting system
will be used to strengthen systems, in the spirit of a ‘just’ safety culture.
CASA safety systems inspector, Leanne Findlay, and ground operations inspector,
David Heilbron, recognise the importance of operational safety personnel
understanding what to report. Training of new staff, combining the use of theory,
role-plays and formal on-the-job experience of hazard identification, can consolidate
awareness of hazards and risks. Training records should document all forms of initial
and recurrent training. Asking experienced staff to mentor newer staff helps them to
recognise potential hazards in the workplace. Each event can have different variables,
and situations will not necessarily follow a scenario that the staff have seen before, or
read about in a textbook.
continued on page 64

30
FEATURE
Text here
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24 - 26 26 July July
The AA&S (Australia) Conference is for the benefit of all those
who operate and sustain our aerospace vehicles, military or civilian, large
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Obsolescence, Propulsion, Logistics and Supply Chain, Cost of
Ownership, Workforce Capability and Unmanned Aerial Systems.
Kindly sponsored by CASA and the RAAF, the event seeks to
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we’ve learned in the past translate to safer fleets for the future.
When and Where:
Brisbane Convention and Exhibition Centre (BCEC) over 24-26 July 2012.
Please see website for further details.
www.ageingaircraft.com.au/aasc

Flight Safety Australia
Issue 87 July–August 2012
31
Sneaky leaks
The problem of pinhole corrosion
When we think about corrosion in aircraft, most of us probably think of airframe structures.
However, there are plenty of unsettling examples of an insidious corrosion infecting the
network of aircraft aluminium plumbing, as fact-finding investigations for CASA’s ageing
aircraft management plan have discovered.
Corrosion is not just a problem for airframes. It’s also a
cancer for aircraft systems. A small but disturbing number
of the many service difficulty reports sent to CASA concern
pinhole corrosion in the aluminium tubing used in aircraft fuel,
hydraulic, oxygen and instrument systems.
Pinhole corrosion starts when moisture gets inside the
aluminium tubing that is embedded throughout the structure of
almost every aircraft. It collects into a pool at the low point, sits
virtually on one spot and provides the catalyst for corrosion
to start. Aluminium tubing can be found in the powered flight
control system, undercarriage brake system, the instrument
system and the fuel system. Moisture also collects in deactivated
oxygen system lines, but is usually only discovered
when the system is operated.
Little information is available on pinhole corrosion in aircraft.
It is, however, a known issue in household plumbing, where
it is attributed to age, water quality and sometimes, cavitation
induced by sharp bends. But there are sufficient reports
of pinhole corrosion reaching CASA for it to be
something every LAME should be aware of.
Not all pinhole corrosion requires liquid in a
pipe. One event known to CASA described
an AS350 helicopter with gross pinhole
corrosion in the engine compressor bleed
air line required for the windscreen de-icer/
demister.
pinhole
corrosion in the
aluminium tubing
used in aircraft fuel,
hydraulic, oxygen
and instrument
systems.
Such was the pressure loss though the corrosion holes that
the demister system, important for helicopter flight in cold or
humid weather, was inoperative.
One of the most disturbing incidents was recently reported to
CASA by an engineer doing an engine run after a scheduled
inspection. Concerned by the smell of fuel in the cabin, the
engineer immediately shut down the engine and eventually
found the cabin trim fabric and the aircraft’s rear seat cushions
were saturated in avgas.
‘This raised the distinct possibility of flight crew incapacitation
due to the fumes, or even fire or explosion in flight, which, of
course, makes a pinhole in a pipe a major defect,’ CASA senior
maintenance engineer, Roger Alder, notes drily.
‘Over the years, we’ve been receiving defect reports on pinholes
in hydraulic lines and fuel system lines, which can be attributed
to water precipitating out of either the fuel and/or the mineral
hydraulic oil and pooling in the low points of the system.
Airborne moisture typically enters the engine
oil, hydraulic oil, and fuel systems via the
vent systems (just by sitting on the ground
“breathing” due to normal atmospheric
changes) where it will later condense and
form small pools.’
‘Although the numbers involved are small,
there has been a recent increase in this type
of report,’ Alder adds.

32
AIRWORTHINESS
Pinhole corrosion
‘Pinhole corrosion in one section of the system can be a warning sign of more
extensive internal corrosion in other sections of the system and therefore may
require replacement of the entire tubing network.’
As any LAME knows, inspecting corrosion in an airframe
is exacting work; inspecting for corrosion on the inside of a
small bore aluminium line as it meanders through the wing
and fuselage is bordering on impossible, without hi-tech
equipment.
‘The key issue is, how do you inspect for this? It is truly
insidious, and inspecting for it requires technology at the
cutting edge of inspection techniques. Very small borescopes,
capable of operating over long distances and special electronic
metal thickness detectors would be required. Then comes the
question as to what data to be used,’ Alder says.
‘It would seem that pinhole corrosion could be mainly due to
aircraft having low utilisation over many years. But there’s
no telling when it could occur—a slight flaw in the anodising
inside a pipe could be enough to precipitate it.
It affects older aircraft more than newer ones, because the
corrosion takes some years to bite its way from the inside to
the outside of a pipe. On the basis of the number of reports
received by CASA, pinhole corrosion appears to be age- rather
than hours-related; although an aircraft which has been used
regularly over a long time might still have the problem. Using
an aircraft infrequently gives water time to collect and sit
between flights. It also gives the special additives added to
avgas at the time of manufacture time to evaporate.
‘While many aluminium pipes are rejected for a number of
reasons, including external corrosion, these pipes can look
perfectly normal on the outside until breached by pinhole
corrosion from the inside,’ Alder says. ‘Remember that the
pipe has been corroding from the inside out. The spot where
the pinhole occurred is just the first place at which it broke
through. You must also look at the matching component or
section of tubing on the other side of the aircraft—it may have
similar problems and be the next item to go.’
Alder says that considering existing manufacturers’
maintenance schedules, particularly those for light aircraft,
which rarely (if ever) include an inspection for internal
corrosion of the aluminium tubing, plus current inspection
techniques and technology, pinhole corrosion in aircraft is
looming as a potentially expensive problem to first of all find,
and then fix. ‘Pinhole corrosion in one section of the system
can be a warning sign of more extensive internal corrosion
in other sections of the system and therefore may require
replacement of the entire tubing network.
‘Some manufacturers permit splicing a replacement section
into a pipe but others do not, citing changes to fluid flow and
the creation of weak points where the splice is joined into
the pipe.’
What can aircraft owners do?
Store your aircraft in the best possible conditions—under
cover in as dry an environment as possible. The major
enemy is ingress of moisture and the main culprit appears
to be moisture in the low points of the system.
Replace tubing that has external corrosion.
Go flying. In other words: use your aircraft. Every flight
that generates heat from the engine, gets fuel and fluid
flowing through the aircraft’s network of pipes, and puts
the aircraft in a variety of attitudes, helps to reduce the
likelihood of pinhole corrosion forming.
Stay informed: If you hear of a case of pinhole corrosion
in a similar aircraft to yours, then you should inspect
or replace the corresponding part on your aircraft. You
can email sdr@casa.gov.au to check pinhole corrosion
occurrences for your aircraft type.
The reports
SDR510014540
Rigid hydraulic tubing located between LH wing root and
engine nacelle-contained corrosion pitting through wall
thickness resulting in loss of hydraulic fluid. Suspect caused
by tubing contacting flexible hose in wing channel.
Gulfstream 500S
SDR510014546
Rigid aluminium fuel line from LH tank to fuel cock contained
pinhole corrosion allowing fuel leakage into cockpit.
Pilot returned to land after smelling avgas in cockpit.
Investigation found corroded and leaking fuel gauge pressure
tube assembly. Tube corroded in area of contact with black
scat hose. Cessna 150
SDR 2011144
Defect description: Very difficult to determine exact cause.
The defect was noted and rectified while the aircraft airconditioning
system was being overhauled. When the cabin
floor panels were removed to carry out reinstallation of

Flight Safety Australia
Issue 87 July–August 2012
33
condensers it was noted that the insulation surrounding the
cross feed tube was fuel soaked and causing a slow drip of
avgas. The insulation was removed, exposing a very small
pinhole leak. Component then removed and replaced. Fuel tube
cut open to determine cause of leak. Corrosion (internal) found
to be the cause.
Opinion as to the cause of the defect: Corrosion and possible
introduction of water to flush fuel system during EDA
(ethylenediamine) cleaning. If water was introduced to fuel
system by any means it would, during periods of non use,
be liable to settle in the cross-feed tube and create the right
environment to start the corrosion process.
SDR 510010841
While performing engine ground runs strong smell of avgas
evident in cabin. On removal of interior trim, soundproofing
found saturated with fuel.
Investigation results: Fuel feed line from R/H source found to
be weeping avgas at the entry into the fuselage.
The solid aluminium tube was holed at this point due
corrosion. Replacement line installed and scoured, fuel
replenished. No leaks evident.
SDR 20020830
Defect description: corrosion due to water contamination.
(Solid aluminium tube was leaking/pinhole.) Opinion as to the
cause of the defect: corrosion and human factors.
SDR 510009700
Pilot returned to land after smelling avgas in cockpit.
Investigation found corroded and leaking fuel gauge pressure
tube assembly. Tube corroded in area of contact with black
scat hose.
SDR 20020090
Defect description: Aircraft was found to leak while in our
hangar for other defects. On further inspection the leak was
found to be coming from the R/H inboard transfer line. This
line was replaced. Inspection of the leaking tube revealed
pitting in the walls due to corrosion.
SDR 20000474
Fuel cross-feed RH tank to LH engine lower outboard fuel line
at the rear of engine firewall corroded approximately one third
of the way in from the end, causing fuel to leak into area rear
of engine firewall.
Hyd line assy left P/N: 31527-00 on flap operation system at sta 74.75
just forward of spar, inside of cabin

34
AIRWORTHINESS
Pull-out section
SELECTED SERVICE DIFFICULTY REPORTS
29 March – 16 May 2012
Note: Similar occurrence figures not included
in this edition
AIRCRAFT ABOVE 5700kg
Aerospatiale ATR42300 Aileron fitting corroded.
SDR 510014684
LH and RH aileron T-pick-up fittings in ribs 4, 11
and 12 corroded.
Aerospatiale ATR42300 Cabin cooling system
check valve broken. SDR 510014678
RH heat exchanger check valve broken. P/No: CT140A
Aerospatiale ATR42300 DC system wire broken.
SDR 510014677
Broken wire on negative stud of 22 PA battery shunt.
Aerospatiale ATR42300 Fuselage stiffener
cracked. SDR 510014683
Outboard aft wing pressure deck angle stiffener
cracked in area adjacent to wire support bracket
aft of frame 27.
Aerospatiale ATR42300 Landing gear actuator
corroded. SDR 510014685
LH and RH landing gear retraction actuators P/Nos:
D22898000-3 and D22897000-3 heavily corroded.
Aerospatiale ATR42320 Elevator stiff.
SDR 510014746
Elevator control system jammed/stiff in operation
– numerous bolts, bearings and bushes corroded/
deteriorated.
Airbus A320-232 Aileron control system
ELAC failed. SDR 510014812
No.1 elevator and aileron computer (ELAC) failed.
P/No: 3945128209
Airbus A320-232 APU smoke/fumes.
SDR 510014536
Strong smell in cabin affecting cabin crew.
APU replaced – no further unusual odours.
Airbus A320-232 APU oil system overfilled.
SDR 510014732
Strong oil fumes in rear of cabin. Investigation found
APU oil system overfull.
Airbus A320-232 Autopilot FMGC failed.
SDR 510014733
No.1 flight management guidance computer
(FMGC) failed.
P/No: 21SN04298A
Airbus A320-232 Door insulation odour.
SDR 510014598
After take-off an unusual smell reported from rear
galley. Crew identified a musty/mouldy smell from
L2 door. Engineer found wet insulation blankets.
Airbus A320-232 Exterior landing light missing.
SDR 510014521
RH landing light missing. Suspect light separated
during previous flight.
Airbus A320-232 Hydraulic pipe worn and
damaged. SDR 510014741
Rigid hydraulic pipe chafed by blue electric hydraulic
pump flexible supply line. Pipe failed, causing loss of
hydraulic fluid. Flexible pipe slipped in P clip and was
resting on the rigid pipe. P/No: D2777022306200
Airbus A330-202 IDG leaking. SDR 510014799
No.1 engine integrated drive generator (IDG) leaking
oil. Initial investigation found the input drive shaft
dislodged, with considerable damage done to the
QAD ring adapter and gearbox drive cup assembly.
Gearbox carbon seal and IDG seal O-ring damaged.
Investigation continuing. P/No: 75216B
Airbus A330-202 Fuselage floor panel melted.
SDR 510014581
Heated floor panel at D4L hot to touch (melted), with
smoke coming from panel. Investigation continuing.
P/No: F5367233300200
Airbus A330-202 Pneumatic distribution system
valve faulty. SDR 510014509
Dual bleed air system failure after fitment of
improved pressure transducer. Maintenance
investigation unable to find any fault with bleed
air system. P/No: 6764B040000
Airbus A380-842 Aircraft fuel distribution
system coupling leaking. SDR 510014749
Fuel leaking from No. 4 engine strut cavity.
Fuel coupling loose and not lockwired. During
disassembly, forward coupling connector P/No:
ABS0108-200 found to be chafed on the inner seal
surface. Investigation continuing.
Airbus A380-842 Fire detection system
connector loose. SDR 510014507
No. 4 engine fire detection system loops A and B
suspected to be faulty. Investigation found a loose
connector 5041VC that had been cross-threaded
and was only held on by half a turn.
Airbus A380-842 Passenger seat lock faulty.
SDR 510014574
First-class passenger seats (4off) had incorrectly
functioning and out of calibration 16G locks.
Investigation continuing.
Airbus A380-842 Wing rib cracked.
SDR 510014512
Wing rib crack inspection carried out iaw EASA AD
2012-0026
ATR72212A Nose/tail landing gear strut/axle
bobbin cracked. SDR 510014628 (photo below)
Nose landing gear towbar bobbin cracked. Suspect
caused by unknown pushback incident. NLG leg
removed for further investigation.
P/No: D56861. TSN: 1,260 hours/1,248 cycles
BAC 146-200 APU smoke/fumes.
SDR 510014690
Fumes from APU during troubleshooting
maintenance on ground.
BAC 146RJ100 Nose/tail landing gear attach
section bolt cracked. SDR 510014595
While carrying out AD/BAE146/071 no cracking of
nose gear actuator attachment diaphragm found.
However, the nose gear actuator to diaphragm
attachment bolt was cracked.
Beech 1900C Aircraft wing structure corroded.
SDR 510014814
Numerous areas of corrosion, cracking and loose
rivets in both wings.
Beech 1900C Hydraulic hose ruptured.
SDR 510014580
Landing gear failed to fully retract then extend.
Investigation found LH main landing gear extend hose
to actuator ruptured at firewall. P/No: 1013880167
Beech 1900C Landing gear position and warning
system switch faulty. SDR 510014743
Nil landing gear down indication. Investigation found
all microswitches serviceable. Further investigation
found a loose screw in the gear indicator switch
preventing a proper connection. P/No: 3080843101
Boeing 737376 Drag control system cable
broken. SDR 510014813
RH inboard flight spoiler control cable WSA2-4
broken approximately 152.4mm (6in) from end fitting.
Cable hanging from RH wing trailing edge.
Boeing 737376 Fuselage frame cracked.
SDR 510014547
Forward cargo door cutout fore and aft frames cracked
from outboard upper fastener hole at door stop
No. 3. Crack length approximately 6.35mm (0.25in).
Found during NDI inspection iaw EI 733-53-292R3.
Boeing 737476 Flight compartment window
delaminated. SDR 510014531
LH No. 5 cockpit window delaminated for
approximately 25.4mm (1in) in vinyl interlayer
at fore lower corner and aft upper corner.
Found during inspection iaw EI Gen56103R5.
P/No: 58935841.
TSN: 3,683 hours. TSO: 3,683 hours.
Boeing 737476 Battery failed. SDR 510014579
Main battery failed. Battery voltage had dropped to
6VDC. Investigation continuing.
P/No: 401767. TSO: 5 hours.
Boeing 73776N Drag control switch out of
adjustment. SDR 510014780
Speed brake lever switch out of adjustment, causing
take-off configuration warning.
Boeing 73776N Fuselage bulkhead doubler
faulty manufact. SDR 510014529
Fuselage doubler installation at Section 46 Stn 727C
to 747 had incorrect rivet pitch with the last row of
rivets failing to reach the tear strap at Stn 747E.
Found during incorporation of Boeing SB737-53-
1304R1 (live TV de-modification).
Boeing 7377Q8 Windscreen post cracked.
SDR 510014656
LH cockpit C-D windscreen post cracked beyond
limits. Crack length 27.9mm (1.1in). Found during
NDT inspection.
TSN: 30,122 hours/21,493 cycles.
Boeing 7377Q8 Pneumatic distribution system
smoke/fumes. SDR 510014665
Fumes reported in cabin after take-off. Engine ground
runs carried out. Investigation could find no definitive
cause for the smell.
Boeing 737-838 Airconditioning system
smoke/fumes. SDR 510014539
During descent a strong smell was noticed by the
flight crew in cockpit and cabin crew in the rear
galley area. Smell was described as ‘electrical,
metallic and burnt plastic’. It lasted for about two
to three minutes then dissipated. Nil defects found.
Aircraft released to service.
Boeing 737-838 Power distribution system
terminal block arced. SDR 510014571
Nose landing gear wiring conduit for gear sensing
and taxi light damaged at terminal modules 2 and 3
due to arcing between pins G2 and H2.
P/No: M817143DD1.
Boeing 737-838 APU FCU failed. SDR 510014752
APU fuel control unit faulty causing APU to shut
down. P/No: 4419215.
Boeing 737-838 EFB power cord damaged.
SDR 510014754
Electronic flight bag (EFB) power cord damaged.
Smoke was seen to be coming from the damaged
part of the cord.

Flight Safety Australia
Issue 87 July–August 2012
35
SELECTED SERVICE DIFFICULTY REPORTS ... CONT.
Boeing 737-838 Fuel indicating system loom
failed test. SDR 510014808
Centre fuel tank fuel quantity indicating system wire
bundle W7580 failed shield loop resistance check.
Resistance greater than maximum value.
Found during inspection iaw EI N37-28-72 Issue C.
Boeing 737-838 Trailing edge flap drive spline
worn and damaged. SDR 510014559
No. 7 flap transmission drive coupling splines on
the outboard side of the transmission coupling were
found to be excessively worn to the point of almost
disengaging completely. Opposite position to
No. 7 also found to be in a similar condition.
P/No: 256A37411.
Boeing 7378BK Rudder control system motor
inoperative. SDR 510014517
Standby rudder valve motor inoperative. Suspect
caused by failure or short circuiting of internal limit
switches. P/No: 106788A131.
Boeing 7378FE Fuel transfer valve faulty.
SDR 510014654
Fuel crossfeed valve faulty.
P/No: 125334D1. TSN: 31,857 hours/18,632 cycles.
Boeing 7378FE Hydraulic pump unserviceable.
SDR 510014692
No. 2 (System B) electric hydraulic pump failed.
Investigation found a faulty internal overheat switch.
P/No: 5718610. TSN: 870 hours/255 cycles.
Boeing 7378FE Bleed air system smoke/fumes.
SDR 510014556
Strong engine oil smell/fumes in cockpit.
Investigation found No. 1 engine had had a
compressor wash prior to its last sector.
Boeing 747-438 Nacelle/pylon access
panel missing. SDR 510014778
No. 4 pylon outboard access panel missing.
P/No: 484DR.
Boeing 747-438 Passenger compartment
lighting relay failed. SDR 510014769
Cabin, toilet and mid galley lighting inoperative.
Relay R1169 failed due to loose terminal posts A2
and C2. P/No: HTC7N060.
Boeing 747-438 Tyre failed. SDR 510014619
Main landing gear tyre failed. Initial investigation
found some panel damage. Investigation continuing.
Boeing 747-438 Windshield wiper separated.
SDR 510014673
First officer’s windshield wiper separated from
aircraft. Investigation could find no damage to the
aircraft. Investigation continuing.
Boeing 767-336 Aileron control gearbox faulty.
SDR 510014621
LH inboard aileron drooping. Investigation found
the LH inboard aileron droop angle gearbox
unserviceable. P/No: 256T34303.
Boeing 767-336 Hydraulic power wiring worn
and damaged. SDR 510014695
Wiring located behind hydraulic control panel worn
due to panel mount bolts being installed in reverse
causing bolt shanks to chafe on wiring.
Boeing 767-338ER Air conditioning smoke/
fumes. SDR 510014755
Strong engine/oil fumes smell. Suspect smell
originated from residual cleaning fluid in the
cargo areas.
Boeing 767-338ER Flight compartment window
damaged. SDR 510014591
First officer’s No. 2 window very hot. Outer pane
cracked and bubbled.
Boeing 767-338ER Fuel boost pump eroded.
SDR 510014725
LH main fuel tank aft boost pump housing inlet area
eroded beyond limits due to cavitation. Erosion also
found on the forward boost pump shut-off sleeve
and aft boost pump strut.
Boeing 767-338ER Nacelle/pylon access
panel missing. SDR 510014533
RH engine strut access panel missing from
inboard side.
Boeing 7773ZGER Galley station oven odour.
SDR 510014728
Burning smell from mid galley No. 3 oven (M711).
Oven removed for investigation.
P/No: 820216000001. TSN: 12,632 hours/1,126
cycles. TSO: 5,337 hours/401 cycles.
Boeing 7773ZGER Galley station oven
unserviceable. SDR 510014729
Forward galley No. 4 oven (F108) unserviceable.
Oven became extremely hot even after turned
off accompanied by a strong burning smell.
Investigation continuing.
P/No: 820216000001. TSN: 14,602 hours/1,208
cycles. TSO: 2,422 hours/182 cycles.
Boeing 7773ZGER Horizontal stabiliser structure
hose leaking. SDR 510014555
During heavy maintenance inspection level 2 and
3 corrosion damage was found in the horizontal
stabiliser compartment aft of Stn 2344. Corrosion
damage was caused by hydraulic fluid exposure to
both skin and stringer 40R and 43R.
P/No: 272W48201.
Bombardier BD7001A10 AC power connector
burnt. SDR 510014549 (photo below)
Wiring and connector behind galley close-out burnt/
melted. Investigation suspected that the wiring was
not correctly secured causing a build-up of resistance
and heat.
TSN: 629 hours/269 cycles.
Bombardier CL604 Pitot/static drain
contaminated with-water. SDR 510014775
Standby airspeed indicator (ASI) failed. Investigation
found water contamination of the pitot drain line.
Aircraft had been flying in heavy rain.
Bombardier DHC8202 Landing gear sparking.
SDR 510014791
Passenger reported sparks from LH main landing
gear in area between the tyres. Precautionary
air turnback carried out. Investigation could find
no defects and this is considered to be a normal
occurrence for metal brakes.
Bombardier DHC8202 Passenger compartment
light fitting burnt. SDR 510014612
Cabin RH side overhead fluorescent light fitting arced
and burnt. Fitting third from front on RH side.
Bombardier DHC8315 Hydraulic main check
valve leaking. SDR 510014792
No. 2 hydraulic system alternate rudder check valve
leaking. Loss of hydraulic fluid.
Bombardier DHC8315 Hydraulic pipe leaking.
SDR 510014655
Hydraulic pipe leaking. Pipe located on the inboard
side of the LH wheel well above the return filter
assembly and near the exhaust. P/No: 82970009279.
Bombardier DHC8402 Pressure valve outflow
valve malfunctioned. SDR 510014566
Aft outflow valve failed. P/No: 88060B010103.
TSN: 4,698 hours/4,939 cycles.
Bombardier DHC8402 Prop/rotor anti-ice/
de-ice system heater burnt. SDR 510014551
(photo below)
No. 1 propeller blade heater element burnt and
blade holed. TSN: 5,486 hours/5,880 cycles.
Embraer EMB120 Aircraft fuel tube worn and
damaged. SDR 510014753 (photo below)
LH fuel quantity indication harness inboard to
outboard fuel tank interconnect tube rubbing on rib
11 at Stn 2996.00. P/No: 12032086007.
Embraer EMB120 Elevator, tab structure trim tab
delaminated. SDR 510014565 (photo below)
LH elevator trim tab delaminated over approximately
75 per cent of upper and lower skin area.
P/No: 12020120015.
Embraer EMB120 Engine control wiring
connector corroded. SDR 510014659
(photo below)
Engine control wiring connector P/No: J0318
contaminated with water and severely corroded.
Wire W608-0114-240R (28VDC) cut through by
corroded connector.

36
AIRWORTHINESS
Pull-out section
SELECTED SERVICE DIFFICULTY REPORTS ... CONT.
Embraer EMB120 EHSI failed. SDR 510014578
Co-pilot’s EHSI (electronic horizontal situation
indicator) failed in cruise. Part replaced but unit failed
again on next flight. The second unit has a history of
premature failure and is to be removed from company
inventory. P/No: 6226342022.
Embraer EMB120 Landing gear retract/extension
system faulty. SDR 510014694
During landing gear retraction following take-off
the RH main landing gear indicating lights failed to
extinguish, accompanied by vibration from RH side of
aircraft. Landing gear extended and vibration ceased,
with the landing gear indicating down and locked.
Embraer ERJ170100 APU silencer delaminated.
SDR 510014623 (photo below)
APU air inlet silencer damaged and delaminated.
Investigation found large areas of delamination on
two of the three splitter plates, with a portion of one
splitter plate separated.
P/No: 4952354. TSN: 5,520 hours/4,600 landings.
Embraer ERJ190100 Escape slide incorrect fit.
SDR 510014544
During inspection of lens cover on L2 door,
emergency evacuation slide found to be unattached.
Investigation found hook brackets fitted correctly in
the clevis brackets but top screw not attached.
Embraer ERJ190100 Hydraulic union
incorrect fit. SDR 510014522
No. 2 engine hydraulic pressure line union incorrectly
installed on incorrect side of false spar, causing
misalignment and leaking from hydraulic pipe to
union connection.
Embraer ERJ190100 Passenger/crew door
cable failed. SDR 510014676
R1 forward service door flexball cable inner conduit
broken preventing door from being fully closed.
P/No: 17084031401.
Fokker F27MK50 Airfoil anti-ice/de-ice system
hose broken. SDR 510014713
LH inner leading edge anti-icing system hose broken.
Fokker F27MK50 Fuselage floor plate corroded.
SDR 510014714
No. 1 galley floor threshold plate badly corroded.
Fokker F27MK50 Wing miscellaneous structure
bolt loose. SDR 510014686
LH and RH wing buttstrap bolts loose.
Fokker F28MK0100 Fuel storage wire damaged.
SDR 510014558
LH and RH fuel collector tank bonding wires
deteriorated/damaged.
Fokker F28MK0100 Fuselage floor panel
corroded. SDR 510014715
Floor structure badly corroded at BL1127R and
BL1127L between Stn 3845 and Stn 4875. Small
spots of corrosion also found in floor beam structures
between Stn 3845 and Stn 4875.
Fokker F28MK0100 Drag control actuator
cracked. SDR 510014527 (photo below)
LH No. 1 and No. 2 lift dumper actuator cracked.
P/No: 1090019. TSN: 38,946 hours/35,475 cycles.
Fokker F28MK0100 Elevator control system
bearing stiff. SDR 510014702
LH and RH elevators heavy in operation.
Fokker F28MK0100 Fuselage structure cracked.
SDR 510014584
RH airconditioning bay cracked. Crack length 53mm
(2in). LH airconditioning bay cracked. Crack length
61mm (2.4in). Found during inspection following
removal of airconditioning units.
Fokker F28MK0100 Landing gear door
bolt sheared. SDR 510014711
RH main landing gear door bolt head sheared off.
Fokker F28MK0100 Landing gear door
hinge worn. SDR 510014601
LH main landing gear transit light remained on
following retraction. Fault remained following gear
recycling. Investigation found the LH main landing
gear inner door contacting the rear structure due to
wear in the door hinge.
Fokker F28MK0100 Wing skin repair patch
separated. SDR 510014618
RH wing inboard upper skin partially disbanded,
allowing composite repair patch to separate and
enter the RH engine. FOD damage to the leading
edge of one IPC blade, with a section of the rotor
path lining missing.
Gulfstream GIV Wing/fuselage attach fitting
corroded. SDR 510014744 (photo below)
LH forward wing link attachment fitting corroded.
Fitting located in fuel tank. Found during investigation
of a wing fuel leak and discovery of damaged sealant
around the fitting.
AIRCRAFT Below 5700kg
Bellanca 8KCAB Fuel storage pipe cracked
and leaking. SDR 510014674
Aluminium fuel line cracked and leaking from flare
at fuselage header tank.
P/No: 714142. TSN: 4,125 hours/380 months.
Beech 200 Fuselage skin cracked.
SDR 510014788
Fuselage pressure hull cracked. Crack only found
following removal of paint. P/No: 1014302051.
Beech 200C Rudder hinge bracket corroded.
SDR 510014573
Rudder hinge bracket corroded. Corrosion found
during preparation for repainting.
P/No: 10164001415. TSN: 11,267 hours.
Beech 58 Elevator control cable corroded
and frayed. SDR 510014708
Forward elevator control cable corroded within
strands. One strand also found to be broken.
Found during inspection iaw AD/Beech55/98.
P/No: 58524015.
Beech 58 Power lever cable broken.
SDR 510014658
RH engine throttle cable failed. Investigation found
cable broken in area of rod end/swage. Outer casing
cracked approximately 12.7mm (0.75in) from rigid
fixing point. P/No: 5038901219.
Beech 95B55 Landing gear retract/extension
system plunger seized. SDR 510014652
RH main landing gear retraction rod floating plunger
seized preventing correct rigging of the landing gear.
P/No: 3581512512. TSN: 6,641 hours.
Cessna 150L Aircraft fuel system pipe corroded.
SDR 510014546
Rigid aluminium fuel line from LH tank to fuel cock
contained pinhole corrosion allowing fuel leakage into
cockpit. P/No: 0400311113. TAN: 13,213 hours.
Cessna 172M Exterior light unapproved part.
SDR 510014639
RH navigation light suspect unapproved (automotive)
part. P/No: W129014.
Cessna 172M Wheel bearing corroded.
SDR 510014637
Nose wheel bearings P/No LM4078 and P/
No LM67010 corroded. Suspect bearings also
unapproved parts. Bearings branded SKF and KOYO.
P/No: LM67048. TSN: 181 hours.
Cessna 210L Wing spar cap cracked.
SDR 510014771
Wing spar cap cracked. Four similar reports received
for this period.
Cessna 404 Elevator, spar corroded.
SDR 510014501
RH elevator spar corroded. Found during routine
inspection of aircraft under Cessna customer care
program. P/No: 5834120.
TSN: 32,562 hours/62,858 landings.
Cessna 404 Fuel shut-off valve incorrect
assembly. SDR 510014597
LH engine cutting out. Investigation found a newly
installed fuel crossfeed shut-off valve incorrectly
assembled internally, resulting in the valve working
in the reverse sense. P/No: 9910204. TSN: 10 hours.
Cessna 441 Fuselage bulkhead angle cracked.
SDR 510014627
Forward pressure bulkhead upper attachment angle
cracked in two places. Crack lengths approximately
60mm (2.36in. Found during SID inspection.
P/No: 57116071.
TSN: 137,230 hours/10,160 cycles/10,160 landings.
Cessna P206B Mixture control cable failed.
SDR 510014644
Mixture control outer cable separated from
lever housing.
P/No: S12203A. TSN: 26 hours/1 month.
Cessna TR182 Aileron control cable frayed.
SDR 510014721
Broken strand in aileron control cable.
P/No: 12600785.

Flight Safety Australia
Issue 87 July–August 2012
37
SELECTED SERVICE DIFFICULTY REPORTS ... CONT.
Cessna TR182 Elevator cable frayed.
SDR 510014722 (photo below)
Broken strands in elevator trim cable.
P/No: 0510105248. TSN: 967 hours.
Socata TB10TOBAGO Wing spar cracked.
SDR 510014561 (photo below)
LH and RH forward wing attachment small spars
cracked in area adjacent to lower inboard bolt.
Fifteen similar reports submitted for this type of
aircraft in reporting period. P/No: TB1011000101.
TSN: 11,893 hours.
Cessna U206F Landing gear attach fitting
cracked. SDR 510014797 (photo below)
LH main landing gear attachment fitting cracked.
P/No: 1211601497. TSN: 8,766 hours.
Cessna U206G Power lever cable binding.
SDR 510014643
Engine throttle cable binding. Cable was an almost
new item with only 37 hours TSN.
P/No: 986305313. TSN: 37 hours/1 month.
Giplnd GA200C Wing spar cracked.
SDR 510014765 (photo below)
Wing front lower spar cap cracked in area between
WS 0.00 and WS 4.50 in area of wing/fuselage
attachment. Crack length approximately 114.3mm
(4.5in). Found during inspection iaw SB GA200-
2011-06 Issue1. Aircraft registered in New Zealand.
P/No: GA2005710025.
Giplnd GA8 Horizontal stabiliser spar cap
cracked. SDR 510014800 (photo below)
Horizontal stabiliser rear lower spar cap cracked.
Found during inspection iaw SB GA8-2002-02
Issue 6. P/No: GA855102115
Giplnd GA8 Trailing edge fitting rusted.
SDR 510014723 (photo following)
LH and RH trailing edge flap torque tube outboard
fittings corroded (rusted).
P/No: GA82750121413. TSN: 3,072 hours.
Gulfstream 500S Hydraulic tube corroded.
SDR 510014540
Rigid hydraulic tubing located between LH wing
root and engine nacelle contained corrosion pitting
through wall thickness resulting in loss of hydraulic
fluid. Suspect caused by tubing contacting flexible
hose in wing channel. P/No: 5052038.
Gulfstream 500S Landing gear retract/extend
system bolt failed. SDR 510014538
Landing gear uplock pivot bolt failed in area
covered by bearing inner face. Investigation indicates
failure might have been propagating for some time.
P/No: AN174C21A.
Piper PA24 Horizontal stabiliser fitting cracked.
SDR 510014796 (photo below)
Stabiliser horn balance attachment cracked
from stabiliser attachment holes to balance tube
attachment. TSN: 2,679 hours.
Piper PA32R301T Fuselage door sill corroded.
SDR 510014593 (photo below)
Rear cabin door had localised corrosion at screw
holes. Interior upholstery stainless steel screws and
moisture in upholstery contributed to the corrosion.
P/No: 68334000. TSN: 1,372 hours/144 months.
Piper PA44180 Emergency exit separated.
SDR 510014704
Emergency exit/window forward latch disengaged
allowing airflow, causing window and frame
to separate from fuselage. P/No: 8660202.
TSN: 8,590 hours.
Piper PA60601B Cabin door opened.
SDR 510014767
Top half of main cabin door opened following
take-off. Investigation found no faults with the door
and no structural damage.
Swrngn SA227AC Nose landing gear shimmy.
SDR 510014577 (photo below)
Nose landing gear shimmy on landing. Initial
investigation found broken bolts at the NLG
steering actuator. P/No: 2752500001. TSN: 30,174
hours/45,110 cycles.
Swrngn SA227DC Brake leaking.
SDR 510014761
RH outboard brake unit leaking and tyre deflated.
Loss of hydraulic fluid.
Swrngn SA227DC Landing gear faulty.
SDR 510014764
Pilots felt a repetitive bump and noticed the hydraulic
pressure fluctuating during landing gear retraction.
Landing gear suspect faulty. Investigation continuing.
TSN: 20,006 hours/22,141 cycles.
Components
Fuel injection system suspect unapproved part.
SDR 510014803
RSA and Silver Hawk EX fuel injection system may be
suspect/counterfeit parts. Precision Airmotive are the
only manufacturer and distributor of these systems.
Balloon cable worn. SDR 510014545
(photo below)
Hot air balloon basket suspension cables worn in
area of contact with burner frame nylon support pole.
TSN: 1,981 hours/138 months.
Balloon load frame cracked. SDR 510013682
Balloon burner load frame had several hairline cracks
along original welds.
P/No: KLF201088. TSN: 1,423 hours/123 months.

38
AIRWORTHINESS
Pull-out section
SELECTED SERVICE DIFFICULTY REPORTS ... CONT.
Turbine Engine
GE CF680C2 Thrust reverser shaft damaged.
SDR 510013773
No.1 engine thrust reverser LH side electromechanical
brake flexible shaft sheared. P/No: 3278500X.
GE CF680E1 Turbine engine compressor stator
blade worn. SDR 510013797
No.1 engine 13th stage high-pressure compressor
variable stator blades (VSV) loose and worn
beyond limits in root/platform area. Found during
borescope inspection.
IAE V2527A5 Engine fuel/oil cooler housing
leaking. SDR 510013640
No.1 engine leaking from fuel diverter return
valve to fuel-cooled oil cooler tube seal housing
P/No 5W8201. Leakage from between seal housing
and pipe. P/No: 5W8201.
IAE V2533A5 Fuel controlling system
probe faulty. SDR 510013814
RH engine low power. Investigation found no
definitive fault. Further investigation found a faulty
alternate N1 speed probe.
PWA PW150A Engine fuel system O-ring leaking.
SDR 510013740
Fuel transfer tube to fuel/oil heat exchanger
O-ring seals P/Nos M83461-1-116 and AS3209-126
deteriorated and leaking.
TSN: 4,372 hours/4,618 cycles.
PWA PW150A Fuel control/turbine engines
FADEC failed. SDR 510013723
No. 2 engine full authority digital engine control
(FADEC) failed. Investigation continuing.
P/No: 8193007009. TSN: 7,013 hours/8,130 cycles.
Rolls-Royce BR700715A130 Turbine blade
failed. SDR 510013660
RH engine high EGT (over 800 degrees during climb).
Investigation found failed HPT1 blade.
Rolls-Royce RB211524G Engine fuel distribution
tube worn and damaged. SDR 510013843
No. 2 engine main fuel delivery tube found with
extensive chafing damage due to contact with
adjacent oil vent tube. Wear approximately
50 per cent of wall thickness (limit is 0.005in).
P/No: UL37972.
Rolls-Royce RB211524G Turbine engine
compressor blade failed. SDR 510013718
No. 3 engine exceeded EGT limits during take-off.
Initial investigation found metal on the chip detector
and in the tailpipe, one IPC stage 7 compressor blade
missing and considerable damage to HPC stages 1
and 2, with one HPC stage 1 blade missing.
Rolls-Royce RB211524G Turbine engine
compressor damaged. SDR 510013872
No. 4 engine had sparks coming from exhaust during
take-off. Engine operated normally during flight.
Borescope inspection found major damage to IPC 6
and HPC 1. Downstream blades also damaged.
Rolls-Royce TRENT97284 Turbine engine oil
system pipe loose. SDR 510013842
No. 4 engine shut down in flight due to low oil
pressure. Investigation found No. 4 engine oil
feed pipe P/No FW48295 loose and leaking.
Deflector lockwire also broken. Loss of engine oil.
Further investigation found oil loss due to the loss
of torque on the ‘B’ nut of the HP/IP turbine bearing
support tube.
Piston Engine
Continental IO470C Reciprocating engine piston
incorrect weight. SDR 510014781
Engine running roughly. Caused by incorrect
opposing piston weights and connecting rod weights.
P/No: 642360. TSO: 500 hours.
Continental IO520F Reciprocating engine
damaged. SDR 510014646
Engine failed due to loss of oil pressure.
Investigation continuing.
P/No: IO520F. TSO: 1,153 hours.
Continental TSIO520M Reciprocating engine
crankcase cracked. SDR 510014502
Crack discovered adjacent to No. 5 cylinder base.
P/No: 642135. TSO: 1,224 hours.
Lycoming AEIO540D4A5 Reciprocating engine
bearing worn and damaged. SDR 510014631
No. 6 connecting rod P/No: LW11750 big end bearing
worn with no bearing material left on bearing shell.
Bearing shell spinning in the connecting rod, causing
damage to rod and crankshaft. Big end bearings
on the other connecting rods also beginning to
delaminate. Metal contamination of oil system.
P/No: 74309. TSN: 721 hours. TSO: 721 hours.
Lycoming IO540AB1A5 Magneto/distributor
points failed. SDR 510014615
RH magneto contact points leaf spring failed at
approximately mid point.
P/No: M3081. TSN: 223 hours.
Lycoming IO540AE1A5 Engine muffler collapsed.
SDR 510014691
Muffler assembly collapsed and exhaust collector
cracked. P/No: C16932.
Lycoming IO540AE1A5 Reciprocating engine
cooling nozzle separated. SDR 510014825
Engine cylinder-mounted piston cooling nozzle
separated from cylinder causing damage to two
pistons. Some camshaft damage also found but not
attributed to the nozzle separation
P/No: 73772. TSO: 1,385 hours.
Lycoming LTIO540J2BD Exhaust turbocharger
oil system contaminated by carbon.
SDR 510014783
RH engine turbocharger oil supply system
contaminated. Flake of carbon obstructing the
metered orifice at the 90-degree oil pressure
supply fitting in the wastegate actuator, preventing
oil pressure supply to the turbocharger controlling
system. P/No: NA. TSO: 2 hours.
Lycoming LTIO540J2BD Reciprocating engine
tappet body cracked. SDR 510014768
No.1 cylinder intake hydraulic tappet body cracked.
Slight damage found to lifter bore.
P/No: 15B26064. TSN: 396 hours.
Lycoming O360A1F6 Reciprocating engine oil
transfer tube loose. SDR 510014587
Oil transfer tube loose in crankshaft.
Tube found to be rotating in the crankshaft bore.
Suspect faulty manufacture.
P/No: 68484. TSN: 6,629 hours. TSO: 1,957 hours.
Lycoming TIO540AH1A Engine fuel pump failed.
SDR 510014647
Engine-driven fuel pump driveshaft failed.
Investigation found that pump was not seized.
P/No: 200F5002. TSN: 723 hours.
Lycoming TIO540AH1A Exhaust turbocharger
bypass valve faulty. SDR 510014731
Turbocharger bypass valve actuator had excessive
play, causing engine hunting.
P/No: 47J22459. TSN: 2,040 hours.
Propeller
Hamilton Standard 14SF9 Propeller hub helicoil
faulty. SDR 510013690
Propeller actuator to hub attachment bolt helicoils
defective. Following removal of the installation tang,
a small part of the tang was left attached to the
helicoil preventing full installation of the bolts.
P/No: MS124698.
Rotol R3904123F27 Propeller hub cracked.
SDR 510013591
Propeller hub cracked from bolt holes. Found during
ultrasonic inspection iaw Dowty SB SF340-61-95R7
and AD/PR/33.
Rotorcraft
Agusta-Bell A109E Rotorcraft cooling fan worn.
SDR 510014629
No. 2 engine oil cooler blower fan output shaft drive
pin wore into shaft, causing excessive backlash.
P/No: 109045501101.
Bell 206B3 Horizontal stabiliser tube corroded.
SDR 510013680
Horizontal stabiliser tube severely corroded.
P/No: 206020120011.
Bell 206B3 Main rotor transmission leaking.
SDR 510013841
Transmission leaking oil from oil filter area.
Filter mounting bowed, causing leak. P/No:
206040002025. TSN: 7,474 hours. TSO 1.597 hours
Bell 206B Engine/transmission coupling worn.
SDR 510013854
Engine/transmission driveshaft inner couplings
worn beyond limits. Outer couplings serviceable.
Found during inspection following over-temperature
indication.
P/No: 206040117001. TSN: 5,532 hours.
Bell 412 Main rotor gearbox contaminated
by metal. SDR 510013608
Transmission had minor vibration in cruise.
After approximately 10 minutes, the vibration
increased, followed by chip detector illumination.
Investigation found metal contamination.
P/No: 412040002103.
TSN: 10,642 hours. TSO: 4,823 hours.
EUROCG BK117C2 Tail rotor control rod cracked.
SDR 510013636
Yaw smart electro-mechanical actuator (SEMA)
control rod cracked on upper end. Crack
confirmed using x10 magnifying glass and
subsequent dye penetrant inspection. Cracking
caused by intercrystalline stress corrosion.
P/No: B673M4004101.
EUROCG BK117C2 Tail rotor gearbox damaged.
SDR 510013786
Tail rotor gearbox chip detector illuminated.
Piece of metal missing from one tooth on the bevel
gear. TSN: 1,931 hours. TSO: 130 hours.
Eurocopter EC225LP AC generator-alternator
drive pin sheared. SDR 510013890
No.1 engine double alternator drive pin sheared,
allowing rotor to spin on shaft. P/No: 9759150100.
MDHC 369E Tail rotor blade debonded.
SDR 510013769
Tail rotor blade leading edge debonding in area near
blade tip. P/No: 500P3100105. TSN: 1,522 hours.
Robinson R44 Main rotor gearbox contaminated
by metal. SDR 510013627
Main rotor gearbox chip detector light illuminated.
Metal contamination of chip detector plug. Chip
detector cleaned and rechecked, finding more metal.
Further investigation found the hard facing coming off
the gears. P/No: C0065. TSN: 503 hours.
Robinson R44 Bulkhead/firewall cracked.
SDR 510013625
Firewall cracked. TSN: 1,495 hours.
SCHWZR 269C Main rotor blade debonded.
SDR 510013851
Main rotor blade outboard leading edge abrasion strip
debonding. Small crack also found in the abrasion
strip in debonded area.
P/No: 269A11851. TSN: 2,742 hours.

Flight Safety Australia
Issue 87 July–August 2012
39
APPROVED AIRWORTHINESS DIRECTIVES
23 March – 5 April 2012
Rotorcraft
Agusta A119 series helicopters
2012-0058 Windows – pilot and co-pilot door
windows bonding – inspection
Above 5700kg
Airbus Industrie A319, A320 and A321
series aeroplanes
2012-0055 Chemical emergency oxygen
containers – modification
Airbus Industrie A380 series aeroplanes
2011-0013R1 Fuselage – wing-to-body fairing
support structure – inspection/replacement /repair
2012-0052 Wings – leading edge shear cleats –
inspection/replacement
2012-0048 Fuselage – rivets at junction of stringer
21 and frame 0 – replacement
Airbus Industrie A330 series aeroplanes
2011-0196 (correction) Fuel/main transfer
system – rear and/or centre tank fuel pump control
circuit – modification
Airbus Industrie A330 series aeroplanes
2012-0053 Landing gear – main and centre
landing gear bogie pivot pins – inspection
Boeing 737 series aeroplanes
AD/B737/334 Amendment 1 – flight deck windows
nos. 2, 4 and 5 – 2
Bombardier (Canadair) CL-600 (Challenger)
series aeroplanes
CF-2012–11 Non-compliant cargo
compartment liners
Cessna 560 (Citation V) series aeroplanes
2012-06-01 Stiff or jammed rudder control system
Embraer ERJ-170 series aeroplanes
2012-03-04 Replacement of tail cone
firewall grommet
Embraer ERJ-190 series aeroplanes
2012-03-03 Replacement of tail cone
firewall grommet
Fokker F27 series aeroplanes
2012-0050 Electrical power centre (EPC) and
battery relay panel – inspection/adjustment
Fokker F28 series aeroplanes
2012-0050 Electrical power centre (EPC) and
battery relay panel – inspection/adjustment
Fokker F50 (F27 Mk 50) series aeroplanes
2012-0050 Electrical power centre (EPC) and
battery relay panel – inspection/adjustment
Fokker F100 (F28 Mk 100) series aeroplanes
2012-0002R1 Nose landing gear main fitting –
inspection/modification/replacement
2012-0049 Time limits/maintenance checks –
maintenance requirements – implementation
2012-0050 Electrical power centre (EPC) and
battery relay panel – inspection/adjustment
Turbine engines
Pratt and Whitney turbine engines –
PW4000 series
2012-06-18 Clogging of no. 4 bearing compartment
oil pressure and scavenge tubes
Pratt and Whitney Canada turbine engines –
PW100 series
CF-2012-12 Propeller shaft crack
Rolls Royce turbine engines – RB211 series
AD/RB211/43 Engine – IP compressor rotor and
IP turbine discs
2012-0057 Engine – intermediate pressure shaft
coupling – inspection/replacement
Turbomeca turbine engines– Arriel series
2012-0054 Engine – module M03 (gas generator) –
turbine blade – modification
6 – 19 April 2012
Rotorcraft
Bell Helicopter Textron 412 series helicopters
CF-2012-14 Crosstubes – life limitation
Eurocopter AS 332 (Super Puma)
series helicopters
2012-0059-E Rotorcraft flight manual – emergency
procedures – rush revision
Eurocopter EC 225 series helicopters
2012-0059-E Rotorcraft flight manual – emergency
procedures – rush revision
Kawasaki BK 117 series helicopters
TCD-8021-2012 Tail rotor head attaching
hardware – inspection
Sikorsky S-92 series helicopters
2012-06-24 Tail rotor blade – inspection
Above 5700kg
Airbus Industrie A319, A320 and A321
series aeroplanes
2011-0069R1 Main landing gear (MLG) door
actuator – monitoring/inspection
Airbus Industrie A330 series aeroplanes
2012-0061 (correction) Flight controls –
trimmable horizontal stabiliser actuator ballscrew
lower splines – inspection/replacement
Airbus Industrie A380 series aeroplanes
2012-0062 Wings – movable flap track fairing –
inspection/repair/replacement
Boeing 737 series aeroplanes
2012-05-02 Engine exhaust – heat damage to the
inner wall of the thrust reversers
Boeing 747 series aeroplanes
AD/B747/361 Amendment 1 – flight station
windows nos. 2 and 3 – cancelled
2012-07-07 Latch pins – lower sills – forward
and aft lower lobe cargo door – inspection
2012-02-16 Flight station windows nos. 2 and
3 – inspection/replacement
Boeing 777 series aeroplanes
2012-07-06 Airworthiness limitations and
certification maintenance requirements
Bombardier (Canadair) CL-600
(Challenger) series aeroplanes
CF-2012-13 Airworthiness limitations and
maintenance requirements
Cessna 680 (Citation Sovereign)
series aeroplanes
2012-07-04 Fuel control cards
Turbine engines
Rolls-Royce turbine engines – RB211 series
AD/RB211/44 Powerplant – fuel flow regulator
adjustment test
AD/RB211/45 Air – IP cabin air offtake ducting
2012-0060 Engine – intermediate pressure turbine
disc – identification/inspection/replacement
Turbomeca turbine engines– Arriel series
AD/Arriel/28 Fuel control unit 3-way union
plug – cancelled
2012-0063 Engine fuel and control – fuel control
unit (FCU) 3-way union plug – inspection
Equipment
Emergency equipment
AD/EMY/34 Amendment 1 – emergency evacuation
slide/raft – pressure relief valves – cancelled
2012-06-25 Emergency evacuation slide/raft –
pressure relief valves
Fire protection equipment
74-08-09R3 Installation of No Smoking placards
and ashtrays
continued on page 42
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/

40
AIRWORTHINESS
A game of many parts
‘If there is an issue in future with corrosion
levels everyone will be on the same page.
It reduces ambiguity in communication.’
CAAP 51-1(2) addresses a mismatch between established
service defect reporting practices and new technology that has
emerged over the last decade.
‘There are two reasons why we decided to amend the CAAP,’
says Peter Nikolic, CASA acting principal engineer, propulsion
and mechanical systems.
A game of many parts:
technology, reporting and safety
One was that we noticed a significant number of major defects
that had not been reported by the industry because some of
the provisions of the CAAP were inadequate as a reference for
modern technology aircraft.’
Nikolic says a problem with major defect reporting had resulted
from the high level of systems integration in modern aircraft.
Like cricket, aviation safety is a fascinating
subject because it is complex and simple at
the same time. The object of aviation safety is
simple—prevent harm—but in the real world
it can only be achieved by a complex interplay
of technology, practice and policy. Recent
changes to CASA’s civil aviation advisory
publication (CAAP) 51, on service difficulty
reporting, illustrate this beautifully.
‘There was a provision in the previous version of CAAP 51
not to report items that were covered under the minimum
equipment list (MEL),’ he says. ‘Operators did not have to
report any defects that were deferrable according to the
minimum equipment list.‘
This was a sensible and safe policy for aircraft that had
separate systems for separate functions, but has been out
dated by the latest generation of aircraft with integrated
modular avionics and highly integrated mechanical systems.
At this point, let’s take a quick overview of avionics. Until
recently, aircraft avionic components could be described as
federated in the way they worked with each other.

Flight Safety Australia
Issue 87 July–August 2012
41
Under the federated model of system architecture, the various
computers in an aircraft could be thought of as like member
states of the European Union (or any other federation,
Australia even). They worked for a common purpose, but
each component was unique. There was a ‘black box’ for the
autopilot, and a separate black box for the inertial navigation
system, for example. They were able to cooperate closely
in some tasks, but not as closely in others. To stretch
the metaphor: they all used the euro, but their individual
economies were very different.
In contrast, integrated modular avionics, as used on the latest
generation of transport aircraft, including the Airbus A380
and Boeing 787 do away with discrete black boxes. They are
replaced by racks of computer modules, which are, in the
words of an Airbus presentation on the A380, ‘non systemspecific’.
It’s like the way a laptop computer can do duty as
a DVD player. As long as the right peripherals (sensors and
actuators in an aircraft) are in place, a computer can turn
its hand to whatever its software allows. Moreover, multiple
systems applications can be executed on the same computer.
The aircraft’s computers speak to each other on a high-speed
multiplexed network.
Integrated modular avionics bring obvious advantages of
system redundancy and robustness. But they also bring new
and subtle hazards in the way they differ from the old federal
architecture.
The Airbus presentation notes: ‘Resource sharing has a direct
impact on the way to design and implement systems since
it creates new dependencies between them, both from a
technical and a process point of view.’
‘With modern aircraft there are more functions, but not items,
included in the MEL’, Nikolic says. ‘Each of these functions
may be carried out by more than one system, some of which
could be critical systems in the aircraft. You might have a
function that is MEL-able, and to repair that function you need
to replace a critical component. However, we have noticed a
significant number of events that were not reported because
the function was MEL-able.’
One example illustrates the potential hazard. An operator flying
a new technology aircraft reported through the SDR system
that its engineers had removed the thrust control quadrant—
the thrust levers and mounting—twice.
A subsequent audit of the operator revealed 17 removals
over 14 months. ‘We asked “why didn’t you report the other
events?” and they said “they were all MEL-able—we didn’t
have to report them”,’ Nikolic says.
Further reading
Jean-Bernard Itier, Airbus presentation on A380 integrated
modular architecture. http://tinyurl.com/bpn6edq
‘Two removals of the quadrant signified nothing much, but
17 was an unambiguous trend. Here was a serious reliability
issue with a major component—and we didn’t know about it.’
‘We realised from this how the MEL could hide potential
defects. Many of these could be precursors to a major event.
If we are not aware of these failures we are not aware of the
reduced reliability of a critical component and we can’t act. ‘
In modern aircraft everything is connected, Nikolic explains.
‘Unless you do a thorough investigation into the
causes, you cannot establish whether any small
functional failure is related, or not, to a potential
major defect that must be reported.’
Under the revised CAAP 51, the MEL provision not to report
a defect does not exist, and it is up to the operator to do a full
investigation and establish whether a defect is major, after
considering the root cause. If the root cause points towards
the major defect, an SDR must be submitted.
The other reason for redrafting CAAP 51 was a significant
number of questions coming from the industry about
corrosion levels.
‘The previous version did not have specific corrosion level
definitions, or details of the corrosion level that required
reporting to CASA,’ Nikolic says. ‘The new draft provides
specific corrosion level definitions and also explains what
corrosion levels need to be reported through the SDR system.’
One result, Nikolic says, is that aircraft makers will be able to
coordinate their internal corrosion reporting systems with the
new CASA one. ‘If there is an issue in future with corrosion
levels everyone will be on the same page. It reduces ambiguity
in communication.’
Two other significant details have been changed. The revised
CAAP 51 says that when a service difficulty investigation
takes more than two months to complete the submitter should
provide follow-up interim reports every two months.
‘In other words: you need to report every two months, even if
it is only to say you are still working on it,’ Nikolic adds.
And a short but significant sentence, added as item (w) to
appendix A, encourages operators not only to submit major
defects that match examples listed in appendix A, but also any
other information they consider to be important.
To sum up: aviation safety in the age of the Reason model
multi-factor accident depends on information. What information
is reported depends on the reporting system. That has been
fixed—for now—but the game will continue to evolve.

42
AIRWORTHINESS
Pull-out section
APPROVED AIRWORTHINESS DIRECTIVES ... CONT.
continued from page 39
20 April – 3 May 2012
Rotorcraft
Agusta AB139 and AW139 series helicopters
2012-0076 Tail rotor blades – inspection/
replacement
Eurocopter SA 360 and SA 365 (Dauphin)
series helicopters
AD/DAUPHIN/27 Amendment 6 – tail rotor
blades – cancelled
2012-0067 Tail rotor blade monitoring
and limitations
Sikorsky S-92 series helicopters
2012-08-01 Engine – inaccurate abovespecification
power margin data
Below 5700kg
Airparts (NZ) Ltd FU 24 series aeroplanes
AD/FU24/67 Vertical stabiliser – cancelled
DCA/FU24/178A Vertical stabiliser – replacement
Pacific Aerospace Corporation Cresco
series aeroplanes
AD/CRESCO/13 Aileron pushrods – cancelled
DCA/CRESCO/12A Aileron pushrods –
inspection/replacement
DCA/CRESCO/16A Vertical stabiliser – replacement
DCA/CRESCO/18 Control column – inspection/
replacement
Robin Aviation series aeroplanes
2012-0072 Power plant – air filter – inspection/
replacement
Above 5700kg
Airbus Industrie A330 series aeroplanes
2012-0069 Navigation – radio altimeter erroneous
indication – operational procedure
2012-0070 High-pressure manifold check valves –
inspection/modification
Avions de Transport Regional ATR 72
series aeroplanes
F-1999-015-040 R2 Icing conditions – revision
to airplane flight manual (AFM)
F-2004-164 Main landing gear – side brace
assembly – secondary side brace upper arm
F-2005-160 Fuel quantity indicators
2006-0216-E Main landing gear – shock absorber –
cross locking bolt of the attachment pin
2006-0283 Electrical power – 120 VU electrical
harness – inspection
2006-0303 Stabilisers – vertical stabiliser fin tip –
inspection/repair/modification
2006-0376 Flight controls – aileron tab bellcrank
assembly – inspection
2007-0164 Equipment and furnishings – thermal/
acoustic insulation blankets – replacement/removal
2007-0179 Ice and rain protection – pitot probe
resistance and low current sensor – inspection/
replacement
2008-0062 Electrical/electronic – rear pressure
bulkhead area and wire chafing – inspection/
modification
2008-0137-E Flight controls – cotter pins and
pitch uncoupling mechanism (PUM) – inspection/
installation
2008-0218 Electrical/electronic – wire bundles in
rear baggage zone – protection/clamping
2009-0159-E Cockpit forward side windows –
inspection/replacement
2009-0170 Indicating/recording systems – multi–
purpose computer (MPC) with aircraft performance
monitoring (APM) function – installation
2007-0226R1 Fuel tank system wiring and sensors –
modification/replacement – fuel tank safety
2009-0242 Time limits/maintenance checks –
certification maintenance requirements and
critical design configuration control limitations
(fuel tank safety)
2010-0061 Fire protection – halon 1211 fire
extinguishers – identification/replacement
2010-0138 Stabilisers – elevator inboard hinge
fitting lower stop angles – inspection/replacement
Avions de Transport Regional ATR 42
series aeroplanes
2012-0064 Flight controls – rudder tab,
rudder pedal and elevator control rods –
inspection/replacement
Avions de Transport Regional ATR 72
series aeroplanes
2012-0064 Flight controls – rudder tab,
rudder pedal and elevator control rods –
inspection/replacement
Boeing 737 series aeroplanes
2012–08–17 Goodrich analog transient
suppression devices – corrosion
Boeing 777 series aeroplanes
2012-08-09 Wing centre section spanwise
beams – inspection
2012-08-13 Rudder bonding jumper brackets
Boeing 767 series aeroplanes
2012-08-14 – wing upper skin fastener
holes – inspection
Bombardier (Boeing Canada/De Havilland)
DHC-8 series aeroplanes
CF-2012-15 Chafing of the nacelle fire detection
wire on the main landing gear yoke
Fokker F27 series aeroplanes
2012-0065 Fuel – wing main tanks – modification
(fuel tank safety)
Learjet 45 series aeroplanes
2012-08-08 Airworthiness limitations and
maintenance requirements
Learjet 60 series aeroplanes
2012-08-16 Engine fire protection wiring
Piston engines
SMA piston engines
2012-0075-E Powerplant – turbocharger and
intercooler hoses – replacement
Turbine engines
Turbomeca turbine engines– Arriel series
AD/ARRIEL/6 Amendment 1 – erosive atmosphere
maintenance – cancelled
2012-0071 Engine – axial compressor, gas generator
4 – 17 May 2012
Rotorcraft
Bell Helicopter Textron 412 series helicopters
CF-2012-14R1 Crosstubes – life limitation
2012-0077-E Equipment and furnishings – hoist
hook – inspection
Eurocopter AS 332 (Super Puma)
series helicopters
2012-0084 Equipment and furnishings –
EADS SOGERMA flight crew seats –
inspection/replacement
Eurocopter EC 225 series helicopters
2012-0084 Equipment and furnishings –
EADS SOGERMA flight crew seats –
inspection/replacement
Eurocopter SA 360 and SA 365 (Dauphin)
series helicopters
2012-0084 Equipment and furnishings –
EADS SOGERMA flight crew seats –
inspection/replacement
Below 5700kg
De Havilland DHC–1 (Chipmunk)
series aeroplanes
G-2012-0001 Wings – recording and consumption
of fatigue lives
Above 5700kg
Airbus Industrie A319, A320 and A321
series aeroplanes
2012-0083 Chemical emergency oxygen
containers – identification/modification
Airbus Industrie A380 series aeroplanes
2012-0078 Nacelles/pylons – finger seals at
interface with nacelle – inspection/replacement
Airbus Industrie A330 series aeroplanes
2012-0082 Flight controls – wing tip brakes –
operational test/replacement
Boeing 737 series aeroplanes
2012-09-06 Seat attach structure
Boeing 767 series aeroplanes
AD/B767/201 Amendment 2 – body station 955
fail-safe straps – cancelled
2012-09-04 Fail-safe straps – rear spar
bulkhead at body station 955 – inspection
2012-09-08 Aft pressure bulkhead – inspection
Bombardier (Canadair) CL–600
(Challenger) series aeroplanes
CF-2005-41R1 Shear pin failure in the pitch
feel simulator unit
Cessna 560 (Citation V) series aeroplanes
2012-09-01 Torque lug – main wheel – inspection
Dassault Aviation Falcon 2000 series
aeroplanes
2012-0081 Airplane flight manual – take-off under
out-of-trim condition – operational limitation
Piston engines
SMA piston engines
2012-0075-E (correction) Powerplant – turbocharger
and intercooler hoses – replacement
Turbine engines
Pratt and Whitney Canada turbine engines –
PT6A series
2012-09-10 Reduction gearbox – first-stage sun
and planet gear – replacement

Flight Safety Australia
Issue 87 July–August 2012
43
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44
FEATURE
Sharing the skies – gliders
Sharing the skies—gliders
Pilots of powered aircraft who
have watched wedge-tailed
eagles effortlessly soaring
may have wondered at their
mastery, but glider pilots say
they feel a kinship with the
eagles. Both fly in the same
way, by soaring on the warm
rising air of thermals, meaning
that both must instinctively
know much more about the
dynamics of the sky than the
typical powered pilot.
‘Formally’, gliders, or sailplanes as they are
now known, have been flying in Australia
for over 60 years, although gliding began
earlier in the ‘20s and ‘30s with opencockpit
trainer gliders launched from
hilltops. The peak association, the Gliding
Federation of Australia (GFA), began in
1949, bringing together the various state
and local bodies which then made up the
gliding community in Australia. The GFA
has a core membership of 2500 pilots,
with short-term memberships catering for
those wanting to give gliding a try swelling
the number during summer.
There are around 1200 sailplanes on
the register (gliders are VH-registered).
The bulk, around 1000, are conventional
sailplanes, while the remaining 200-odd
are powered. And because they are VHregistered
aircraft, gliders are subject to
the same airworthiness regime as other
VH-aircraft, with regularly scheduled
inspections. The GFA administers this
ongoing airworthiness, with approved and
certified inspectors.
There are several methods of launching
gliders, with the most commonly used in
Australia being ground-based winch and
aerotow, which uses a tug plane to take
the glider to launch altitude, explains Chris
Thorpe, GFA operations manager. Winch
launching and aerotow each have unique
characteristics.
Bacchus Marsh airfield, for example,
is home to three gliding clubs, and
uses winches and tug planes. In winch
operations, Thorpe says, ‘the glider goes
up pretty quickly, at a 45-degree angle,
and only takes about 30-40 seconds to
get to release height (2000ft AGL).’ Since
the winch cable ‘in Australia, in the main,
is 3.5mm spring steel and can go up to
3000 or 4000 feet in the right conditions’,
Thorpe advises pilots to check the relevant
world aeronautical chart (WAC) to look
for a winch symbol for the area they are
planning to fly over. ‘You don’t want to
be flying over an aerodrome if it is doing
winch operations,’ he says. ‘Crosswind
joins are especially dangerous; in any
case, pilots should give the circuit a bit
of margin.’ For this reason, ‘the reporting
point for the airfield has been moved to the
Bacchus Marsh township, so that pilots
don’t fly over the aerodrome’.
‘Aerotow is fairly sedate,’ he says, but it
has still some unique features powered
pilots should be mindful of. The glider/
tow plane combination is not very
manouverable, and the tow plane, often
flying nose-high, cannot see particularly
well to the front, and cannot take
significant evasive action without releasing
the glider. So pilots of powered aircraft
should be aware of the limited capacity of
a glider under tow to get out of the way
– ‘it’s basically formation flying’, Thorpe
adds, ‘so give the glider plenty of room,
and don’t fly too close’.
Pilots of powered aircraft should be aware
of the distinct flight characteristics of
gliders, Thorpe says. Landing, in particular,
is a phase of flight that is very different for
unpowered aircraft.

Flight Safety Australia
Issue 87 July–August 2012
45
‘It’s very important that powered pilots understand that gliders
only have one shot at landing, so it’s not a good idea to cut in front,
or exercise a perceived right over a glider that’s set up for landing.
‘Every landing we do is a forced landing,’
he says. ‘We don’t have the luxury of
having another go’.
‘It’s very important that powered pilots
understand that gliders only have one shot
at landing, so it’s not a good idea to cut in
front, or exercise a perceived right over a
glider that’s set up for landing. In fairness,
most powered pilots are good like that.’
A nasty little detail for IFR powered pilots
to remember is that for some aerodromes
(Kingaroy, Queensland, for example)
the missed approach procedure directs
traffic through gliding areas. This is
not an issue in actual IFR conditions,
obviously, but could contribute to a
major fright—or worse—should an IFR
pilot in training, head-down, practise a
missed approach without first reading the
ERSA and NOTAMs, and broadcasting
conscientiously on the correct frequency.
In their ceaseless quest for lift, glider
flightpaths differ from those of powered
aircraft. Gliders rarely fly in a straight line
for more than a few minutes at most, and
their airspeed also varies, as pilots seek
the optimum cross-country speed. ‘We
go from A to B via C, D, E, F and G (in a
saw-tooth profile of descending and then
climbing in thermals),’ says Thorpe.
Gliders generally fly in class G and class
E (non-controlled for VFR) airspace, but
can be found in class A airspace at up
to 35,000ft. This is legal if the glider has
received block clearance from ATC, usually
by prior arrangement.
The world glider altitude record is 50,679ft
and VNE for most gliders is about 140kt.
Circuit speeds are usually between 65kt
and 45kt and speeds between thermal
climbs can be anywhere from 60kt to
120kt, depending on type. However, during
competitions, high-performance gliders
can sometimes return to the airfield at low
level and at speeds of up to 150kt.
A skilled glider pilot who finds a rising
column of air will often exploit the glider’s
efficient wings to stay inside it. Gliders in
thermals will often turn much more steeply
than most powered aircraft. Banks of 45
degrees are common in this situation, with
60-degree banks not unknown. Rates of
climb in thermals can exceed 1000fpm on
a hot summer day. On a day with cumulus
clouds, thermalling gliders will be found
close to the cloud base, their white wings
blending all too effectively with the grey
cloudbase.
Three frequencies have been allocated
for gliders to use. They are 122.5, 122.7
and 122.9. Gliders flying in a common
traffic advisory frequency (CTAF) area
will use the CTAF frequency, but they
have an exemption from monitoring area
frequency, as gliders flying closely together
cross-country and during competitions
will usually communicate on one of the
allocated glider frequencies. ‘We fly the
same radio procedures as everybody else,
except for that exemption,’ says Thorpe.
Gliders are not currently required to carry
transponders, but many use FLARM,
a collision warning system similar in
principle to ADS-B that provides proximity
advice for gliders and tugs so equipped.
FLARM, short for flight alarm, is an
off-the shelf, low-cost proximity-warning
system suited to relatively slow-moving
aircraft such as gliders. FLARM does
not communicate with other automatic
dependent surveillance systems, but this
function is being considered.
Sample NOTAM for Bacchus Marsh
1. Gliding OPS HJ - Aerotow and winch
launched. Gliders and tugs normally
operate inside and below standard
1000ft circuit.
2. All circuits left-hand. Unforseen
circumstances may occasionally force
a glider to fly a right-hand circuit.
3. Gliders and tugs operate from righthand
side of RWY short of displaced
THR. Other ACFT must not make low/
shallow approaches and must land
beyond displaced THR.
4. When gliding OPS in progress the duty
RWY is the RWY in use by the gliding
operation. All TKOFs to commence
from the displaced THR.
5. If wind is BLW 5KT and VRBL, RWY
19 or 27 must be used by all ACFT.
WInd ABV 5KT, operate on the most
into wind RWY.
6. Overflying the AD is discouraged.
If operationally necessary, overfly at
2,000FT AGL (2,500FT AMSL).
7. When inbound it is suggested ACFT
track via and call on the CTAF at
one of the following points - Melton
Reservoir, Merrimu Reservoir, Pykes
Creek Reservoir or Mt. Anakie.

46
CLOSE CALLS
Hot and shaky
Name withheld by request
Turbulence is often associated with flying through clouds, wake turbulence in the
vortexes of other aircraft, clear air turbulence when flying close to jetstreams, or mountain
wave turbulence near high terrain; but have you ever experienced a ‘fake’ turbulence that comes
in bursts of a few seconds, followed by complete calm?
We were at FL350, on a smooth night flight from Kuala Lumpur
to Johannesburg, on a B744, when the quiet of the ride was
interrupted by a sudden shudder that felt as though we had just
flown through a cloud top. Peering quickly out through the front
windshield, I saw nothing. Then I strained my eyes through the
side window towards the left wing, and again I saw nothing.
It was a clear night. There were definitely no jetstreams.
We were over the middle of the Indian Ocean. Some moonlight
would have helped me to spot clouds without the aid of the
radar, but there was not a cloud to be seen.
‘What could it be?’ I asked myself, and so did my colleague,
a captain acting as my first officer in the right-hand seat. The
flight was a three-pilot operation. The other first officer was
in the bunk resting. I looked around the cockpit to see if there
was anything unusual. I held the speedbrake lever and assured
myself that it was in the down detent. I saw that the flap lever
was in the ‘up’ slot. Rudder and aileron trims were all at normal
in-trim positions. The gear lever was in the ‘Off’ position. There
was nothing on radar except for the normal returns of the sea at
the edge of the navigation display.
A few minutes elapsed, and my captain/first officer quipped
‘Maybe we hit the wake turbulence of another aircraft?’ But
there was no traffic within VHF range that could have escaped
our awareness. The traffic collision avoidance system also
showed nothing and it was a clear night.
I resigned myself to accepting the fact that it had to be some kind
of clear air turbulence, but then, again breaking the stillness of
the night, there was a similar shake, this time more pronounced.
It felt like moderate turbulence, but only lasted for a second.
I had been in moderate turbulence before on numerous
occasions, but it had never felt like this – this was too brief!
Again, I checked the same controls and levers again, to ensure
that I had not missed anything, but only felt more perplexed
about what was going on.
Suddenly, the intercom chimed and there was a loud knock on
the cockpit door. My colleague answered and said in surprise,
‘It’s the chief stewardess!’ I released the remote door latch
and she rushed in. From the way she sounded, panting as she
spoke, there was definitely something important happening.
Almost hysterically, she described what she had observed from
the cabin – ‘fire right side of aircraft!’
I thanked her for the invaluable information and gave her what
little reassurance I could muster. In the cockpit, no words were
uttered from then on. I selected the engine parameters on
the lower EICAS and we turned our attention to the starboard
engines. Within seconds, the now familiar shake occurred
again. However, this time, the shudder throughout the whole
aircraft was followed by a rapid rise in No. 3 exhaust gas
temperature (EGT) towards the red limit. Seeing that, my
colleague and I confirmed No.3 engine and I quickly retarded
the No. 3 thrust lever to idle position. The stillness that followed
was so comforting that I sighed with great relief. Although the
EGT had subsided somewhat, it was still higher than normal
compared with the other engines. No noticeable vibration
could be felt from the cockpit but the engine vibration indicator
showed that some broadband (BB) vibration persisted. It was
now obvious what had caused the ‘turbulence’. After a brief
discussion with my colleague, the engine was shut down, using
the quick reference handbook (QRH) checklist.

Flight Safety Australia
Issue 87 July–August 2012
47
Almost
hysterically,
she described
what she had
observed from the
cabin – Fire right side
of aircraft!’
As we were just under three hours away from our
destination, I decided to continue the flight to Johannesburg,
after discussing weather and fuel with my crew. My rested
first officer had just been awakened, not by the engine-induced
turbulence, but by his internal alarm clock. When he realised
what had happened, he wasted no time in resuming his duty,
as this was also his first three-engine real-life landing ever.
Close cabin crew collaboration
Praise is due for the alertness of the chief stewardess (chief
purser) in spotting the flames, despite the window shades being
shut because the cabin was in ‘sleep’ mode. Her vigilance and
situational awareness were a major factor in the successful
handling of the situation, as they gave me a vital clue and a
crucial advantage. Who knows what could have happened if
there had been any delay in applying corrective action and the
engine had continued to run erratically and unbalanced on fire
and at high thrust? In hindsight, on all three shudders, there had
been no yaw, only up and down motion, and the autopilot had
remained engaged.
Conclusions
As conscientious pilots, we are the last line of defence, and if
we are compelled by circumstances to fly an aircraft with an
engine that had a previous surge-related problem, we should be
aware that there could be extraordinary events throughout the
flight, especially in the critical take-off phase when the engine is
under greater stress.
During less critical phases, it is important to remember that
in addition to the warning and monitoring systems in the
cockpit, we should be aware of unusual vibrations, noises and
odours. These subtle indicators could be initial warnings of an
impending engine failure.

48
CLOSE CALLS
Live, learn, survive and be happy
Live, learn, survive
and be happy
Name withheld by request
‘I’ve learned
that feelings of
invulnerability,
hopelessness
or resignation
are recognised
hazardous
attitudes that can
be overcome.’
I hadn’t planned on writing yet another ‘close call’ story –
after all, my experiences are probably similar to everyone
else’s – but there really isn’t a better way of illustrating
how my attitude to risk in flying has changed over time.
So, I’ve included a few brief stories at the end of this
article as examples of lessons learned or mistakes I wish
I’d never made.
Back in my bush flying days, it seemed the list of things
that could kill me was almost endless – overloaded
machines with barely adequate performance, lousy
weather, the kind of territory where an engine failure
inevitably meant disaster, dodgy maintenance, indifferent
company management etc. etc.
I eventually became inured to these everyday risks, and
a fatalistic attitude set in. I used to think to myself: Well,
if one thing doesn’t get me, something else probably will,
so what’s the point of even trying to manage anything?
Besides, I’m fireproof and it’ll never happen to me anyway,
so why worry? Just press on and hope for the best.
This went on for years and somehow I survived, but some
of my colleagues didn’t. It gradually dawned on me that,
if I wanted to live, I’d better start managing all the risks
I possibly could. I mean, how long could my luck last?
Sure, there were plenty of things I still had no control over,
but (when I thought about it) I could influence a surprising
number, for better or worse.
So, when I was next faced with situations outside my
comfort zone, I either adjusted things until I felt the odds
were mostly in my favour, or I declined the task altogether.
If pressured by my employer to continue unsafe or unduly
risky practices, I quit. I lost a few jobs that way, but it
didn’t do me any harm in the long run and, perhaps more
importantly, I’m still around to talk about it.
Since those days, I’ve learned that feelings of
invulnerability, hopelessness or resignation are recognized
hazardous attitudes that can be overcome. I wish I’d
known that beforehand, instead of belatedly discovering
them for myself, but better late than never, I suppose.
The first story concerns fuel – or lack of it, to be precise.
In the interest of satisfying my employer’s or my
customer’s demands for max payload, I used to fly without
legal and/or sensible alternate fuel for weather diversions.
I figured I would always make it to my destination, either
because I knew the area well and felt I could safely bust

Flight Safety Australia
Issue 87 July–August 2012
49
the proper procedures (like scud run), or because I had
some ‘homemade’ instrument approaches worked out if
conditions were really bad. Actually, I always did manage
to make it (although sometimes with only fumes in the
tank and my heart in my mouth) but, looking back and
thinking about the risks I ran in those days – for no good
reason – now makes my blood run cold.
Still on the subject of carrying max payloads to please the
boss, I’ve lost count of the number of times I’ve squeezed
out of tiny take-off areas and missed obstacles on climbout
by the skin of my teeth. All in a day’s work, you might
say, but the margin for error really shouldn’t be zero ...
I recall one occasion when my task was to land a heavy
load of passengers on a ridge-top pad. From prior
experience, I knew the helicopter’s performance would be
marginal at best, but I pressed on regardless, not bothering
to carry out a detailed assessment of the approach, or
to consider other options (such as landing elsewhere
and making the passengers walk). The upshot was that
I ran out of power on short final, exceeded engine and
transmission limits and touched down rather firmly on the
pad with the rotor low-rpm horn blaring and the collective
up around my armpit. A narrow escape... but why did I
do it?
I think the three factors mentioned earlier could be relevant
to these (probably no uncommon) incidents: invulnerability
(‘I’ve done this before’), hopelessness (‘The passengers
expect me to land there’) and resignation (‘My job is on the
line if I don’t do this’).
These days, I do my best to be consciously on guard
against potentially hazardous feelings such as this, as part
of my intention to live a long, happy and safe flying life.
ever had a
CLOSE CALL?
Write to us about an aviation incident or
accident that you’ve been involved in.
If we publish your story, you will receive
$
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.

50
CLOSE CALLS
Taking control
Name withheld by request
I was flying an international heavy jet to New Chitose, Japan,
also known as Sapporo. It was May 2012, and the usual threats
of cold weather, snowy conditions and contaminated runways
which plague the airport early in the year were fortunately not
in evidence this time. Our early afternoon arrival was in clear
skies, with 25km visibility reported by ATIS and ATC suggesting
a visual approach.
Before descent, and after the approach briefing, the captain
suggested that we should have an extra stage of flap out than
normally specified when abeam the threshold. The descent
was normal and radar vectors were given until in sight of the
aerodrome, then a visual approach clearance was issued.
By late downwind, I selected autopilot off and with everything
normal I turned base leg.
The captain commented about the military runway at the far side
of the airport which, given our position, in my judgement, was
not a threat or concern. I prefer to hand-fly visual approaches,
and by manipulating the controls manually, I guarantee a tighter
turn than one made with the autopilot, ensuring a shallow
intercept onto final. I also do this as a preventative measure
against overshooting, or straying onto a parallel runway area.
The gear was selected down with the final stage of flap to go,
and the landing checklist to be completed. This is always a
busy time. The captain, focused on the navigation display,
muttered something about the geometry of the turn and not
going to intercept final correctly. I was now halfway through
the base turn with the runway in sight. Everything looked as
it should. The vertical deviation indicator showed the profile
was good and I was happy to continue, seeing no need to
modify anything.
I noticed the captain becoming uncomfortable, even agitated.
Suddenly, forcefully, and without warning, he took control of
the thrust levers and control stick, saying ‘I have control’.
Immediately, I changed to pilot-monitoring duties, and
acknowledged: ‘you have control as per our SOPs’.
I didn’t know the reason for his decision, but at this stage of
the approach there was no discussion. From my situational
awareness everything was within limits and normal, nothing
had been breached. It had not occurred to me before, so I asked
myself ‘was there something missed, or some information the
captain knew which I didn’t, or hadn’t recognised?’ I had to
be open-minded. We all make mistakes, but judging by the
captain’s action, this was no small error.
The captain took control and stopped the base turn. I did not
understand why, but I did know that unless he corrected the new
flight path he had established, it would be an unstable approach.
An incursion of the adjacent runway’s airspace would quickly
follow, and if allowed to continue, an infringement of military
restricted airspace. And this would happen in seconds. I was
not thrilled about control being taken away, without knowing
why. The captain began manoeuvring towards the next runway.
Only a second had passed since handing over control, and I
noticed him focusing on the military runway, two runways away
from ours, and adjusting track to land there. From our current
position it would be difficult to achieve at best, even though the
military runway seemed closer to us. It is located further north
than the two civil runways, but from our position northeast
of the airport, its lighter-coloured tarmac made it appear
more obvious.
I was astonished as the situation unfolded. My next thought was
to take over from the captain, as per our procedures and crew
resource management (CRM) principles. But would that be the
best fix, considering where we were on the approach as well as
our cultural differences? What if he didn’t surrender control?
I knew clearly what had to be done in a very short time frame
to make this a successful approach, but that window was
closing fast.
This captain and first officer were thinking two very different
things. One of us was right, the other was wrong. Unfortunately,
the one who was wrong had assumed command of the controls,
but he did not know he was wrong, making it a dangerous
situation. It was now up to me to prove his error—and quickly.
His situational awareness was compromised when he
tried matching the picture he had developed from the
navigation display with the one he could see through
the window.
He believed he was making a bad situation better. In fact, he was
doing the opposite: turning a normal, within-limits manoeuvre
into something unsafe.

Flight Safety Australia
Issue 87 July–August 2012
51
military runway
hand-fly visual approaches
navigation display
wrong situational awareness
turned base leg
01R/19L
3,000m/9,843ft
01L/19R
3,000m/9,843ft
18R/36L
2,700m/8,858ft
18L/36R
3,000m/9,843ft
I shouted at him very
deliberately, so there would be
no misunderstanding,
‘No!’,
pointed to the runway at our 10 o’clock
position, and said,
‘that’s our runway’.
Finally, he turned the aircraft in the correct direction; I will
never forget the lost and confused look on his face. He asked
for landing flap and landing checklist, and we completed the
landing normally within the stable approach parameters.
So much went on in just a few seconds. At the time I don’t know
what thinking made him arrive at his decision. But whatever
the reason, he made a basic error. The situation could rapidly
have escalated into something worse if I had failed to challenge
him, or had passively accepted his wrong decision. To many
this is obvious, but in some cultures they do not challenge and
will accept a bad decision, even if they know it is wrong. Many
aircraft accidents occur because of this, as we often read in
FSA and other aviation magazines.
A pilot taking over from a normal condition and unwittingly
attempting to take it into an unsafe condition is not something
you specifically train for in simulator exercises. Standard
procedure is to back up the other pilot but offer assistance
where necessary—that is to give a heads-up if you think an
error will be made. This is part of CRM, but you have to adapt to
different situations and respond accordingly: scenarios may not
play out as described in quick reference handbooks, manuals,
textbooks, or simulator exercises.

24 Hours
1800 020 616
Web
www.atsb.gov.au
Twitter
@ATSBinfo
Email
atsbinfo@atsb.gov.au
How safe is
Australian
aviation?
You may have seen some recent media
coverage suggesting that the high number
of aviation occurrences reported to the ATSB
reflects a low standard of aviation safety in
Australia. With a bit of context, you’ll see that
the opposite is true.
Australia has an extensive mandatory
reporting scheme and a healthy reporting
culture that sees a broad range of occurrences
reported to the ATSB. These include reports
from all sectors of aviation, ranging from
sport and recreational flying in ultra-lights and
gyrocopters, to private flying and commercial
passenger operations.
It’s important to remember that Australian
aviation has many layers of defence to protect
safety. If even one of these layers is breached,
then the ATSB needs to know about it. We
use the information from occurrence reports
to determine whether to investigate an
incident or accident and to make real practical
improvements to the safety system.
The large number of occurrences reported to
the ATSB reflects a strong reporting culture.
It does not represent a low standard of
aviation safety in Australia. In fact, through our
investigations and analysis of occurrence data,
the ATSB has not seen any overall increase
in risk or systemic safety issues in Australian
aviation. If we did, we would immediately
bring it to the attention of industry and the
relevant safety authority.
I encourage the Australian aviation industry to
continue the great job of reporting incidents
and accidents to the ATSB. Through your
reports, we make flying safer.
Martin Dolan
Chief Commissioner
General aviation:
Continuing safety
concern
The ATSB has released its latest statistical report
– Aviation Occurrence Statistics 2002 to 2011 –
providing the most up-to-date portrait of aviation
safety in Australia.
There were 130 accidents, 121 serious incidents,
and 6,823 incidents in 2011 involving VH-registered
aircraft.
General aviation operations continue to have an
accident rate higher than commercial air transport
operations—about four times higher for accidents,
and nine times higher for fatal accidents in 2011.
Most commercial air transport accidents and
serious incidents were related to reduced aircraft
separation, and engine issues.
Charter operations accounted for most of the
accidents, including two fatal accidents in 2011
within air transport. Air transport incidents were
more likely to involve birdstrikes or a failure to
comply with air traffic control instructions or
published information.
For general aviation aircraft, accidents and serious
incidents often involved terrain collisions, aircraft
separation issues, or aircraft control problems.
General aviation incidents commonly involved
airspace incursions, failure to comply with air traffic
control, and wildlife strikes.
In most operation types, helicopters had a
higher rate of accidents and fatal accidents than
aeroplanes, except for in charter operations. Even
though the fatal accident rate is generally higher,
helicopter accidents are generally associated with
fewer fatalities than fixed-wing aircraft.
The figures and insights from the report are helping
the ATSB concentrate its efforts on transport safety
priorities. The report also reveals that many of the
accident types are avoidable (especially for general
aviation) and can be prevented through good flight
management and preparation.
Aviation Occurrence Statistics 2002 to 2011 is
available for free at www.atsb.gov.au •

If in doubt, don’t take-off
ATSB investigation AO-2011-016
A fatal accident involving a Robinson
Helicopter Company R44 helicopter is a
powerful reminder to stay on the ground
if something isn’t right with your aircraft.
On 4 February 2011, a Robinson R44
Astro helicopter, registered VH-HFH,
crashed after part of the aircraft’s flight
controls separated from the hydraulicboost
system during circuit operations at
Cessnock Aerodrome.
Following a landing as part of a simulated
failure of the hydraulic boost system
for the helicopter’s flight controls,
the flight instructor assessed that the
hydraulic system had failed and elected
to reposition the helicopter on the apron.
As the helicopter became airborne, it
became uncontrollable, collided with
the runway and caught fire. The pilot
survived, but the flight instructor and a
passenger died in the accident.
What caused the
accident
A number of factors—both human and
mechanical—contributed to the accident.
The ATSB’s investigation found that a
flight control fastener had detached,
making the aircraft uncontrollable. The
ATSB was unable to determine the
specific reason for the separation as a
number of components could not be
located in the wreckage.
Testing conducted by the manufacturer
showed that the ‘feel’ of the flight control
fault mimicked a hydraulic system failure.
That behaviour, together with the report
that the hydraulic system had been
leaking and the apparently unsuccessful
attempts to re-engage the hydraulic
boost system while on the ground,
probably resulted in the misdiagnosis
of a hydraulic system fault. The fault,
however, was with the flight controls,
not the hydraulic system and when
the helicopter became airborne for
repositioning, control was lost.
Following the preliminary results of
its investigation, in March last year
the ATSB issued a Safety Advisory
Notice encouraging all operators of R44
hydraulic system-equipped helicopters
to inspect and test the security of the
flight control attachments on their R44
helicopters, paying particular attention to
the connections at the top and bottom of
the servos.
The risks of aluminium
fuel tanks
The fatal injuries sustained by the
instructor and passenger were caused
by the post-impact fire. The investigation
identified that a large number of R44
helicopters, including VH-HFH, did not
have the upgraded bladder-type fuel
tanks. These tanks reduce the risk of
post-impact fuel leak and subsequent
fires.
R44 Service Bulletin 78, issued by
Robinson Helicopter Company on
20 December 2010, advised that R44
helicopters with all-aluminium fuel tanks
be retrofitted with bladder-type tanks as
soon as practical, but no later than
31 December 2014. In February this year
the manufacturer revised the date of
compliance to 31 December 2013.
Tragically, the post-impact fire from
another R44 crash claimed two more
lives at Jaspers Brush, NSW in February
2012 (ATSB investigation AO-2012-021).
Aircraft wreckage
What we’ve learnt from
this accident
This accident reinforces the importance
of thorough inspections by maintenance
personnel and pilots. The investigation
identified that self-locking nuts used in
many aircraft, including R22, R44 and
R66 helicopter models, can become
hydrogen-embrittled and fail. The
Robinson Helicopter Company and the
Civil Aviation Safety Authority (CASA)
have published information advising pilots
and maintenance personnel that any
cracked or corroded nuts be replaced.
The ATSB also urges all operators and
owners whose R44 helicopters are fitted
with all-aluminium fuel tanks to replace
those tanks with bladder-type fuel tanks
as soon as possible. Compared to the allaluminium
tanks, the bladder-type tanks
provide improved cut and tear resistance
and can sustain large deformations
without rupture. The safety benefits
of incorporating the requirements of
manufacturer’s service bulletins in their
aircraft as soon as possible cannot be
underestimated. •

The success of the system
ATSB investigation AO-2010-035
Often things go wrong in safety because
we’re all human and prone to error.
Inevitably, in any type of operation, some
human, somewhere, is eventually going
to make a human error. That includes
the field of aviation. But it’s for that
very reason that our systems have so
many defences built into them. The
success of these defence systems was
demonstrated in a 27 May 2010 incident
at Singapore’s Changi International
Airport. Several events on the flight
deck of an Airbus A321-231 distracted
the crew during the approach. Their
situational awareness was lost, decision
making was affected and inter-crew
communication degraded.
At 6.45 pm, the aircraft, operating as
Jetstar flight JQ57 from Darwin Airport,
was undertaking a landing. The first
officer (FO) was the pilot flying (PF) and
the captain was the pilot not flying for the
sector. The FO had, on the instructions of
Air Traffic Control, descended to 2,500 ft
and turned onto the designated heading.
The FO disconnected the autopilot.
Immediately, the master warning
continuous chime was activated for
six seconds. An AUTO FLT A/P OFF
message was activated and remained
displayed on the monitor. The FO called
for action, requesting that the captain set
the ‘Go Around Altitude’. However, the
captain was preoccupied with his mobile
phone. The FO set the altitude himself,
but the landing gear was left up, and the
landing checklist was not initiated.
About two minutes later, as they
descended through 750 feet, the
undercarriage was still up. The master
warning chimed and the ‘EGPWS – Too
Low Gear’ alarm sounded, alerting
the crew to the situation. Neither the
captain nor the FO communicated their
intentions to each other—a problem
since the FO perceived that the captain
wanted to land, while the captain had
always intended to go around.
The go-around was completed
successfully, and the aircraft landed
safely, but it could not be considered a
textbook approach.
‘It is not, by any means, an ideal series of
events,’ said ATSB Chief Commissioner,
Martin Dolan. ‘However, the defences
that exist helped to retrieve the situation,
and our investigation did not identify any
organisational or systemic issues that
might adversely impact the future safety
of aviation operations. In addition, the
aircraft operator proactively reviewed
its procedures and made a number of
amendments to its training regime and
other enhancements to its operation.
Everyone has learned valuable lessons
from this.’ •
Proposed changes to reporting
requirements
The ATSB is developing new
regulations for the mandatory
reporting of accidents and incidents,
and confidential reporting of safety
concerns in Australia.
‘This is an important step in the
ongoing development of aviation
safety in Australia,’ said Martin
Dolan, Chief Commissioner of the
ATSB. ‘We have been working with
industry for the last couple of years
to develop these reforms in the
interests of ensuring that reporting
makes the greatest possible
contribution to future safety.’
There are two changes proposed
to the mandatory reporting of
accidents and incidents.
‘The first is that we are proposing to
share with CASA all the mandatory
notifications that we receive,’ said
Mr Dolan. ‘It is a standard practice
around the world for the regulator to
be copied into a notification. In many
countries it is the regulator who
receives the notification in the first
instance. With this change CASA
will be better placed to perform its
safety regulation functions.’
This change will not place any
new burdens or responsibilities on
aviation stakeholders.
The second change will involve
the revision of the existing list of
accidents and incidents that need
to be reported as immediately
reportable and routine reportable
matters.
Mr Dolan says that, ‘The new
system we are working on will be
less prescriptive than it is now. The
requirement to report will be based
around the severity of the risk that
surrounds an occurrence.’
There will also be some changes
made to the Voluntary and
Confidential Reporting (REPCON)
system as a result of the ATSB’s
increased role in rail from 1 January
2013.
‘REPCON will be a multi-modal
scheme covering the aviation,
maritime and rail transport
industries,’ explained Mr Dolan.
‘However, rest assured that the
scheme will continue to give a
high level of protection for people
who submit reports. The priority of
REPCON will always be to provide
a secure avenue for people to share
their concerns while protecting their
identity.’
‘The expansion of REPCON will
enable all three industries to learn
from each other’s experiences.’
The next step for the ATSB will be
reviewing the comments received
from industry, and assessing any
suggestions for integration into the
amendments.
More information will be published
in future editions of Flight Safety
Australia. •

Night flying–make sure you’re qualified
ATSB investigations AO-2011-043 and
AO-2011-087
Two ATSB investigations into fatal
accidents highlight the dangers facing
pilots who fly at night without the
appropriate qualifications.
One accident resulted in the death of a
pilot of a Robinson R22 helicopter. The
other accident involved a Piper Saratoga
PA-32R-301T aircraft, and claimed the
lives of the pilot and three passengers
and left two other passengers seriously
injured.
‘Flying at night presents unique, and
dangerous challenges,’ said Julian Walsh,
General Manager of Strategic Capability
at the ATSB. ‘It is troubling that some
pilots are ignoring their own lack of
qualifications, and putting themselves in
these situations.’
The helicopter accident took place on
27 July 2011, 14 kilometres north-west of
Fitzroy Crossing in Western Australia. The
owner-pilot had departed from the Big
Rock Dam stockyards about half an hour
after sunset on a moonless evening. As
the flight progressed, conditions became
very dark and the pilot was probably
forced to operate using the helicopter’s
landing light. The pilot was attempting to
return to Brookings Spring homestead
at low level in an area without any local
ground lighting.
About halfway into the flight, the pilot
inadvertently allowed the helicopter to
develop a high rate of descent, resulting in
a collision with terrain.
The subsequent investigation found
that the pilot’s licence had not been
endorsed for flight under the night Visual
Flight Rules (VFR). Also, there was no
evidence that the pilot had received any
night flying training, although anecdotal
reports suggested that this was not the
first time the pilot had flown at night. An
examination of the helicopter found no
evidence of any pre-existing defects or
anomalies.
The second aircraft accident happened
in March 2011, at Moree in New South
Wales. The Piper Saratoga was returning
to Moree Airport from Brewarrina Airport
with a pilot and five passengers on board.
R22 helicopter wreckage of VH-YOL
The flight had been conducted under the
night VFR.
The aircraft flew over the airport at about
8.00pm before the pilot conducted a left
circuit for landing. Witnesses observed
the aircraft on a low approach path as it
flew toward the runway during the final
approach leg of the circuit. The aircraft
hit trees and collided with level terrain
about 550 metres short of the runway
threshold.
Although the pilot had a total aeronautical
experience of about 1,010 flying hours, he
did not satisfy the recency requirements
of his night VFR rating. In addition, the
aircraft’s take-off weight was found to be
in excess of the maximum allowable for
the aircraft, reinforcing the importance of
pilots operating their aircraft within the
published flight manual limitations.
‘Flying at night adds a level of complexity
to every development,’ commented Mr
Walsh. ‘If a safety situation arises, the
element of darkness makes it that much
more difficult to react effectively.’
Flying safely at night requires pilots to rely
on well-developed skills that address the
risks that night flight poses. Night recency
requirements, as determined by the Civil
Aviation Safety Authority, are a minimum
standard that assists pilots to identify
and address those risks. Though multiple
factors contributed to both accidents, the
fact that both pilots were flying in night
conditions when they were not properly
qualified to do so demonstrates the
dangers of such practices.
‘If you are going to be flying at night,’
said Mr Walsh, ‘it is vital that you have
received the proper training, and that
your qualifications are up to date.’ The
ATSB takes this issue seriously enough
that the topic of flying at night will be a
future subject for the Avoidable Accidents
series.
The reports are available from the ATSB
website www.atsb.gov.au •

Wirestrikes go unreported
A new research investigation has found
that more than 40 per cent of aviation
wirestrikes that occur in Australia
were not reported to the ATSB. This
investigation commenced following
anecdotal information from stakeholders
who were aware of more wirestrikes
than had been reported.
by electricity distribution companies.
And then there’s the fact that disused
overhead wires are not tracked, so
when they are damaged by an aircraft,
electricity companies aren’t notified.
Finally, there are many private power
lines out there, and we don’t have any
figures for them.’’
‘We’re urging pilots, and all aviation
stakeholders, to report any wirestrike to
the ATSB even if there’s no damage to
the aircraft and/or no injuries. There may
not even be any damage to the wires.
But the more we know, the better we
can do our job, which is to make flying in
Australia safer.’
The report Underreporting of Aviation
Wirestrikes is available on the ATSB
website at www.atsb.gov.au
Notifications of safety related events can
be made via the toll free number
1800 011 034 (available 24/7) or via the
ATSB website. •
Wirestrike
Wirestrikes pose an on-going danger
to Australian aviators. They can happen
to any low-flying aircraft involved in any
operation, such as aerial agricultural,
other aerial work, recreational or scenic
flights. Intrigued by the possibility that
this lack of reporting was common,
the ATSB reached out to electricity
distribution companies, asking for
information. And the electricity
companies delivered.
Before this investigation, 166 wirestrikes
were reported to the ATSB between
July 2003 and June 2011. The new data
from the electricity companies, however,
revealed another 101 occurrences that
had not been reported to the ATSB. At
least 40 percent of the wirestrikes in
Australia had never been formally tallied.
‘And it’s possible that the incidence
of wirestrikes may actually be even
higher,’ said Dr Godley, the ATSB’s
Manager of Research Investigations
and Data Analysis. ‘There are several
reasons for us to believe that. Firstly,
a major telecommunications company
did not have a single repository of this
information to be able to provide the
ATSB with information of wirestrikes on
its network. In addition, not all wirestrikes
result in a broken wire or interrupted
power supply, and so are not recorded
When wildlife strike
Bats and galahs are among the most
common wildlife to be struck by
Australian aircraft according to a new
ATSB research report.
The report provides the most recent
information on wildlife strikes in
Australian aviation. In 2011, there
were 1,751 birdstrikes reported to
the ATSB. Most birdstrikes involved
high capacity air transport aircraft.
For high capacity aircraft operations,
reported birdstrikes have increased
from 400 to 980 over the last
10 years of study, and the rate per
aircraft movement also increased.
For aeroplanes, takeoff and landing
was the most common part of a
flight for birdstrikes. Helicopters
sustained strikes mostly while
parked on the ground, or during
cruise and approach to land.
Birdstrikes were most common
between 7.30 am and 10.30 am with
a smaller peak in birdstrikes between
6pm and 8pm, especially for bats.
All major airports, except Hobart and
Darwin, had high birdstrike rates per
aircraft movement in the past two
years compared with the average
for the decade. Avalon Airport had a
relatively small number of birdstrikes.
But, along with Alice Springs, Avalon
had the largest strike rates per
aircraft movement for all towered
aerodromes in the past two years.
In 2010 and 2011, the most common
types of wildlife struck by aircraft
were bats/flying foxes, galahs, kites
and lapwings/plovers. Galahs were
more commonly involved in strikes
of multiple birds.
Animal strikes were relatively rare.
The most common animals involved
were hares and rabbits, kangaroos
and wallabies, and dogs and foxes.
Damaging strikes mostly involved
kangaroos, wallabies and livestock.
The report is a reminder to everyone
involved in the operation of aircraft
and aerodromes to be aware of the
hazards posed to aircraft by wildlife.
While it is uncommon for a birdstrike
to cause any harm to aircraft crew
and passengers, many strikes
result in damage to aircraft. Some
birdstrikes have resulted in forced
landings and high speed rejected
takeoffs.
Timely and thorough reporting of
birdstrikes is vital. The growth of
reporting to the ATSB seen over
the last 10 years has helped us to
understand better the nature of
birdstrikes, and where the major
safety risks lie. This helps everyone
in aviation to manage their safety
risks more effectively.
The report Australian aviation wildlife
strike statistics: Bird and animal
strikes 2002 to 2011 is available for
free on www.atsb.gov.au •

REPCON BRIEFS
Australia’s voluntary confidential aviation reporting scheme
REPCON allows any person who has an aviation safety concern to report it to the ATSB
confidentially. All personal information regarding any individual (either the reporter or any
person referred to in the report) remains strictly confidential, unless permission is given by
the subject of the information.
The goals of the scheme are to increase awareness of safety issues and to encourage
safety action by those best placed to respond to safety concerns.
Ambiguous procedures
for missed approach
Report narrative:
The reporter raised a safety concern about
the ambiguity that lies within the rules
surrounding the turn onto any missed
approach with the wording ‘Track XXX ‘
and the missed approach point defined
by a radio aid. The concern is, should a
pilot turn the aircraft so as to make good a
track of XXX, or should the pilot intercept
the radial XXX outbound from the missed
approach point. The rules do not specify
one way or the other.
Responses/received:
The following is a version of Airservices
Australia’s response:
Departure and Approach Procedures
(DAP)
Airservices Australia’s DAP, page 1-1,
paragraph 1-7 states:
‘All procedures depict tracks, and pilots
should attempt to maintain the track by
applying corrections to heading for known
or estimated winds.’
Aeronautical Information Publication
In addition, the Australian Aeronautical
Information Publication (AlP), paragraph 1.1
0.2 refers to a missed approach conducted
from overhead a navigation facility:
In executing a missed approach, pilots
must follow the missed approach
procedure specified for the instrument
approach flown. In the event that a missed
approach is initiated prior to arriving at the
MAPT [Missed Approach Point], pilots
must fly the aircraft to the MAPT and then
follow the missed approach procedure.
The MAPT in a procedure may be:
a. the point of intersection of an electronic
glide path with the applicable DA; or
b. a navigation facility; or
c. a fix; or
d. a specified distance from the Final
Approach Fix (FAF).
Application
Airservices Australia considers there are
generally two different scenarios when
conducting a missed approach and these
are described, in general terms, as text on
the DAP plate as follows:
1. Turn Left (or Right), Track xxx°, Climb to
xxxxft
Tracking is made without reference to
the Navaid and the expectation is that
the pilot will use Dead Reckoning (DR) to
achieve the nominated track. Allowance
for wind must be included to make good
this nominated track. A Navaid may
be used to supplement track keeping
during the missed approach when it is
a straight continuation of the final track,
however guidance is not mandatory. Most
procedures in Australia that have been
designed with a navigation facility utilise
DR navigation in the missed approach
segment. The area of consideration when
designing an instrument approach and
landing procedure is larger for DR tracks
than those assessed when a navigation
aid is used.
2. Turn Left (or Right), Intercept xxx° xx NDB
(or VOR), Climb to xxxxft
Tracking is made with reference to the
Navaid and the expectation is that the pilot
will make an interception of the nominated
track. Where an intercept is required it will
be both stated and shown in diagram on
the procedure plate. As an example, refer
to the approach chart for Cairns ND8-8 or
VOR-8.
The missed approach instruction states,
‘At the NDB or VOR, Turn Left to intercept
040° CS VOR or NDB. Climb to 4000ft
or as directed by ATC.’ This is displayed
diagrammatically on the procedure plate.
The primary reason is to avoid critical
terrain located near or within the splay
tolerance area. The use of the navigation
facility can significantly reduce this area
compared to a DR track and also provides
situational awareness to pilots and ATC
as to where the aircraft will be during that
phase of flight. If a pilot does not intercept
the radial/bearing, the aircraft may not
be contained within the splay protection
area and result in the aircraft not clearing
an obstacle by the required minimum
obstacle clearance.
ATSB comment:
Enquiries conducted by the REPCON
Office have revealed a different
perspective between ATC and flight crews
in respect of how missed approaches
should be conducted from overhead an aid
(NDB/VOR).
The ATSB provided a number of
suggestions to CASA that may assist in
removing the ambiguities relating to the
missed approach procedure, particularly
where the MAPT is overhead an aid.
The following is a version of the response
that CASA provided:
CASA has reviewed this matter internally
with subject matter experts and considers
that Airservices Australia’s comment
is accurate in that it reflects the way
procedure designers design these types of
missed approach procedures. That there
seems to be misunderstanding within
industry suggests a need to explain this
reasoning in the Aeronautical Information
Publication. CASA will be generating a
Request for Change (RFC) to the AlP. This
should ensure that pilots are provided with
a greater level of information regarding a
missed approach. The AlP change will be
coordinated with Airservices.
How can I report to REPCON?
Online:
www.atsb.gov.au/voluntary.aspx

58
FEATURE
Air Blue Flight 202
Pride before a
Macarthur Job looks at how
an A321, minutes away from
touchdown, crashed into the
Margalla Hills
Captain Pervez Iqbal Chaudhary’s last day on earth did not begin
well. The investigation report published after his death noted that
while programming the flight management system for Air Blue Flight
202, he appeared to be confusing the destination, Islamabad, with
the origin, Karachi.
Flight 202 took off at 7.41am on July 28 2010. The aircraft was an
Airbus Industrie A321, built in 2000, with just over 16,000 hours
of service. It had been serviced that day, with no defects recorded.
The cockpit voice
recorder, recovered
scorched but
intact a few days
later, revealed
an aggressive
interrogation
that continued at
intervals for about
an hour
During climb, and contrary to company procedures, the highly
experienced Captain Chaudhary chose to examine the knowledge
of the comparatively junior first officer in a harsh and overbearing
manner. The cockpit voice recorder, recovered scorched but intact
a few days later, revealed an aggressive interrogation that continued
at intervals for about an hour. First officer Muntajib Ahmed had
been an F-16 pilot in the Pakistan Air Force, but under Chaudhary’s
verbal assault he ‘remained subdued, appearing under-confident
and submissive,’ the Pakistan Civil Aviation Authority report said.
About 155nm from Islamabad, the crew selected the automatic
terminal information service frequency, and learned that the duty
runway was runway 12. The captain also checked the weather
conditions at Peshawar and Lahore. Finding them anything but
encouraging, he appeared to become apprehensive.

Flight Safety Australia
Issue 87 July–August 2012
59
The single runway at Islamabad Airport is oriented 12-30.
Approach procedures are for ILS, DME, VOR and straight-in
approaches to runway 30, and a circling approach to land on
runway 12. There are two prohibited areas in the vicinity, one to
the south-west and another to the north-east, and a hilly area to
the north-east of the airport.
As the aircraft neared Islamabad, the crew realised that, after
making an instrument descent on the ILS for runway 30, they
would be required to execute a visual circling approach to
runway 12. Becoming increasingly worried about poor weather
and low cloud, the captain called Islamabad Approach to
request a right-hand, downwind visual approach to the runway.
The radar controller refused this, because of ‘procedural
limitations’.
The captain then decided to fly the circling approach in
navigation mode, and the aircraft began descending at 8.58am.
Shortly afterwards, the radar controller informed the aircraft to
‘expect arrival to ILS, runway 30, circle to land runway 12’.
The first officer then asked Approach if they could now
be cleared to a ‘right downwind runway 12 for the approach’.
This time the controller responded:
‘Right downwind runway 12 is not available at
the moment because of low clouds’.
Acknowledging, the captain responded: ‘we understand right
downwind is not available—it will be ILS down to minima and
then left downwind—OK?’ The crew then discussed a waypoint
five nm to the north-east of the runway, on a radial 026 from
the runway 12 threshold. Discussion followed on another
intended waypoint.
At 9.34am, with the A321 now down to an altitude of 4300ft, the
radar controller cleared it to descend to 3900ft in preparation for
intercepting the ILS for runway 30, to be followed by a circling
approach to land on runway 12. Two minutes later, at an altitude
of 3700ft, the aircraft became established on the ILS with both
autopilots engaged, and the crew extended the undercarriage.
Now in contact with the control tower, the crew again asked:
‘How’s the weather for a right downwind?’ The tower controller
responded that a right downwind was not available—only a left
downwind for runway 12.
It was the captain’s intention to descend to 2000ft on the ILS,
(little more than 300 feet above the runway altitude of 1688ft)
but the first officer reminded him that 2500ft was minimum
descent altitude.
The crew levelled out at 2500ft, disengaged no. 2 autopilot, and
with only no. 1 autopilot engaged, continued to fly the aircraft
on the runway heading to the VOR.
The crew’s intended break-off to the right from the ILS approach
to fly the right downwind circuit was delayed because they had
not become visual in the poor visibility. Meanwhile, the tower’s
confirmation that an aircraft of a competing airline had just landed
safely (albeit on the third attempt) put the captain under more
pressure to complete his approach and landing.
Almost immediately the aircraft broke out of cloud, and the tower
instructed the crew to report when established on a left downwind
for runway 12. Seconds later, passing over the VOR, 0.8km short
of the runway 30 threshold, the crew turned the aircraft to the right
on the autopilot, and very shortly afterwards lowered the selected
altitude to 2300ft, presumably in an effort to remain visual in the
poor conditions. The aircraft began descending again, violating the
minimum descent altitude.
The tower controller now suggested to the captain that he fly a
bad weather circuit, but the captain ignored this transmission,
commenting to the first officer: ‘Let him say whatever he wants
to say’. It was evident that the captain had already decided to fly a
‘managed approach’, using waypoints unknown to Islamabad Air
Traffic Control.
Although the captain had said he would fly the circling approach in
the navigation mode, the aircraft was still in the heading mode. The
first officer pointed this out, saying: ‘OK sir, but are you visual?’
The captain replied, ‘Visual! OK’.
While planning for his intended approach pattern, the captain told
the first officer where in the circuit he was to extend the flaps.
At 9.39am, when the aircraft was more than 3.5nm from the

60
FEATURE
Air Blue Flight 202
runway centreline, and abeam the threshold of runway 12
on a heading of 352 degrees, the crew turned the aircraft left
onto 300 degrees through the autopilot, and the autopilot was
reselected to navigation mode.
A minute later, when the aircraft was one nm to the south of a
prohibited area, the tower controller instructed the crew to turn
left in order to avoid entering the no-fly zone. Shortly afterwards,
with the aircraft now five nm to the north of the airport, the
aircraft’s ground proximity warning system enunciated:
‘TERRAIN AHEAD’! The first officer urged: ‘Sir! Higher ground
has been reached! Sir, there is terrain ahead! Sir, turn left’!
By this time the captain was displaying frustration, confusion
and some anxiety, his speech indicating that he was
becoming rattled.
At 9.40am, the tower controller asked the crew if they were
visual with the airfield. The crew did not respond to the
transmission, the first officer asking the captain: ‘What should
I tell him, sir?’
At the insistence of the radar controller, the tower controller
then asked the crew again if they were visual with the ground.
Both the captain and the first officer said they were. Then
again the first officer exclaimed: ‘Sir! Terrain ahead is coming!’
The captain replied: ‘Yes, we are turning left.’
But the aircraft was not turning. At the same time, two more
‘TERRAIN AHEAD’ enunciations sounded. In his increasingly
flustered state, and trying to turn the aircraft to the left on the
autopilot, the captain was moving the heading bug onto reduced
headings, but failing to pull out the heading knob to activate
change, as required with the autopilot in navigation mode.
Forty seconds before impact, the autopilot mode was changed
from ‘navigation’ to ‘heading’. At this stage, the aircraft’s
heading was 307 degrees, but the captain had reduced the
selected heading to 086 degrees. As a result, the aircraft
immediately started to turn the shortest way towards this
heading, in this case to the right, towards the Margalla Hills.
From that time on, more ground proximity warning system callouts,
‘TERRAIN AHEAD, ‘TERRAIN AHEAD, PULL UP!’ began
sounding, continuing until impact.
Meanwhile, the first officer called out twice in an alarmed voice,
‘Sir turn left! Pull up! Sir, sir, pull up!’ In response, the thrust
levers were advanced, the autothrust disengaged, the selected
altitude was changed to 3700ft and the aircraft began climbing,
still turning right. Seconds later the thrust levers were retarded
to the climb detent, the autothrust re-engaged in the climb
mode, and the selected altitude reduced to 3100ft.
The first officer called out yet again, ‘Sir—pull up, sir!’ and the
no. 1 autopilot was disconnected, with the aircraft still rolling 25
degrees to the right. The captain then applied full left stick with
some left rudder. The aircraft began turning left at an altitude of
2770ft and increasing.
In the last few seconds of the flight, the captain applied more
than 50 degrees of bank to increase the turn, also making
some nose-down inputs. The aircraft pitched down nearly five
degrees. As its speed increased, the auto thrust spooled down
the engines, and the aircraft began descending at a high rate.
Although the first officer again shouted, ‘Terrain sir’ and the
captain started to make pitch-up inputs, the high rate of descent
could not be arrested in time. For the last time, the first officer
called out: ‘Sir we are going down ... Sir we are going d...’
Seconds after 9.41am, in a slightly nose-down attitude and
a steep left bank, the aircraft flew into the Margalla Hills at an
elevation of 2858ft. Its rate of descent was more than 3000ft
per minute. The aircraft was completely destroyed and all 152
people on board were killed instantly.
The weather at Islamabad Airport at the time of the crash
was three octas of cumulus cloud at 1000ft, four octas
of stratocumulus at 3000ft and seven octas of altostratus
at 10,000ft, with a visibility of 3.5km. The wind from 050
degrees was 16kt. The temperature was 24 degrees C and rain
was likely.
There was also a weather warning, valid to 12 noon, for
thunderstorms and rain for 50 miles around, and for south-east
to north-east winds at 20 to 40kt, gusting up to 65kt or more.
Visibility could reduce to one kilometre or less in precipitation.
Moderate to severe turbulence could occur in 1-2 octas of
cumulonimbus at 3000ft.
Findings
The captain’s behaviour towards the first officer was harsh,
snobbish and contrary to established norms. This curbed
the first officer’s initiative, created a tense environment, and
a conspicuous communication barrier.
The captain seemed determined to make a right-hand
downwind approach to runway 12, despite his knowledge
that Islamabad procedures did not permit this, and there
was low cloud in the area.
Contrary to established procedures for circling to land
on runway 12, the captain elected to fly the approach in
the navigation mode and asked the first officer to feed
unauthorised waypoints into the flight management system.
The first officer did not challenge his instructions.

Flight Safety Australia
Issue 87 July–August 2012
61
The intention of the captain to fly this type of
approach was not known to air traffic control.
His violation of established procedure took the
aircraft beyond the protected area.
The captain exhibited anxiety, confusion and
geographical disorientation, particularly after
commencing descent.
After a delayed break-off from the ILS because of
poor visibility, the captain turned right, but did not turn
left to parallel the runway.
While flying the northerly heading, the captain descended
below the MDA to 2300ft. This time the first officer
did not challenge him. The captain also failed to
maintain visual contact with the airfield.
The tower controller could not see the aircraft on
downwind or final legs, and sought radar help. The
aircraft was identified close to the no-fly zone and was
instructed to turn left.
When the tower asked the crew if they had contact with
the airfield, the first officer’s question to the captain, ‘What
should I tell him, sir?’ indicated a possible loss of visual
contact, as well as geographical disorientation.
the aircraft’s ground proximity
warning system enunciated:
‘TERRAIN AHEAD’!
The first officer urged: ‘Sir! Higher
ground has been reached!
Sir, there is terrain
ahead! Sir, turn left’!
The crew took the aircraft out of the protected area, 7.3nm
from the runway 12 threshold.
During the last 70 seconds of the flight, despite calls from
the tower, the GPWS sounding ‘Terrain ahead’ 21 times,
‘Pull up’ 15 times, and seven warnings from the first officer,
the captain did not pull up.
The first officer did not assert himself as he watched the
captain’s steep banks, continued flight into hilly terrain at
low altitude in poor visibility, and failure to pull up.
Conclusion
The accident was primarily caused by the crew’s violation of
all established procedures for a visual approach to runway 12,
their disregard of several calls by air traffic controllers, and of
21 GPWS warnings of rising terrain.
The official investigation termed the crash ‘a classic CRM
failure’. Why this failure occurred is unclear; Captain
Chaudhary’s motivation and state of mind remain unknown.
The investigation declared: ‘Both the crew members were …
medically fit to undertake the flight on 28 July 2010.’ However,
unconfirmed reports appearing in Pakistani newspapers in
2011 said that Chaudhary had been treated in hospital for
diabetes, hypertension and cardiac problems.

62
FEATURE
Fly neighbourly
WATCH OUT WHALES ABOUT!
The majestic
spectacle of
seeing some of
the world’s largest
mammals from the
air is one of the
moments when all
the hassles and
expense of owning
an aircraft seem
a small price to
pay for a moment
of magic. But
there are simple
commonsense
rules for aerial
whale watchers
to obey.
From May to November whales migrate along the
Australian coastline, often with new calves, and
your aircraft’s speed, noise, shadow or downdraft can
cause them considerable distress.
For the safety of the mammals and the public, laws
for approaching whales (and dolphins) from above are
enforceable over both state and commonwealth waters.
During the 2012 whale migration season, Operation
Cetus will again be active across Australia and New
Zealand. It will conduct joint federal, state and national
ocean patrols to protect whales, monitor flights over
them and educate the public about whale approach
laws. In 2011, Operation Cetus patrols detected
over 45 alleged offences involving over-enthusiastic
whale watchers or operators, with 33 requiring
further investigation.
As a pilot, it is your job to spot and navigate around a
whale’s position and movements, and to ensure that
your aircraft maintains the minimum whale approach
distances throughout the flight.
Whale approach laws vary between coastal areas and
you are responsible for checking the regulations and
guidelines specific to the waters you are flying over.
Some of these include:
aircraft (including gliders, airships and balloons,
but not helicopters) must not fly lower than 1000ft
within a 300m radius of a whale
helicopters (including gyrocopters) must not fly
lower than 1650ft within a 500m radius of a whale
helicopters must not hover over the no-fly zone
no aircraft of any type is permitted to approach
a whale head-on
no aircraft of any type is permitted to land on
water to watch whales
if a whale shows any sign of disturbance you
must cease your approach and alter your flight
path immediately.
These regulations also apply to dolphins.
Signs of disturbance
The following reactions may indicate that a whale or
dolphin is disturbed:
attempts to leave the area, or avoid the vessel
(quickly or slowly)
regular changes in direction or speed of swimming
hasty dives
changes in breathing patterns
increased time spent diving, compared to time
spent at the surface
changes in acoustic behaviour
aggressive behaviours, such as tail slapping and
trumpet blows.
It is very important to be able to recognise some general
behaviours of cetaceans that may be related to distress,
fear, or disturbance. In such cases cetaceans should
be left alone, and it is vital to immediately move out of
the area:
Blowing air underwater should be taken as a
warning sign
Lobtailing (tail slapping) and tail sweeping
Anomalous dive sequences and unusually prolonged
dives with substantial horizontal movements.
Remember that you should never chase cetaceans.
It is always better to have an expert on board because
distress signs are not always easy to recognise.
For a complete list of whale approach laws visit
environment.gov.au/whales To report an incident
email compliance@environment.gov.au or call
1800 110 395

Flight Safety Australia
Issue 87 July–August 2012
63
500m/1650ft
300m/1000ft
photo: Shutterstock

64
FEATURE
Hazard ID
continued from page 28
The following scenario illustrates a day in the life of City Air,
a fictitious airline.
City Air has recently rolled out the latest version of its SMS
course to operational staff. The course included a module
on hazard identification: what hazards are, how to identify
them, and how and when to report them. It also talked about
the risk assessment process the airline followed and its
feedback process to those who submitted the hazard incident
report. All these are crucial for supporting the safety culture
of the organisation and improving staff engagement with, and
commitment to, the safety reporting system.
As you read through the scenario note down your thoughts,
identify the hazards and help staff improve safety at City Air.
In the next issue of Flight Safety Australia we will follow up on
any reader feedback. The following questions could assist you:
What are the hazards in the scenario?
Should they be reported and why?
Will they assist in improving safety at City Air?
Scenario
Note: The characters and airline in the story are fictional.
The stories have been compiled from data and experiences
from different situations, airlines and countries, and are not
a reflection of any particular airline.
At check-in
Tuesday morning appears to be a regular working day for
ground staff at the City Airport. Check-in opens on time and
passengers are ready to check in or drop their bags off.
At counter one, passenger Sarah presents her cabin bag to the
agent. It appears to be larger than the size accepted as cabin
baggage. The check-in agent asks Sarah to put the bag in the
cabin baggage test unit next to the counter, but then realises
there is no test unit nearby. Sarah refuses to check the bag in
and leaves for the boarding gate.
At counter four, the check-in agent hears that passenger Gary
is going camping and has a small gas burner in his cabin
baggage. The check-in agent tells Gary he is unable to take the
burner on board, or pack it in his checked-in luggage, because
it is a dangerous goods item.
While Dianne checks in at counter four she is talking to her
travel companion and mentions the quality of the bathroom
cleaner she has packed, which will easily remove the stains
on the tiles of her beach house. The agent overhears the
conversation and explains to the passengers that cleaning
agents are considered dangerous goods and Dianne will not
be able to check in her bag until she has removed the cleaner
from it.
At counter two, 11-year-old Patrick and his little sister Jane
(five years old) have just turned up on their own. They explain
that their grandmother is parking the car and will be in the
terminal shortly, but they are flying back home without her.
When the check-in agent looks up the children’s details
on the computer, he notices that they are not identified as
‘unaccompanied minors’ in the reservations system.
At the gate
At gate one, Anna approaches the gate agent and asks if
she can change her seat allocation. The seat she has been
allocated is in the emergency exit row and she thinks it will
not recline. The agent makes the change, expecting the seat
to be filled by another passenger because check-in is open
for another 15 minutes.
Boarding has commenced at gate three. The agent at the
gate notices passenger Robert carrying what appears to be
a small suitcase with a cover. When the agent sees Robert’s
boarding pass she notices that he has used web check-in
and decided to ask him if he is carrying anything particular
in the suitcase. Robert explains that it is an oxygen cylinder
he carries because of a respiratory condition. The agent asks
Robert to show her the oxygen cylinder, and also if she can
see a medical certificate permitting him to travel on an aircraft.
She notices that the oxygen bottle is a brand listed in the
dangerous goods manual, but after seeing Robert’s medical
certificate allows him to board the aircraft. However, the gate
agent then realises she has never actually seen an oxygen
bottle that could be transported as cabin baggage.
On the tarmac
While a City Air staff member is marshalling passengers onto
an aircraft via the tarmac she notices a teenage passenger
using her mobile phone. When the staff member approaches
her, passenger Victoria explains she was texting her mother to
tell her that the flight was about to depart. Victoria also says
that because she was using earphones, she had not heard the
boarding announcement at the gate telling passengers to turn
off mobile phones before walking on to the tarmac. Victoria
turns her mobile phone off and boards the aircraft.
At bay 6, ramp staff are handling an aircraft that is due to
depart in 35 minutes. One of the tug drivers drops off two
barrows at bay 6, on his way to the baggage room. As he
approaches the taxiway crossing, he receives a radio call.
He answers it and talks for what seems to be about 30
seconds, taking his eyes off the road. After the conversation
he lifts his head and sees an aircraft taxiing in front of his tug.

Flight Safety Australia
Issue 87 July–August 2012
65
CANBERRA ² BRISBANE
CBR ² BNE
FLIGHT
FSA87
BOARDING TIME
2030
GATE
8
SEAT NO.
12B
PASSENGER
CITIZEN / JOHN MR
FLIGHT
FSA87
On board
Almost all the passengers have boarded the aircraft departing
from gate one. Sarah is trying to make her sports bag fit in the
overhead locker. There is no room for the bag, so she presses
the call button. One of the cabin crew comes over to help her
and says that the sports bag is too big and heavy and should
have been checked in. Sarah agrees and the bag is taken by
one of the ground staff.
John and his wife Claire realise they have left vital medications
at home and will have to disembark. They tell ground staff they
have checked in four bags, so these have to be offloaded. It
takes more than half an hour for ramp staff to find the bags. An
executive sitting in the emergency row with his wife decides
that they also have to disembark because he will not make
it to his meeting. The emergency exit row is now empty and
according to the airline’s policy at least two passengers need
to sit in that row, so they can help to open the over-wing exits
in an emergency. The cabin crew now have to find suitable
passengers to sit in the exit row. All this causes another
15-minute delay.
Preparation for take-off
The last door on the delayed flight at gate one is closed and
the cabin crew are securing the cabin for take-off. The safety
demonstration has finished and the crew are walking to their
seats. A passenger is talking on his mobile phone. The cabin
crew ask him to turn it off. In the meantime, another passenger
stands up and starts to walk to the toilet. Cabin crew remind
the passenger that the seatbelt sign is on, so she has to
stay seated.
The young passenger returns to her seat and apologises,
saying that she had been listening to music during the safety
demonstration and that this was the first time she had ever
been on an aircraft.
In the next edition of Flight Safety we will discuss some of the
hazards that can be identified in the above scenario. We will
talk about why they needed to be reported and what possible
consequences they could have for the safety of City Air.
Remember that all reported hazards are important data for
your SMS. They should all be reported, even if the problem
can be fixed on the spot.
The eleven basic risk factors (BRFs)
1. Hardware
2. Design
3. Maintenance management
4. Procedures
5. Error-enforcing conditions
6. Housekeeping
7. Incompatible goals
8. Communication
9. Organisation
10. Training
11. Defences
For more information
ICAO Doc 9859. AN/474 Safety Management Manual
(SMM) Second edition, ICAO (2009), Montreal, Canada
ICAO Doc 9859. AN/474 Safety Management Manual
(SMM) Third edition, ICAO (2012) is due for release shortly
SMS for aviation: a practical guide. CASA resource kit,
due mid-July 2012.

66
AV QUIZ
Flying ops | Maintenance | IFR operations
FLYING OPS
1. Fog formation of significance to aviation becomes
more likely:
a) as the ambient temperature approaches the dew
point, particularly if there is a light surface wind to
promote mixing.
b) as the ambient temperature approaches the dew point,
particularly if there is no wind.
c) as the dew point depression decreases, particularly if
there is no wind.
d) as the dew point depression increases, particularly if
there is a light wind to promote mixing.
2. At the leading edge of a cold front, the atmosphere is:
a) unstable, because the temperature decreases rapidly
with increasing height.
b) unstable, because the temperature increases rapidly
with increasing height.
c) stable, because the temperature increases rapidly
with increasing height.
d) stable, because the temperature decreases rapidly
with increasing height.
3. In a continuous-flow fuel-injected piston engine, one
function of the fuel manifold valve assembly is to:
a) time the delivery of fuel to the appropriate cylinder
during engine operation.
b) provide a positive fuel shut-off to the fuel nozzles
during engine shutdown.
c) compensate for air density.
d) compensate for ambient air pressure and temperature.
4. With reference to helicopter operation, a vortex ring
state is:
a) a lenticular rotating air mass at the top of an obstacle in
the presence of a strong wind.
b) a rotating air mass in the lee of an obstacle in the
presence of a strong wind.
c) a stable state that occurs when a helicopter is
moving rapidly forward and the main rotor downwash
recirculates through the rotor.
d) a hazardous condition in helicopter flight usually
associated with a high rate of descent, a comparatively
low airspeed, a relatively high power setting and the
main rotor downwash recirculating through the rotor.
5. Autokinesis is:
a) an illusion where a point source of light in a dark
environment appears to move.
b) a sensation of pitching nose-down during acceleration.
c) a false sensation that an aircraft is banked.
d) a false turning sensation.
6. An anti-servo tailplane is one where:
a) a small trim tab is moved in order to move the
main tailplane.
b) there is one fixed surface and two moving aerofoil
surfaces.
c) a small trim tab moves to oppose the movement of
the main stabilator.
d) a small trim tab moves to assist the movement of
the main stabilator.

Flight Safety Australia
Issue 87 July–August 2012
67
7. If a pilot permits the elevator to move after tailwheel
contact when a tailwheel aircraft bounces during
landing, any resultant movement of the elevator:
a) will always be upwards, thus reducing the
subsequent bounce.
b) will always be upwards, thus increasing the
subsequent bounce.
c) will always be downwards, reducing the
subsequent bounce.
d) will always be downwards, contributing to the
subsequent bounce.
8. During flight, pilots must maintain a time reference
that is accurate to within:
a) ± 2 minutes and is powered independently of the
aircraft electrical system.
b) ± 2 minutes.
c) ± 30 seconds.
d) ± 15 seconds
9. In aircraft design, longitudinal stability can be
achieved by:
a) designing a greater incidence on the tail plane than
on the main plane.
b) designing a lesser incidence on the tail plane than
on the main plane.
c) washout on the main plane.
d) dihedral on the main plane.
10. A GNSS satellite transmits on two frequencies:
a) in order to correct for ionospheric propagation
delay of the signal.
b) in order to provide redundancy.
c) to split the data from the identification component.
d) to achieve selective availability.
MAINTENANCE
1. The FAR 23 requirement for fuel pump delivery
capability is a minimum of:
a) 125 per cent of the maximum fuel flow required by the
engine at take-off power.
b) 150 per cent of the maximum fuel flow required by the
engine at take-off power.
c) 175 per cent of the maximum fuel flow required by the
engine at take-off power.
d) 200 per cent of the maximum fuel flow required by the
engine at take-off power.
2. During starting of an engine with a Hall-effect ignition
system, a common method of retarding the spark is to:
a) initiate the spark from the leading edge of the
timing pulse.
b) initiate the spark from the trailing edge of the
timing pulse.
c) provide a second distributor cam for starting.
d) close the point gap.
3. On a turbocharged piston engine, the upper deck
pressure is the pressure of the air:
a) at the turbine inlet.
b) leaving the intercooler.
c) leaving the turbo compressor outlet.
d) in the cooling air plenum chamber above the cylinders.
4. A recent Airworthiness Bulletin (AWB 27-001 issue 3)
concerning corrosion of stainless steel control cable
fittings recommends a:
a) 15-year retirement life of fittings made from a certain
grade of stainless steel.
b) 15-year retirement life of all stainless steel or carbon
steel control cable fittings.
c) 20-year retirement life of fittings made from a certain
grade of stainless steel.
d) 20-year retirement life of all stainless steel control
cable fittings.
5. Visual inspection of control cable fittings made from
SAE-AISI 303Sc stainless steel for the defects as
outlined in AWB 27-001:
a) is a satisfactory way of inspecting provided high
magnification is used.
b) will not necessarily reveal evidence of internal inter
granular corrosion.
c) is not satisfactory, but dye penetrant inspection
is satisfactory.
d) is satisfactory in conjunction with magnetic
particle inspection.

68
AV QUIZ
Flying ops | Maintenance | IFR operations
6. A helicopter operated under night VMC must have a
separate and independent power source for:
a) turn coordinator and directional gyro.
b) attitude indicator and transponder.
c) standby attitude indicator and directional gyro.
d) attitude indicator, standby attitude indicator or
turn indicator.
7. Where a helicopter is operating under night VMC,
in order to comply with CAO 20.18, an acceptable
alternative source of power required for some specific
instruments is:
a) a separate fuse for each gyro instrument.
b) a separate circuit breaker for each gyro instrument.
c) a separate circuit breaker and sub-bus for the
specified instruments.
d) a separate emergency bus running directly from the
battery for the specified instruments.
8. Referring to an inflated tyre and wheel assembly,
particularly if hot, the safest direction from which
to approach is:
a) the side at which it is installed on the axle.
b) the side away from which it is installed on the axle.
c) the front or rear of the tyre i.e. in the plane of rotation.
d) above.
9. A piston engine with a continuous-flow type of fuel
injection system requires a:
a) positive displacement fuel pump i.e. one in which
the fuel flow is proportional to the engine RPM.
b) positive displacement fuel pump i.e. one in which the
fuel flow is inversely proportional to the engine RPM.
c) constant pressure fuel pump in which the output
pressure is constant regardless of flow.
d) constant pressure diaphragm type pump.
10. Part number MS21251 refers to a:
a) turnbuckle barrel or body.
b) cable eye end.
c) cable stud end.
d) turnbuckle lock-nut.
IFR OPERATIONS
Building an Approach
For something different with this quiz, I thought I would give
you some extracts from a novel called The Temple Tree by
David Beaty, in which he very ably describes the flight testing
of an ILS at a fictitious airport called Tallaputiya in Ceylon
(Sri Lanka), flying a Boeing 707. Then we can consider how
you might visualise the approach being constructed and flown.
… In the cockpit of a 707 flying over Colombo at three
thousand feet. ‘Coming up to Tallaputiya now’ … The pilot
punched the stop clock as the radio compass turned abruptly
180 degrees.
‘We go out on a course of 100 degrees for two minutes.’ He
pointed to the round dial of the ILS cut exactly in two halves
– one yellow and one blue – by the localiser needle. ‘Dead
on the beam outbound’ … ‘Two minutes’, the first officer
said. ‘Procedure turn.’ The pilot tilted up the port wing to alter
course forty-five degrees to the right and started to descend.
… Gracefully the aircraft executed a pear-shaped manoeuvre
back toward the beam.
… Hannacker kept his eyes on the ILS needles – the localiser
at full travel over in the yellow sector, the glide path tucked up
at the top of the instrument, both showing the aircraft had not
yet started to cut the beams. Then very gradually, the localiser
needle started to move, and at exactly the same time, the pilot
slightly increased the left bank. Imperceptibly the 707 slid
into the beam on to a heading of 280 degrees. The needle on
the radio compass now indicated Tallaputiya beacon dead
ahead and nine miles away, exactly in line with their course.
From the top of the ILS … the glide path needle began
slowly to descend, till it cut the round face of the instrument
horizontally across.
‘On glide path.’ ‘Descending at five hundred feet per minute’.
… Airspeed 140 knots, altimeter unwinding methodically.
‘The glide path is three degrees.’ …

Flight Safety Australia
Issue 87 July–August 2012
69
1. If a holding pattern was constructed over the Talliputiya
beacon (NDB), with the inbound track being the initial
approach track, and it was a ‘standard’ pattern, which of
the following would apply?
a) Left hand, 2 minutes
b) Left hand, 1 minute
c) Right hand, 2 minutes
d) Right hand, 1 minute
2. From what direction would the Boeing be arriving in
order to go ‘straight in’ to the initial approach and not
require a sector entry?
a) East South East
b) West North West
c) North North West
d) South South East
3. If the 707 was experiencing a 20-knot northerly wind
along the initial approach, what approximate heading
would be flown to maintain the track?
a) 100
b) 090
c) 290
d) 280
4. Still tracking outbound on the initial approach, the
localiser needle begins to move right. Which of the
following is correct?
a) Command sense, fly left to correct
b) Command sense, fly right to correct
c) Non command sense, fly left to correct
d) Non command sense, fly right to correct
5. Still tracking outbound…
If the localiser needle was to move to the position in the
diagram, how many degrees off track is the aircraft?
a) 1 degree off track to the right
b) 4 degrees off track to the right
c) 1 degree off track to the left
d) 4 degrees off track to the left
6. After two minutes outbound the Boeing executes a turn
back inbound to the ‘front’ beam of the localiser. Which
of the following is correct concerning the turn?
a) It is a left-hand procedure turn to 145 degrees initially,
then after the specified time, reversal turn onto 325
degrees for intercept
b) It is a right-hand procedure turn to 145 degrees
initially, then after the specified time, a reversal turn
onto 325 degrees for intercept
c) It is a left-hand procedure turn to 055 degrees initially,
then a reversal turn onto 235 degrees for intercept
d) It is a right-hand base turn to 145 degrees initially, then
a reversal turn onto 325 degrees for intercept
7. If the aircraft were descending at 600fpm on the
glideslope, what approximate groundspeed would
it be doing?
a) 140kt
b) 100kt
c) 120kt
d) 160kt
8. Now established inbound heading 285 and descending,
the localiser needle moves to the position in the
diagram. How many degrees off track is the aircraft?
a) 2 degrees off track to the left
b) ½ a degree off track to the right
c) 2 degrees off track to the right
d) ½ a degree off track to the left
9. The heading is altered to re-intercept the localiser.
Once this is achieved, which of the following headings is
correct to remain on the localiser?
a) 280 since the wind is lighter
b) 275 since the wind is stronger
c) 285 since the wind is steady
d) 290 since the wind is stronger
10. If the heading is now 290, what would the fixed card
radio compass (the ADF) be indicating, if tuned to the
Tallaputiya beacon (the NDB)?
a) 350 R
b) 170 R
c) 010 R
d) 360 R

70
CALENDAR
Dates for your diary
Upcoming events
July 28
Access all information areas
seminars – Brisbane
Register online now!
go to www.casa.gov.au/avsafety
ACT/NEW SOUTH WALES
July 4
AvSafety Seminar – Camden
www.casa.gov.au/avsafety
July 17
AvSafety Seminar – Forbes
www.casa.gov.au/avsafety
July 18
AvSafety Seminar – Temora
www.casa.gov.au/avsafety
July 22
AvSafety Seminar – Sydney
www.casa.gov.au/avsafety
August 22
Aviation Safety Education Forum – Sydney
www.casa.gov.au/avsafety
SOUTH AUSTRALIA
July 19
AvSafety Seminar – Murray Bridge
www.casa.gov.au/avsafety
WESTERN AUSTRALIA
July 24
AvSafety Seminar – Exmouth
www.casa.gov.au/avsafety
Nov 7–8
ATO Professional Development Program
www.casa.gov.au
QUEENSLAND
July 24–26
Aircraft Airworthiness & Sustainment
Conference – Brisbane
www.ageingaircraft.com.au/aasc.html
July 26
AvSafety Seminar – Horn Island
www.casa.gov.au/avsafety
July 28
Aviation Safety Education Forum – Brisbane
www.casa.gov.au/avsafety
August 1
AvSafety Seminar – Cairns
www.casa.gov.au/avsafety
August 2
AvSafety Seminar – Atherton
www.casa.gov.au/avsafety
August 8
AvSafety Seminar – Gympie
www.casa.gov.au/avsafety
August 9
AvSafety Seminar – Maroochydore
www.casa.gov.au/avsafety
August 25
Aviation Careers Expo – Brisbane
www.aviationaustralia.aero/expo/
August 29
AvSafety Seminar – Redcliffe
www.casa.gov.au/avsafety
October 10–12
Regional Aviation Association of Australia
(RAAA) Convention – Coolum, Queensland
www.raaa.com.au/
NORTHERN TERRITORY
July 25
AvSafety Seminar – Alice Springs
www.casa.gov.au/avsafety
July 26
AvSafety Seminar – Uluru
www.casa.gov.au/avsafety
August 22
AvSafety Seminar – Gove
www.casa.gov.au/avsafety
August 27
AvSafety Seminar – Darwin
www.casa.gov.au/avsafety
August 29
AvSafety Seminar – Victoria River Downs
www.casa.gov.au/avsafety
VICTORIA
July 5
AvSafety Seminar – Lilydale
www.casa.gov.au/avsafety
July 17
AvSafety Seminar – Tyabb
www.casa.gov.au/avsafety
August 1
AvSafety Seminar – Lethbridge
www.casa.gov.au/avsafety
INTERNATIONAL
July 9–15
Farnborough International Airshow –
Farnborough, UK
www.farnborough.com/
August 27–30
ISASI 2012 43rd Annual Seminar –
Baltimore, Maryland USA
www.isasi.org/isasi2012.html
August 28–29
Asia Pacific Airline Training Symposium
(APATS) – Singapore
www.halldale.com/apats-2012
September 17–18
Flight Safety Conference – London, UK
www.flightglobalevents.com/flightsafety2011
October 23–25
International Air Safety Seminar –
Santiago, Chile
www.flightsafety.org/aviation-safety-seminars/
international-air-safety-seminar
October 23–25
International Cabin Safety Conference –
Amsterdam, The Netherlands
www.ldmaxaviation.com/Cabin_Safety/
International_Cabin_Safety_Conference
To have your event listed here,
email the details to fsa@casa.gov.au
Copy is subject to editing.
Please note: some CASA seminar dates may
change. Please go to www.casa.gov.au/
avsafety for the most current information.
CASA events
Other organisations’ events

AUSTRALIAN
Flight Safety Australia
Issue 87 July–August 2012
71
pa.com.au
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QUIZ ANSWERS
AUSTRALIAN
pa.com.au
Flying ops
1. (a)
2. (a)
3. (b)
4. (d)
5. (a)
6. (c)
7. (d) when bouncing from tailwheel to
mainwheels, down elevator increases
the downward velocity of the mains.
8.
(c) ENR 1.1.19.4
9. (b)
10. (a)
Maintenance
1. (a) FAR §23.955(c).
2. (b)
3. (c)
4. (a) CASA AWB 27-001.
5. (b) CASA AWB 27-001 figure 4.
6. (d) AWB 24-005 and CAO 20.18
7. (d) AWB 24-005 issue 2.
8. (c)
9. (a)
10. (a)
IFR operations
1. (d) AIP ENR 1.5-22 PARA 3.1.3 and 3.2.1 (c)
2. (b) AIP ENR 1.5-23 FIG 3.2a
AIP ENR 1.5-17 PARA 2.4.1b (3)
3. (b) Initial approach TR is 100 outbound with a northerly wind, thus drift correction
to the left 090.
4. (c) Outbound on an ILS with this ‘raw data’ equipment, the localiser is non
command, hence a turn opposite to the needle i.e. to the left (it could indicate
that the northerly wind is strengthening).
5. (a) With ILS, each ‘dot’ is only ½ a degree, remembering that on this instrument
presentation the outside of the circle is considered to be one ‘dot’.
6. (b) AIP ENR 1.5-19 PARA 2.7.2a
It is the ‘international version’ of a procedure turn as shown where applicable
in Jeppesen plates, as distinct from the ‘80/260’ version in Airservices plates.
Procedure turns are defined by the initial turn direction.
7. (c) The rule of thumb to maintain the 3 degree glideslope is groundspeed x 5 = R.O.D.
Thus 600 ÷ 5 = 120kt. Note, not the I.A.S. of 140kt.
8. (d) Each ‘dot’ is ½ a degree, and needle is now command sense.
9. (d) The original HDG of 285 was not keeping the 707 on the LOC and with the
north wind it must be stronger, thus more drift allowance needed.
10. (a) HDG 290, LOC TR 280, thus with the NDB ahead 360 – 10 = 350 R

72
NEXT ISSUE / PRODUCT REVIEW
Essential aviation reading
COMING NEXT ISSUE
Sept – Oct 2012 online
www.casa.gov.au/fsa
Aviation communication – why
‘plane’ speaking matters
A fresh look at fatigue – new rules
Hazard ID and SMS ... part 2
... and more close calls
Product reviewDS-B BOOK
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– Aerial work
For more information on a demonstration flight in your region please contact
Charles Gunter on 0417 108 602 or charles.gunter@aviaaircraft.com.au
www.aviaaircraft.com.au

2012
Have trouble finding
aviation information?
CASA, Airservices, ATSB, the Bureau of Meteorology and
the RAAF, present a new series of aviation safety education
forums. The full-day forums (to run from 0900-1630) will
feature presentations from each of these industry members,
covering vital aviation safety information. There will be a
special focus on human factors issues.
Come armed with your tablet or smartphone—presenters
will show how you can ‘access all areas of aviation safety
information’ online.
Book now!
Access all information areas forums
Brisbane Griffith University 28 July 2012
Sydney University of NSW 22 August 2012
Melbourne Swinburne University 17 September 2012
Adelaide University of SA 28 September 2012
Perth
Mt Pleasant Baptist
Community College
03 October 2012
Register now! Attendance is free but bookings
are essential.
Go to www.casa.gov.au/avsafety and register online.
For more information, contact your local Aviation Safety
Adviser, on 131 757.

There has never been a better time
to be with good people.
Good people to be with.
QBE Insurance (Australia) Limited ABN: 78 003 191 035, AFS Licence No 239545
Contact details for you and your broker:
Melbourne Ph: (03) 8602 9900 Sydney Ph: (02) 9375 4445
Brisbane Ph: (07) 3031 8588 Adelaide Ph: (08) 8202 2200